roots international No. 2, 2022

Cover / Editorial / Content / Endodontics fine motor skills with the use of conventional and 3D microscopy—a comparative study / Innovative endodontics using SWEEPS technology / Less-Prep Endo—is a paradigm shift in root canal preparation ahead of us? / The importance of irrigation in challenging cases / Treatment of compromised teeth: The usual suspects / Endodontic treatment and the magic lamp / Building a sustainable dental practice / Study examines public perceptions regarding sustainable dentistry / Manufacturer news / Meetings / Submission guidelines / Imprint

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issn 2193-4673 • Vol. 18 • Issue 2/2022

roots
international magazine

of endodontics

study

Endodontics fine motor skills
with the use of conventional
and 3D microscopy

case report

Less-Prep Endo—
is a paradigm shift in root canal
preparation ahead of us?

features

Building a sustainable dental practice

2/22

[2] =>

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Due to Doctor‘s Choice function, flexible use with individual file sequences is also possible.

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[3] =>

editorial

Magda Wojtkiewicz
Managing Editor

Innovations
Innovation has become a very desirable thing. When we
think about innovation, we think about a new product,
material or technology to use. As customers, we like innovations. Every year, hundreds of thousands of people
around the globe eagerly await the latest iPhone or other
electronic device. A similar thing happens in the dental
industry ahead of the International Dental Show (IDS),
which takes place in Cologne in Germany every two
years. Dentists, dental assistants, dental technicians,
many other dental professionals and dental students
enthusiastically look forward to the innovations to be
presented at IDS.
Innovation concerns more than new products, materials
and service however. Innovation can also be the use of
existing products and procedures to improve efficiency,
as well as the development of new methods or protocols
of treatment.
Minimally invasive endodontics is considered an innovative treatment method. Unlike conventional endodontics,
it is not only focused on eliminating bacteria from the
infected root canal and preventing reinfection of the
tooth, but it also aims to retain as much of the healthy
tooth tissue as possible, which significantly impacts
the long-term viability of an endodontically treated tooth.
Minimally invasive endodontics is a great example of
an innovative approach to existing methods, products
and materials. This is a growing area of development and
according to the IDS 2023 organisers, minimally invasive
endodontics together with regenerative procedures will
be in focus during the next exhibition.
Digitalisation is another area where innovative thinking
can change the approach to treatment methods.

An increasing number of digital tools are being developed
which allow general practitioners to properly diagnose
and perform endodontic treatment backward planning.
According to the organisers, IDS 2023 will showcase
an abundance of suitable software for endodontic planning and smooth communication between the different
practices involved.
There will be a great deal to discover during IDS 2023,
which will be a jubilee event, celebrating 100 years since
the first IDS took place in 1923, as well as the 40th edition
of the trade fair. “Enhancements and alternatives to
recognised endodontic treatment routines have repeatedly been presented at IDS,” said Mark Stephen Pace,
chairman of the board of the Association of the German
Dental Industry. “That was already the case at the very
first trade fair of its kind in the year 1923; for example,
in its era, the Walkhoff paste was considered to be
a novel bacteria-eliminating root filling material. And the
same will also be true in 2023 when we celebrate the
100th anniversary of IDS. [...] As the leading global trade
fair of the dental industry, IDS 2023 provides a unique
orientation as to how a dental practice can strive to attain
these achievements. The trade fair is celebrating its
100th anniversary from 14 to 18 March 2023 in Cologne.”
I hope that you will find this issue of roots innovative, and
I look forward to the next issue, in which we will write
more about the new products, materials and methods
to be presented at IDS 2023.

Magda Wojtkiewicz
Managing Editor

roots
2 2022

[4] =>

| content
editorial
Innovations

03

Magda Wojtkiewicz

study
Endodontics fine motor skills with the use of conventional 		
and 3D microscopy—a comparative study
06
Drs Jenner Argueta, Ana Jiménez, Rafael Genao & Rodrigo Vargas

research
page 06

Innovative endodontics using SWEEPS technology

10

Drs Giovanni Olivi, Linhlan Nguyen, Matteo Olivi & Jason Pang

case report
Less-Prep Endo—								
is a paradigm shift in root canal preparation ahead of us?
18
Dr Bartlomiej Karaś

The importance of irrigation in challenging cases

28

Dr Marco Martignoni
page 18

Treatment of compromised teeth: The usual suspects

32

Drs Robert E. Grover & Kenneth S. Serota

Endodontic treatment and the magic lamp

36

Dr Anne Heinz

features
Building a sustainable dental practice

38

Dr Sanjay Haryana

Study examines public perceptions regarding sustainable dentistry

40

Brendan Day

page 36

manufacturer news

42

meetings
Registration for 2023 Chicago Dental Society Midwinter Meeting is open 45
IDS organisers herald beginning of post-COVID-19 era
46
International events
48

Cover image courtesy of Seiler
(www.seilermicro.com).
2/22

issn 2193-4673 • Vol. 18 • Issue 2/2022

roots
international magazine

of endodontics

study

Endodontics fine motor skills
with the use of conventional
and 3D microscopy

case report

Less-Prep Endo—
is a paradigm shift in root canal
preparation ahead of us?

features

Building a sustainable dental practice

04

roots
2 2022

about the publisher
submission guidelines

49

international imprint

50

[5] =>

[6] =>

| study

Endodontics fine motor skills with
the use of conventional and
3D microscopy—a comparative study
Drs Jenner Argueta, Ana Jiménez, Rafael Genao & Rodrigo Vargas, Dominican Republic & Guatemala

Introduction
Owing to the introduction of magnification principles in
dentistry, new techniques have been implemented for the
successful performance of endodontic treatments. Microscopes have become an integral part of modern endodontics,1 and the use of conventional microscopy is becoming
more frequent.2–4 Despite the significant cost and training
required, the use of the operating microscope is highly recommended to improve the visualisation of the operative
field and to enhance the diagnostic capacity of the clinician,
including the identification of isthmuses, accessory canals,
complex pulp chamber anatomy, calcifications, obstructions
and microfractures, among others,5, 6 which would otherwise be difficult to identify and treat. This results in better
quality care and a higher success rate of treatments.7, 8
It has also been shown that the use of the operating microscope leads to a considerable improvement in ergonomics
and therefore tends to reduce the occurrence of injuries
related to poor posture and stress due to repetitive movements during the clinical workflow. All the advantages begin
to be more palpable and applicable after going through the
appropriate clinical training for acquiring the required skills
to work under the microscope.9, 10
Through technological advances, a new generation of
microscopic equipment with 3D technology has been
developed that eliminates the binocular elements and
offers an improvement in perception, clarity, depth of field,
freedom of movement and clinical productivity in treatments.
However, 3D microscopes have not been widely investigated, and scientific findings on their use and their influence on the fine motor skills of the operator are still limited.
The purpose of this study was to evaluate and compare
fine motor skills with the use of the conventional microscope and the 3D microscope in endodontic practice.

Methodology
Fifteen dentists who had no regular or recent clinical
experience in the use of the operating microscope
participated in this study. The study participants were
1

Fig. 1: Alpha Air 6 dental operating microscope.

06

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study

2
Fig. 2: The PromiseVision 3D surgical microscope being used during an apical microsurgery procedure.

final-year students and lecturers at the dental school
of the Universidad Mariano Gálvez de Guatemala in
Guatemala City. Each participant performed three manual tests of precision and dexterity divided into three
stages as follows: unaided vision, using an Alpha Air 6
operating microscope (Seiler Instrument; Fig. 1) set
to 8× magnification and using a PromiseVision 3D
microscope (Seiler Instrument; Fig. 2) set to 8× magnification.
All the dentists involved in the study received 6 hours
of theoretical and practical training on the basic use
of conventional and 3D microscopy. The training was
given by second-year residents in endodontics from the
Universidad Nacional Pedro Henriquez Ureña in Santo
Domingo in the Dominican Republic. After the training,
the participants performed the manual dexterity and
fine motor skills tests. The tests required accurately
penetrating a series of millimetric circular targets using
a 21 mm #10 K-file. The targets were printed on a
#20 calibre paper sheet with eight spaces, each space
having ten circular targets inside (Fig. 3). Four of the
spaces contained targets of 0.3 mm in diameter and
the remaining four contained 0.35 mm diameter targets,
corresponding to the letter “O” calibration in sizes 2 and
2.5, respectively. The position of each target within the
field was determined by a Microsoft Excel randomised
number generator.

During the fine motor skills tests, the time that the participants took to complete the test was recorded, from
the penetration of the first target to the penetration of the
last target (Fig. 4). To score accuracy and dexterity, a
grading system of 0–3 points was used, 0 being the least
accurate and 3 being the most accurate. A score of 3 was
assigned if the file penetration was entirely within the target, a score of 2 was recorded if the penetration touched
the edge of the target and was more than 50% within the
target, a score of 1 was assigned if the penetration
touched the edge of the target, but was more than 50%
off the target, and a score of 0 was assigned if the target
was completely intact, was missed or was penetrated
more than once.

Table 1: Time differences and effectiveness
Average time to
complete the tests
in seconds (CI)

Mean
microscopic
precision score (CI)

No magnification

304 (259–347)

150 (128–171)

Conventional
microscope

656 (525–780)

193 (173–210)

3D microscope

640 (554–773)

185 (174–197)

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| study
The completed test sheets were evaluated by two calibrated blinded evaluators with the help of a tabletop
microscope. The scores for the 80 targets were calculated individually, obtaining a maximum possible score
of 240. The statistical analysis was performed using the
RealStatistics Using Excel program. The Shapiro–Wilk
p > 0.01 test was performed to evaluate the normality of
the data sample.

Results
Using the one-factor analysis of variance test for correlated differences, statistically significantly lower precision (p < 0.05) was found for working without magnification. The Tukey post hoc test showed statistically
significantly greater precision (p < 0.05) when the 3D microscope was used. The one-factor analysis of variance
test and Tukey’s post hoc tests found statistically significant differences (p < 0.05) in terms of the time needed to
perform the precision test, working without magnification
taking less time than working with conventional magnification and with 3D microscopy.

3
Fig. 3: Sheet chart used during the fine motor skills tests.

The time needed for the operator to adjust the microscope and to feel comfortable to start working on
the tests was also measured. A shorter adjustment
time was needed when the 3D microscope was used
in comparison with the conventional microscope,
and this difference was statistically significant. The
mean adjustment time was 1.19 and 4.13 minutes,
respectively.
The analysis of the results revealed that the tests
with the greatest difference (p < 0.05) in both variables
(time required and precision demonstrated) were those
carried out when working without magnification, compared with working with conventional and 3D microscopy. It can be seen in Table 1 that it took less time on
average to perform the test when not using magnification, but the scoring results on accuracy were directly
proportional to time: the less time it took to perform
the test, the less accurate the operator was. With the
use of conventional and 3D magnification, significant
differences were found in both time and effectiveness.
It can be seen in Table 1 that the completion time was
shorter for the tests using the 3D microscope, compared with the tests carried out with a conventional
microscope. The accuracy score obtained was higher
when the conventional microscope was used. It is
worth mentioning that the precision tests were performed on flat images, which may have influenced the
perception of objects when performing the test using
the 3D microscope. It is recommended to carry out
a similar study by carrying out precision tests on
3D objects.

Discussion

4
Fig. 4: The study participants working on the fine motor skill tests.

roots
2 2022

It is necessary to understand the importance of magnification to achieve quality results in dental procedures
and to reduce the margin of error, and the use of magnification in turn requires fine motor skills in dentistry.
That is why this study aimed to evaluate and compare
fine motor skills without the use of magnification, with
the use of a conventional microscope and with the use

[9] =>

study

of a 3D microscope. Over the years, the advantages
of magnification in dentistry have been demonstrated.
Now, we have progressed to studying the new 3D magnification system plus the contributions that it can make
to clinical practice.

participants to achieve better results. 3D microscopy
is a novel tool that is likely to become part of the standard equipment in dentistry, contributing positively to
the implementation of microscopy in all specialties of
dentistry.

The results showed that the magnification systems
used effected an increase in the fine motor skills of the
participants, regardless of the type of magnification
used. Regardless of the time it took to learn to work under the microscope or to complete a test, it is evident
that the use of magnification improved the results and
made the motor skills of the participants more efficient, resulting in marked precision during the testing.
These results are quite similar to those reported by
Wajngarten et al., demonstrating that magnification
makes a significant contribution to and allows for better
results in clinical work.7, 11, 12

Editorial note: A list of references is available from the
publisher.

It is understandable that, initially, the working time tends
to be shorter when the microscope is not used, and
the quality of the work is directly proportional to the
time needed to perform the task. Using magnification
requires theoretical and practical learning that, once
achieved, will provide advantages in quality of work
and improvements in the operator’s motor skills and
ergonomics.7, 8, 13 It is important to note, as previously
mentioned, that the use of magnification provides better
visualisation and illumination of the operative field, helps
to avoid long-term health problems, reduces the probabilities of occupational stress and improves working position.9, 10 The contributions of conventional microscopy
have been well studied. It has effected a positive change
in modern dentistry, facilitating better quality treatments
with less execution time and higher success rates and
thereby promoting a more pleasant experience for the
dental professional and for the patient.
Despite being a relatively new magnification device and
little studied so far, the 3D microscope achieves the
desired quality standards. It is a tool that makes it easier
for us to achieve results like those obtained with conventional microscopy and has the additional advantage
of offering greater freedom of working position to the
operator and an outstanding depth of field. Regarding
the comparison with conventional microscopy, some
differences could be linked to the time it takes to master
the use of this technology; however, both magnification
tools provide a considerable contribution to the execution of any dental treatment.13, 14

Conclusion
Through evaluating and comparing fine motor skills
with the conventional microscope and the 3D microscope, we found that both devices contributed to
the enhancement of fine motor skills, allowing the

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about
Dr Jenner Argueta earned his
degree in dentistry and master’s
degree in endodontics from the
Universidad de San Carlos de Guatemala
in Guatemala City in Guatemala,
where he achieved multiple awards
as an outstanding student.
He is a certified researcher at the
Guatemalan national council for
science and technology and teaches endodontics at the
Universidad Mariano Gálvez de Guatemala in Guatemala City.
Dr Argueta also runs a clinical practice focused on microendodontics and micro-restorative dentistry. He was president
of the Academia de Endodoncia de Guatemala (endodontic
academy of Guatemala) from 2016 to 2020 and is the Guatemalan
representative for the Latin American Endodontic Association.
Dr Argueta can be contacted at jennerargueta@gmail.com.
Dr Ana Jiménez is a second-year
resident in endodontics and
microsurgery at the Universidad
Nacional Pedro Henriquez Ureña
in Santo Domingo
in the Dominican Republic.

Dr Rafael Genao is a second-year
resident in endodontics and
microsurgery at the Universidad
Nacional Pedro Henriquez Ureña
in Santo Domingo
in the Dominican Republic.

Dr Rodrigo Vargas is a doctor
in biomedical sciences and
a research professor at the
Universidad Mariano Gálvez de
Guatemala in Guatemala City.

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09

[10] =>

| research

Innovative endodontics
using SWEEPS technology
Tips and tricks
Drs Giovanni Olivi, Linhlan Nguyen, Matteo Olivi & Jason Pang, Italy & Australia

Conventional endodontic treatment is based on different phases, resulting in the elimination of acute or chronic
inflammation of the pulp and periapical area (Table 1).1–3
The different phases of the therapy are:
– initial cleansing of the endodontic space,
– shaping the root canals to a size sufficient for delivery
of irrigants,
– final cleansing and 3D disinfection of the endodontic
space, and
– 3D sealing of the endodontic space and restoration of
the post-endodontic space and the crown to conclude
the therapy.
The cleansing and shaping phases include two different
types of cleansing: a chemical cleansing, carried out by
different irrigating solutions, and a mechanical cleansing, carried out by endodontic instruments that shape
the root canals. However, many studies have demonstrated the incomplete action of the tested instrumentation, which left 35% or more of the canal surface area
unchanged.4–6 Accordingly, it is the efficient irrigation of
the endodontic space that determines the success of the
therapy. During the shaping phase, hand irrigation is performed using a syringe with an end- or side-vented needle, alternating with instrumentation using files of different
sizes. Besides reducing the bacterial load, irrigants act
as a lubricant during filing prior to the final activated irrigation protocol. The purpose of this article is to present
an innovative rationale for endodontic therapy using the

Not previously treated

Previously treated

Asymptomatic irreversible pulpitis
Symptomatic irreversible pulpitis
Asymptomatic apical periodontitis

Asymptomatic apical periodontitis

Symptomatic apical periodontitis

Symptomatic apical periodontitis

Table 1: Diagnostic classification of endodontic pathology.1–3

10

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newest cutting-edge laser technology SWEEPS (shock
wave enhanced emission photoacoustic streaming).

Irrigating solutions in endodontics
In endodontics, different irrigating solutions are used to
kill microorganisms, dissolve the organic components
(pulp remnants and collagen), and chelate and remove
the inorganic components (calcification and debris).7 The
smear layer is composed of both organic and inorganic
components. However, there is no irrigating solution that
has all the ideal characteristics.7 An effective irrigation approach is based on a specific alternating sequence of
use of different irrigating solutions, before, during and at
the end of the therapy. After creation of an access cavity,
root canal therapy is started by cleaning the pulp chamber and canals using an irrigant with antibacterial and
pulp-dissolving action.
Sodium hypochlorite
Sodium hypochlorite (NaOCl, 1–6%) is the main irrigant
used in endodontics owing to its high bactericidal activity and pulp tissue dissolution action.7 Higher NaOCl concentrations achieve faster bacterial load reduction; however, the more concentrated the solution of NaOCl, the
thicker it is, resulting in reduced wetting ability. NaOCl
is still recognised today as the gold standard solution
in endodontics because of its use from the initial to final phases of the therapy.7 NaOCl has significant biological toxicity risk for periapical tissue when pushed under
pressure through the root canal orifice.8 The outcome is
significantly worse for higher concentrations.
EDTA
Irrigation with chelating solutions such as ethylenediaminetetraacetic acid (EDTA, 15–17%) is often utilised
during root canal therapy. When alternated with NaOCl,
such as in cases of calcified canals and at the end of the
treatment, EDTA cleans the canal walls of debris and the
smear layer produced during instrumentation, just before
the final decontamination. EDTA is slightly irritating but
not toxic to periapical tissue.

[11] =>

research

Chemomechanical systems

Positive pressure systems

|

Negative pressure systems

Hand dynamic
XP-endo Finisher
Sonic
Multi-sonic
Self-Adjusting File

EndoVac

Ultrasonic
Laser-activated irrigation
(PIPS* and SWEEPS**)

* PIPS = photon-induced photoacoustic streaming. ** SWEEPS = shock wave enhanced emission photoacoustic streaming.
Table 2: Irrigant agitation techniques.

Chlorhexidine
Chlorhexidine (2%) has good antibacterial properties, but
it is not able to dissolve pulp tissue. This suggests its use
only in an additional final decontamination step because
of its unique substantivity property, which could allow
persistent residual antimicrobial action. It is important to
prevent interaction between NaOCl and chlorhexidine, by
rinsing the canals with distilled water in between solutions
to avoid the formation of precipitates that may discolour
the tooth and that may contain potentially mutagenic
compounds.9,10 Its inability to dissolve organic tissue also
explains the absence of toxicity to periapical tissue.11,12
Other solutions
Other chemical solutions have been investigated and
used in endodontics. Among these, hydrogen peroxide,
iodine, citric acid, ozone (gas) and ozonated water are
available, but none of them have demonstrated superior properties and results to the previously cited NaOCl
and EDTA solutions. EDTA plus Cetavlon and a mixture
of doxycycline, citric acid and a detergent are new solutions that combine different components, surface-active
agents and antibiotics which can be very effective and
have broader action. The experimental use of nanoparticles is also very promising.

Irrigant activation techniques
The initial irrigation phase and the irrigation during shaping are performed using a syringe with an end- or sidevented needle that can only negotiate the canal up to the
middle third. Therefore, it must be considered that the efficacy of hand irrigation is quite limited; thus, supplementary, active and dynamic irrigation (Table 2) is proposed
at the end of the treatment to ensure the cleaning of the
dentinal walls and the deep decontamination of the endodontic system.13 Among the various activation methods,
we can find systems that heat the irrigating solutions or
that activate the solutions by agitation, with positive or
negative apical pressure.

Heating
Scanning electron microscope studies on intra-canal
heating of NaOCl at 180 °C have proved this method to
be more effective for cleaning the canal walls than extracanal heating at 50 °C, which left a higher quantity of
debris and the smear layer widely distributed.14 Other
studies have reported that NaOCl at a concentration of
1% heated to 60 °C was significantly more effective than
5.25% at 20 °C. The advantage of using lower concentrations of NaOCl, heated to higher temperatures, could
be related to a twofold effect: the same effectiveness
and less systemic toxicity than that of non-heated, highconcentration NaOCl.15
Agitation techniques
However, the effect of agitation on tissue dissolution was
proved greater than that of temperature and with continuous agitation resulted in the fastest tissue dissolution.16
Comparing the efficacy of various agitation systems, De
Gregorio et al. found a limited penetration of the irrigant into lateral canals using an apical negative pressure
irrigation system, whereas passive ultrasonic irrigation
demonstrated significantly more penetration of irrigant
into lateral canals.17 Nevertheless, it could be reasonable
to combine the two techniques, using heated NaOCl and
agitating it with the preferred method.
Laser-activated irrigation using SWEEPS
The physical concepts behind laser-activated irrigation
and SWEEPS technology have already been explained in
a previous issue (4/2019) of this magazine.18 One of the
great advantages of SWEEPS over all of the other activation techniques is its profound effectiveness. Unlike all
the other techniques, SWEEPS action is not limited to the
vicinity of the tip, as is the case with ultrasonic irrigation,
but it is also effective at distant regions of the root canal
system.19,20 For this reason, SWEEPS only requires positioning of the tip in the access cavity to stream the irrigant
into all of the endodontic space at the same time. This is
different to other techniques, which require needle or tip/

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Fig. 1: Tooth #12—the radiograph showed a large periapical lesion. The asymptomatic tooth was prepared with an ISO 25/.06 TF Adaptive file (Kerr Dental).
Fig. 2: Tooth #12—root canal filling was performed with mineral trioxide aggregate (ENDOSEAL MTA, Maruchi). Note the sealing of the apical ramification, possible because of the effective cleansing and decontamination of the apical terminus. There was almost complete healing after 12 months. Fig. 3: Tooth #33—
the patient showed a buccal sinus tract that radiographically corresponded to the area between tooth #32 and tooth #33. The CBCT and radiograph showed a
large periradicular lesion, especially on the distal side. Preparation was performed with a 20/.07v ProTaper Gold (F1; Dentsply Sirona). Fig. 4: Tooth #33—root
canal obturation was performed with a sealer and carrier-based gutta-percha (AH Plus and Thermafil, Dentsply Sirona). The radiographic control six months
post-op showed that several lateral canals had been filled and the healing process was in progress.

file or probe insertion up to the apical third of each canal
or so for irrigation after the root canals have been prepared. Thus, SWEEPS can be used from the initial phase
up to the final phase of the therapy, permitting a progressive decrease in the bacterial load before any file is used.
The efficacy and effectiveness of SWEEPS rely on both
chemical activation of the endodontic solutions by agitation,21,22 improving the ability of irrigants to kill bacteria
and to dissolve tissue, and mechanical flushing action to
clean the root canal wall.23,24
Researchers have found the SWEEPS dual modality to
be more effective than the single-pulse modality SSP
(super-short pulse; PIPS, photon-induced photoacous-

tic streaming).25–28 Using the SWEEPS dual-pulse modality, the sudden expansion of the second bubble,
generated by the second laser pulse, exerts additional
pressure on the first bubble, leading to its violent collapse, during which shock waves are emitted also in
very small canals. Furthermore, shock waves are emitted from the collapsing secondary cavitation bubbles
that form naturally throughout the entire length of the
canal during laser-activated irrigation.25–29 The secondary cavitation bubbles are in close proximity to the canal
walls during their collapse, generating shear stress and
vortical flows that are able to remove debris, the smear
layer and biofilm from the root canal surface, as well as
from undetected and uninstrumented anatomical areas,
such as isthmuses, lateral canals, loops and ramifications, thereby increasing the cleaning and decontamination mechanism even further (Figs. 1–4). The enhanced
pressure generation along the root canal consequently
also increases the depth of penetration of irrigants into
dentinal tubules.25–28

Clinical protocols

5
Fig. 5: Proper isolation for SWEEPS is important. A liquid dam was interlocked beneath the dam clamp. Traditional access cavity preparation of the
maxillary first molar was performed using a cylindrical or round diamond bur
under magnification (4.5–6.0 x).

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2 2022

Proper patient draping with a waterproof bib to protect
clothing is highly recommended. Local anaesthesia is
performed in all cases (asymptomatic and symptomatic)
to avoid any unpleasant sensation of internal pressure
during the treatment. A dental dam is then applied, and
a liquid dam is interlocked beneath the clamp to ensure
complete isolation (Fig. 5). In case of occlusal or proximal decay or a defective filling, complete removal of the
carious tissue and filling must be performed, followed by
composite reconstruction of the entire tooth crown; this

[13] =>

research

preliminary step is mandatory to minimise leakage and
reinfection. Furthermore, good marginal sealing prevents
any irrigant extrusion during laser-activated irrigation.
Access cavity preparation
At this point, the access cavity is opened using a small
carbide, or cylindrical or round diamond bur under magnification (4.5–6.0 x). Traditional access cavity preparation, following the laws of centrality and concentricity, is
advisable (Fig. 5).30 Several studies have demonstrated
the lack of usefulness of ultra-conservative “ninja” access cavity preparation in terms of fracture strength and
preservation of the original canal anatomy during shaping
compared with traditional access cavity preparation, particularly at the apical level. Furthermore, standardised access cavity preparation is advisable when the X-SWEEPS
modality is chosen for laser-activated irrigation. Future
publications will explain this topic in depth in order to establish the correct laser settings to be used with standardised access cavity preparation volumes. Whatever
the pathology is, the concept is to minimise the root
canal shaping, optimising the cleansing and decontamination of the endodontic space by exploiting the chemomechanical flushing of SWEEPS. The main difference
between asymptomatic and symptomatic pulpitis and
apical periodontitis therapy is in the longer or shorter initial NaOCl SWEEPS-activated irrigation phase. Retreatment also involves a few differences in the energy applied during the initial phase when filling material has to
be removed.
Asymptomatic and symptomatic irreversible pulpitis
In the case of irreversible pulpitis, the pulp is irreversibly
inflamed, with or without acute symptoms. The patient’s
age and preoperative radiograph give information on a
possible immature apex; this condition contra-indicates a
full-power SWEEPS irrigation and suggests a more careful intervention and lowering of the energy used (more to
follow). Once the pulp chamber has been opened, excessive bleeding may be present, indicating the presence of inflamed pulp tissue inside the chamber and root
canals. In this case, one-visit therapy is advisable. The
treatment starts with NaOCl irrigation by syringe (3–5 ml)
and simultaneous activation by Er:YAG laser (2,940 nm;
LightWalker AT, Fotona), using the dual-pulse (25 µs duration) Auto-SWEEPS modality for 30–40 seconds. The
resting time after irrigation can be extended to 1–2 minutes to allow more NaOCl pulp dissolution. A flat- or
radial-ended SWEEPS tip (400 μ) is used. The pulp tissue
may show different grades (levels) of inflammation, up to
initial necrotic degeneration. It is important to consider at
this stage whether the pulp tissue itself is preventing any
extrusion of the irrigant so that full-power Auto-SWEEPS
activation (20 mJ at 15 Hz and 0.6 W) can be performed
up to almost complete pulp dissolution, which is indicated by a progressive decrease in bleeding. According
to the tooth type and condition, this initial phase can be

6
Fig. 6: After the cavity access has been prepared, laser-activated irrigation of NaOCl using
SWEEPS is performed in the access cavity. Then lubricant gel containing urea peroxide is
placed on the file (or in the cavity) to lubricate and avoid tissue plugging when sliding the file to
the apical constriction. (Courtesy of Dr Giovanni Olivi)

repeated for two to three cycles for single-rooted teeth
and up to three or four cycles for premolars and molars.
The initial irrigation phase also decreases the bacterial
load. The access cavity can now be observed under
magnification (6–10 x) in order to locate all canal orifices. If
the orifices are not all visible, the use of ultrasonic tips can
easily discover orifices hidden under calcification in the
pulp chamber. These are usually located at the angles, at
the floor–wall junction and at the terminus of the root developmental fusion lines. Then pre-flaring of the orifices
and enlarging of the coronal thirds of the canals allow
easy and direct access to the canals. Subsequently, a
direct glide path to the apical third is established by hand
or dedicated rotary instruments, up to 3–4 mm from the
apex. This manual or rotary instrument step produces
debris and dentine chips that must be removed by AutoSWEEPS NaOCl irrigation, again for 30–40 seconds,
followed by 30 seconds of resting time. At this point, use
of a small stainless-steel hand file (ISO 06 to 10) is recommended with a cream containing urea peroxide or
EDTA to lubricate and avoid tissue plugging when sliding the file to the anatomical opening to scout the canal
and determine the anatomical length (Fig. 6). It must be
emphasised that by now most of the pulp tissue will have
already been dissolved by NaOCl and the possibility of
dislodging pulp remnants or debris inside unreachable
anatomical areas is very difficult if the previous phases
have been correctly followed. Also, the bacterial load is
highly decreased so that apical transportation of bacteria is minimal or absent. Use of an electronic apex locator
and radiographic confirmation provide verification of the
anatomical length of the tooth.
Different approaches to the apical constriction can be
used: working to the anatomical length or 1 mm shorter,

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2 2022

[14] =>

| research
can be done occasionally during check-ups with radiographic control. It ranges from minimal lamina dura dilatation to larger periapical radiolucent lesions. If symptomatic, the tooth presents with a painful dull ache,
intermittent pain, gingivae that can be sore to the touch,
up to excruciating pain in cases of flare-ups, possible
buccal swelling and a possible visible buccal sinus tract,
and the tooth is tender to percussion. More frequently,
such a tooth has undergone previous dental treatments,
such as a full-crown or deep restoration with or without
recurrent caries, and may have untreated deep decay
(cavity) extending to the pulp chamber. In this case, carious removal and cavity filling reconstruction are preliminarily performed as previously mentioned.

8
Fig. 7: In order to prevent possible over-instrumentation of the apex with enlarging of the
apical opening, the authors suggest working to 1 mm shorter than the anatomical length.
Fig. 8: Recapitulation with the smaller first instrument (ISO 06 or 08) is performed to the apical anatomical constriction (working length + 1 mm) to ensure apical patency and remove any
possible dentinal plugs produced during instrumentation. The last millimetre is just cleansed
and disinfected by SWEEPS. (Courtesy of Dr Giovanni Olivi)

in order to prevent possible over-instrumentation of the
apex with enlarging of the apical opening. This is one reason for possible extrusion at the end of treatment (Fig. 7).
At this point, the canals can be minimally prepared. Because SWEEPS technology does not require the tip to
be placed in the canal, it is not necessary to prepare the
canals to a large size. This results in a more conservative
and biomimetic result: 20/.06 and 25/.06 are sufficient
to warrant a hermetic apical obturation. These two or
three mechanical preparation steps are always alternated
with Auto-SWEEPS NaOCl irrigation and recapitulation
with the smaller first instrument (ISO 06 or 08) used at
the apical anatomical constriction to ensure apical patency and remove any possible dentinal plugs produced
during instrumentation (Fig. 8).
Asymptomatic and symptomatic apical periodontitis
Chronic pathology can last for years without symptoms
and without temperature hypersensitivity, and diagnosis

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2 2022

When creating the access cavity, the chamber and the
canals are usually empty, with no pulp tissue. Sometimes,
especially in molars, the pulp condition can differ from
one canal to another. Some may present with minimal
bleeding. In case of swelling and a periapical abscess,
pus may flow out of the tooth from the opening into the
canal orifices. Treatment starts with two to three cycles
of saline irrigation (3–5 ml by syringe) and simultaneous
activation by Er:YAG laser (2,940 nm; LightWalker AT),
using the dual-pulse (25 µs duration) Auto-SWEEPS modality for 30–40 seconds, at 20 mJ and 15 Hz. This preliminary irrigation with saline, besides its initial cleansing
and antibacterial action,33 helps to test the patency of the
apical constriction to the pressure applied. Frequently,
chronic periapical inflammation can lead to an enlargement of the apical constriction so that irrigant extrusion
can occur, especially in cases of apical contraction larger
than ISO 40–50. Then NaOCl irrigation is activated by
Auto-SWEEPS, using a low energy, 10 mJ, at 15 Hz for
30 seconds to start the decontamination and lubrication
of the canals prior to using the ISO 10 hand file to explore the canal and verify patency and anatomical length.
Once apical patency and working length are established,
new NaOCl irrigation activated by Auto-SWEEPS is performed. The possibility of decreasing the energy output from 20 mJ to 15 or 10 mJ allows reduction of the
streaming pressure to the apex. However, the dual-pulse
Auto-SWEEPS modality promoted an almost constant
flow rate for different pulse energies of between 10 mJ
and 20 mJ, compared with the single-pulse modality
SSP, indicating superior safety of Auto-SWEEPS regardless of the pulse energy.29
Furthermore, the pressure efficacy is higher for a smaller
fibre tip diameter (400 vs 600 µ), and radial-ended fibre
tips are slightly less effective for generating pressure in
comparison with cylindrical tips.28 To simplify, in case of a
larger apical size, it is suggested to use the Auto-SWEEPS
modality with a larger size tip (600 µ), preferably with the
radial-ended tip (X-Pulse). This management of energy
and tip choice allow beginner users to work carefully in
case of altered apical anatomies. When the apical open-

[15] =>

research

ing is more than ISO 40–50, a simple operation that permits control of any unwanted irrigant extrusion is the use
of a particularly smooth needle file of different calibres
(from ISO 40 to ISO 100). The apical end closes the apical opening of the canal while laterally all the irrigant flows
throughout the canal.

Calcified canals
Sometimes canal restrictions and calcifications, due to
tertiary dentine formation, may be found, hindering the
negotiation of the canal (Figs. 9 & 10). In case of a multirooted tooth, another canal may be accessible and the
usual protocol can be applied up to completion of root
canal filling (Figs. 11–13). In a separate session, the calcified canal is irrigated by EDTA solution, activated and
forced by full-power Auto-SWEEPS, at 40 mJ and 15 Hz
(Figs. 14 & 15). The single-pulse USP mode (25 µs) can
also be more effective for pressure generation. Note that,
if the canal is obstructed by calcification while the other
canals have already been prepared with files, this procedure at higher energy is very safe. EDTA in this case is
used to chelate and soften the dentine, but sometimes
the use of a thin, rigid ultrasonic tip is necessary to remove the calcification in the coronal third. Stainless-steel
hand files with EDTA gel can be used to help bypass the
blockage in the middle and apical thirds.

Final irrigation protocol
At the end of the preparation and before the final irrigation protocol, the root canal system has already been
cleansed and disinfected by the SWEEPS protocol used
from the beginning of the therapy. Further research is required to confirm the reported efficacy and effectiveness
of SWEEPS’s cleansing ability and pressure generation
regarding decontamination. Several researchers have reported the superior decontamination results of the SSP
modality using PIPS.34–36 Therefore, this evidence-based
protocol is used for the final NaOCl disinfection (Fig. 16).
Continue using the tip size and shape (flat- or radialended) chosen:
– Two cycles of 30-second EDTA (15–17 %) irrigation by
syringe is performed, delivered in the access cavity and
activated by Auto-SWEEPS at 20 mJ and 15 Hz. In case
of an open apex, the energy can be reduced to 15 or
10 mJ. Each cycle is followed by 30 seconds of resting
time, to allow the solution to react on the dentinal walls.
At this point, gutta-percha points can be tested after
calibrating length and apical size. Apical friction and
retention should be checked and adjustments made if
necessary. This simple operation contributes, with its
hand dynamic action, to irrigation efficacy.
– One cycle of 30-second irrigation with distilled water
(or water directly from the 0/1 laser spray) is performed
to rinse the canals before the final decontamination.

Fig. 9: The symptomatic maxillary second premolar showed a periapical
lesion on radiographic examination. The preparation of the buccal and
palatal canals was performed with a 25/.08v ProTaper Gold (F2) to 4 mm
short of the radiographic apex. A size 10 hand instrument was used up to
2 mm short of the apex. Fig. 10: The calcified canals hindered the negotiation of the apical constriction. Full-power Auto-SWEEPS (40 mJ, 15 Hz)
activation of 15% EDTA solution was able to force through the blockage
to cleanse and disinfect the last 2 mm of the confluent curved canals.
Obturation was performed with Thermafil and AH Plus sealer. Fig. 11: A
symptomatic maxillary first molar with large mesioocclusal decay and a
large periapical lesion. Fig. 12: Root canal preparation was performed
with a 25/.06 ProTaper Next X2 (Dentsply Sirona) in the buccal canals
and 40/.06 X4 in the palatal canal, which demonstrated pre-existing apical resorption. Obturation was performed with EndoSequence BC Sealer
(Brasseler) and gutta-percha. The first and second mesiobuccal canals
merged into one unique larger canal in the apical third. Fig. 13: The
three-month post-op radiographic examination showed that healing was
progressing rapidly. Fig. 14: Radiograph showing deep distal caries with
a large periapical lesion on symptomatic tooth #47. The mandibular molar
presented with a typical C-shaped canal, and it was prepared with an
ISO 25/.06 TF Adaptive file. Fig. 15: Auto-SWEEPS (20 mJ, 15 Hz) activation of 4% NaOCl and 15% EDTA solution was able to dissolve the
tissue and debris from the complex radicular anatomy, allowing a sealer
(EndoREZ, Ultradent) to fill the full endodontic space (five-month post-op
radiograph).

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2 2022

[16] =>

| research
SWEEPS promotes fluid streaming throughout the entire
root canal system, even in the microscopic areas that
conventional treatments cannot reach. The chemomechanical flushing action of SWEEPS produces superior
cleansing and decontaminating action over conventional
irrigation methods, reducing the need for canal shaping
and allowing new flowable sealer and gutta-percha to
obturate the endodontic space three-dimensionally. In
this way, the root canal preparation size can be minimised, preserving more dental structure without losing
the efficacious action of the irrigants.
Editorial note: A list of references is available from the publisher.
16
Fig. 16: SWEEPS final irrigation protocol: at the end of therapy, the final irrigation protocol entails two cycles of 17% EDTA activated by Auto-SWEEPS for 30 seconds each and 30 seconds
of resting time, followed by rinsing with distilled water activated by SWEEPS for 30 seconds,
then three cycles of 5% NaOCl activated by USP/SSP for 30 seconds each and a resting time
of at least 30 seconds. A final distilled water rinse completes the protocol.

– Three cycles of 30-second NaOCl (5% minimum) irrigation using a syringe is performed, delivered in the
access cavity and activated by SSP at 20 mJ and 15 Hz.
The resting time after each cycle can be easily extended from 30 seconds up to 120 seconds, if needed
(acute infection). The energy can be reduced to 15 or
10 mJ in order to prevent any risk of extrusion. If the
apical size is larger than ISO 40–50, a thin, smooth file
of the same apical master size is chosen to occlude
the apical terminus before the disinfection cycles start.
– Before obturation, the canals must be rinsed with distilled water agitated by laser and dried using sterile paper points.
Root canal filling
The final obturation can be performed as usual. However,
the use of flowable sealer is recommended to better fill
the previously inaccessible endodontic areas, the cleansing and decontamination of which were made possible
by SWEEPS. Additionally, the proven combination of
carrier-based gutta-percha and warm vertical condensation is recommended for complete 3D obturation.

Conclusion
Er:YAG laser, in vivo at very low energy, combined with
the innovative dual-pulse SWEEPS technology, allows
further optimisation of the already effective SSP procedure (PIPS) during root canal therapy in everyday practice. The ability to effectively activate the irrigants directly
at start of the root canal therapy plays an important role
in the advantage of laser-activated cleansing and decontamination over the conventional chemomechanical preparation. SWEEPS promotes shock wave energy
to clean and disinfect the root canal system with fewer
files than needed during standard root canal therapy.

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2 2022

about
Dr Giovanni Olivi graduated cum laude in Medicine and Surgery
(MD) from the Università Cattolica del Sacro Cuore in Rome in Italy
and in Dentistry (DDS) from the University of Rome Tor Vergata.
He is a contracted professor and scientific coordinator of the
laser dentistry proficiency course and Master of Science in Laser
Dentistry at the Università Cattolica del Sacro Cuore in Rome.
He is the President of the International Academy of Innovative
Dentistry and an active member of the Italian Society of Endodontics.
Dr Linhlan Nguyen completed her BDS at the University of
Sydney in Australia in 1996, a Master in Laser Dentistry at the
Laser and Health Academy in 2017 and is currently completing
a Master of Science in Laser Dentistry at the Università Cattolica
del Sacro Cuore. She has been a fellow of the International
Congress of Oral Implantologists since 2015 and the International
Academy for Dental-Facial Esthetics since 2016.
Dr Matteo Olivi graduated in Dental Medicine from the Victor
Babes˛ University of Medicine and Pharmacy in Timis˛oara in
Romania. He obtained the European Master Degree in Oral Laser
Applications from La Sapienza University of Rome. Dr Olivi is
co-author of several peer-reviewed articles and books on laser
dentistry topics and a member of the Italian Society of Endodontics.
Dr Jason Pang completed his BSc in Biomedical Science in
1994 at the University of Technology Sydney in Australia, receiving
a university medal. He completed his BDS at the University
of Sydney in 2002, a Master in Laser Dentistry at the Laser
and Health Academy in 2017 and is currently completing
a Master of Science in Laser Dentistry at the Università Cattolica
del Sacro Cuore. Dr Pang is chairman of the Australian study club
of the Academy of Laser Dentistry.

contact
Dr Giovanni Olivi
InLaser Dental Practice
Piazza Francesco Cucchi 3
00152 Rome, Italy
+39 06 5809315
olivi@inlaser.it

[17] =>

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[18] =>

| case report

Less-Prep Endo—
is a paradigm shift in root canal
preparation ahead of us?
Dr Bartlomiej Kara ś, Poland

In vitro trials—Fig. 1: Pre-op radiograph of a mandibular molar showing the isthmus, ramifications and lateral canals. Fig. 2: Post-op radiograph of the
same mandibular molar showing the isthmus, ramifications and lateral canals filled with the sealer. Figs. 3– 5: Post-op radiograph of a mandibular molar.
Fig. 6: Post-op radiograph of a maxillary molar.

Introduction
Lasers were introduced to dentistry in 1965 by Leon
Goldman. The first application was a failure because of
excessive thermal damage. We can only wonder whether
Goldman was aware of the major advancement he had
made for the twenty-first century dentistry. More than
five decades later, different types of lasers are very commonly used in different branches of dentistry, for tissue
conditioning, regeneration, gingival surgery, restorative
dentistry, debonding of prosthodontic crowns and
bridges, and endodontics.
Since 1974, when Herbert Schilder established his
principles of root canal shaping as the main approach
to endodontic treatment, almost nothing has changed.
We all try to perform root canal shaping procedures
to achieve a tapered preparation shape, keep the apical
foramen as small as possible and prepare the space for
irrigants to perform successive disinfection of the root
canal systems. Unfortunately, the root canal shaping
procedure does not enable the removal of all the infected
tissue from the root canal and using rotary files produces
a great deal of hard-tissue debris, which accumulates
in isthmuses, fins, ramifications and accessory canals.
Although the conventional procedure has drawbacks,
so far we have not known of a better procedure.

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2 2022

Various concepts for root canal shaping and irrigation
protocols have been introduced that are intended to
eliminate the vast majority of the hard-tissue debris.
Techniques such as the in and out technique introduced
by Grzegorz Witkowski were developed to eliminate
much more debris during instrumentation than the most
commonly used multiple-stroke mechanical preparation
does. Shaping protocols with continuous flow of sodium
hypochlorite (NaClO) have also been introduced. Finally,
the GentleWave irrigation device (Sonendo) has been
introduced, preceded by much less preparation of the
root canal space than we are used to.
The introduction of lasers to dentistry was not promising
in the very beginning, especially in endodontic treatment.
The issue of thermal damage caused by ruby lasers
meant that these kinds of lasers could not be used
for root canal disinfection. Fortunately, the development
of new laser technologies resulted in laser devices
suitable for root canal therapy, especially laser-activated
irrigation.
In light of the above, I have developed a new shaping and
irrigation protocol, the Less-Prep Endo (LPE) concept
(Table 1). In this article, I will discuss the origin of the
idea, the first in vitro trials of the LPE concept and cases
performed according to this protocol.

[19] =>

case report

The origin
Micro-CT scans allowed clinicians to improve their
knowledge about the complexity of the root canal system.
This kind of image can help the clinician to understand
the network of blood vessels inside the roots, especially
in the molars. Comparison of micro-CT scans with radiographs available on the internet reveals that there is a
visible difference between the micro-CT scans and the
postoperative radiographs regarding the quality of obturation. The most visible difference is in the area of the
apical delta and isthmuses between the canals. This difference led us to deduce that, even though root canal
therapy procedures are very successful, a great deal of
root canal space is not cleaned of hard-tissue debris and
filled with obturation material.
Fotona’s SWEEPS (shock wave enhanced emission
photoacoustic streaming) technology is based on a laser
pulse with a wavelength of 2,940 nm for a few micro
seconds. This very short laser pulse creates a great deal
of energy, producing bubbles which collide with each
other and collapse, creating a shock wave. This concept
is described in the literature as the one of the most
effective in terms of hard-tissue debris removal and
disinfection of dentinal tubules.

In vitro trials (Figs. 1–6)
The first trials of the LPE concept were performed on
extracted human molars. Although the dynamics of
fluid during root canal irrigation are completely different
in vivo than in extracted teeth, these kinds of trials
provide initial information about the procedure. Some of
these teeth had apices closed with a coat of wax and
composite resin to close the apical delta and simulate
the periapical tissue. After creation of the access cavity,
the pulp chamber was cleaned with continuous irrigation with 5.25% NaClO activated with a SkyPulse laser
(Fotona) in AutoSWEEPS mode (20 Hz, 15 mJ). A 25/.07
reciprocating file (Shenzhen Perfect Medical Instruments)
was used to perform the pre-flaring procedure. After
opening the coronal third, continuous irrigation with
5.25% NaClO activated with the laser was used to clear
the debris for 30 seconds. After removing the debris,
a #10 C-PILOT file (VDW) was used to establish apical
patency, without forcing the file if possible. In some
cases, apical patency was reached already at this stage

of root canal preparation. In all cases, the second step
of instrumentation was the preparation of the middle
third with the same file, and the same irrigation pro
cedure was performed. Subsequently, the C-PILOT file
was used to reach the apical foramen. At this stage,
apical patency was reached in most cases, but in some
roots, there was no possibility of entering the apical
foramen. The working length was confirmed with a radiograph with the hand file. Usually, the next procedure
to be done is apical preparation, but the LPE concept is
based on an enhanced irrigation protocol. Following this
protocol, irrigation was performed for 5 minutes with
continuous flow of 5.25% NaClO activated with the
SkyPulse laser in AutoSWEEPS mode (20 Hz, 20 mJ)
with a conical sapphire fibre. The next step was alternating
irrigation with 17% EDTA for 30 seconds, with 5.25% NaClO
for 30 seconds and with 17% EDTA for 30 seconds, all
activated with AutoSWEEPS, followed by irrigation for
another 5 minutes with 5.25% NaClO activated with
AutoSWEEPS. In most cases, the next step after this
stage of enhanced irrigation was the calibration of the
apical constriction rather than apical preparation per se,
but this step requires further investigation.
LPE sequence:
1. Pre-flaring up to size 25/.06 or 30/.08 (or with your
favourite orifice opener)
2. Irrigation with NaClO with SWEEPS activation for
10–15 seconds
3. Instrumentation to two-thirds of estimated working
length up to size 25/.06, 25/.07 or 25/.08
4. Establishing patency with a #10 hand file (if possible
at this stage)
5. LPE enhanced irrigation protocol
6. Establishing patency with a #10 hand file
7. Apical preparation (an apical gauging procedure can
be useful)
8. Final irrigation protocol

Apical preparation
During the in vitro stage, different protocols for shaping
the apical third were used. In some cases, only the coronal and middle thirds of the roots were prepared; in some
cases, apical preparation was performed only with a #15
K-file; and in some cases, the preparation was performed
with a 25/.07 reciprocating file. No significant difference
was observed in terms of the apical extrusion of the

Table 1: Less-Prep Endo enhanced irrigation protocol.
Time

5 minutes

30 seconds

5 minutes

Irrigant

5.25% NaClO

17% EDTA

5.25% NaClO

17% EDTA

5.25% NaClO

NaClO = sodium hypochlorite.

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2 2022

[20] =>

| case report

7

8

9

10

11

12

13

14

15

16

17

20

21

23

20

18

24

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2 2022

19

22

25

26

[21] =>

case report

Case 1—Fig. 7: Pre-op CBCT image showing a radiolucency above the apical parts of the MB roots of the maxillary first and second molars. Fig. 8: Pre-op
CBCT image showing a radiolucency above the MB root of the maxillary first molar. The radiolucency could be seen more clearly near the expected apical
foramen of the MB2 canal. Fig. 9: Pre-op CBCT image showing a radiolucency above the MB root of the maxillary second molar. The radiolucency could be seen
more clearly near the expected apical foramen of the MB2 canal. Fig. 10: The maxillary first molar with the temporary restoration before treatment. Fig. 11: The
maxillary second molar before treatment. Fig. 12: The maxillary second molar after removal of the old restoration and after cusp reduction. Fig. 13: The maxillary
first molar after removal of the temporary restoration and after cusp reduction. Fig. 14: Temporary build-up for increasing the amount of irrigant during the
Less-Prep Endo enhanced irrigation protocol. Fig. 15: Temporary build-up for increasing the amount of irrigant during the Less-Prep Endo enhanced irrigation
protocol. Fig. 16: The MB1 canal and isthmus. Stage of locating the MB2 orifice in the second molar. No patency was reached. Fig. 17: The MB1 canal and
isthmus. Stage of locating the MB2 orifice in the first molar. Fig. 18: Scouting the orifice of the MB2 canal in the first molar. There was no possibility of establishing
apical patency. Fig. 19: The pulp chamber of the second molar. The MB2 orifice was located closer to the palatal canal. Fig. 20: The MB1 canal, isthmus and
MB2 canal. Fig. 21: The pulp chamber of the first molar with filled canals. Fig. 22: The pulp chamber of the second molar with filled canals. Fig. 23: Post-op
radiograph of both molars. Fig. 24: Post-op radiograph, distal shift, showing that the MB2 canal of the second molar was filled with the sealer. Fig. 25: Post-op
CBCT image showing three portals of exit in the mesiobuccal root of the first molar. Fig. 26: Post-op CBCT image showing two portals of exit in the mesiobuccal
root of the second molar, one isthmus in the medial part and one isthmus in the apical part of the mesiobuccal root, and part of the palatal and distobuccal roots.

sealer and the homogeneity of the sealing material, but
the sample size was too small to determine definitively
whether the LPE enhanced irrigation protocol could
replace the apical preparation stage.

LPE concept incorporated into treatment
The in vitro trials and the final radiographs guided my
modification of the instrumentation and irrigation protocol
in patient cases.

Case 1 (Figs. 7–26)
A 30-year-old female patient was referred to the office
for non-surgical retreatment of the maxillary left first and
second molars. The retreatment had been started by
another dentist, but the case was referred after an unsuccessful attempt at locating the second mesiobuccal
(MB2) canal. The CBCT imaging revealed two periapical
lesions around the mesiobuccal roots of both molars.
The retreatment was divided into two appointments.
At the first appointment, both teeth were opened, the old
restorations were removed, all the root canal orifices were
located and the first mesiobuccal (MB1), distobuccal (DB)
and palatal canals were shaped. In both teeth, the MB2
orifices were located, but the canals were not shaped.
The preparation phase was similar to that explained
earlier. During the root canal preparation phase, the hand
file was used to establish patency after each reciprocating instrument, and the canals were flushed with NaClO
activated with the SkyPulse laser in AutoSWEEPS mode
for 10–15 seconds. After reaching two-thirds of the
estimated working length with the reciprocating files, the
LPE enhanced irrigation protocol with the SkyPulse laser
was employed. The apical preparation was not performed
at this stage. Owing to a lack of time at this appointment,
the canals were flushed with EDTA and sterile water, and
a 2% solution of chlorhexidine was poured as an intra-
canal dressing. Both teeth were closed with temporary
composite restorations.

At the second appointment, the temporary restorations
were removed, and the chlorhexidine was washed out
with sterile water and EDTA. After opening the orifice of
the MB2 canal in the first molar, the operator was not able
to reach patency in the canal. Therefore, the isthmus
between the MB1 and MB2 orifices was opened with
diamond-coated ultrasonic tips. Finally, patency was reached.
Shaping the MB2 canal in the second molar was possible
only to the place of the junction with the MB1 canal. The
CBCT imaging had revealed previously that the MB2
canal should have its own lumen in the apical third, but the
place of the junction was below the curvature. The possibility of locating this space without damaging the root
was very poor. At this stage, the LPE enhanced irrigation
protocol was performed again.
After performing of the irrigation protocol, the apical
preparation was performed for all the canals. The final
irrigation protocol was performed with 5 minutes of constant flow of 5.25% NaClO, alternating with 17% EDTA
for 30 seconds, with 5.25% NaClO for 30 seconds and
17% EDTA for 30 seconds, and irrigation with 5.25%
NaClO for 5 minutes. All the irrigants were activated with
an EDDY sonic tip (VDW). After performing the periapical
radiographs, a CBCT scan was performed to confirm
the separate path of the sealer that filled previously
unprepared spaces of the MB2 canals in both teeth.
In both cases, it was clearly visible on the CBCT image
that all the previously unprepared spaces were filled
with the obturation material.

“The in vitro trials and
the final radiographs
guided my modification
of the instrumentation
and irrigation protocol.”
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| case report

Case 2—Fig. 27: Pre-op CBCT image of the mandibular first molar. Fig. 28: The mandibular first molar with the temporary restoration before treatment.
Fig. 29: The mandibular first molar after removal of the temporary restoration. Fig. 30: The mesial canals after instrumentation. Fig. 31: The distal canals
after instrumentation. Fig. 32: Gutta-percha cones fitted in all three distal canals at the same time. Fig. 33: The pulp chamber with filled canals.
Fig. 34: Post-op radiograph. Fig. 35: Post-op radiograph, distal shift, showing a close-up of the mesial root with the filled isthmus. Fig. 36: Post-op CBCT
image showing the great amount of sealer extrusion at the lateral portals of exit.

Case 2 (Figs. 27–36)

Case 3 (Figs. 37–46)

A 25-year-old female patient presented to the office owing
to constant pain related to the mandibular left first molar.
Pulp necrosis was diagnosed. After the emergency appointment, the patient was referred for complete treatment. The tooth was treated in the same manner as
described in the previous paragraphs. After creation of the
access cavity, the orifices were located. In the root chamber, the orifices of the MB, mesiolingual, DB, distomesial
and distolingual canals were present. After pre-flaring and
preparation of the middle third, the LPE enhanced irri
gation protocol with the SkyPulse laser was performed.
After the irrigation protocol in the mesial root, the irrigants
started to flow between lingual and buccal canals. Such
an observation suggested to the operator that some
space in the isthmus had been created. It is worth mentioning that at this stage apical enlargement was not performed. Final preparation of all five canals was performed
with the reciprocating file, and the final irrigation protocol
was performed as in the previous case. The radiograph
clearly revealed that the isthmus space was filled with the
sealer. The radiograph and CBCT image revealed that
there were four portals of exit in the mesial root.

A 30-year-old female patient presented to the office
owing to pain related to the maxillary right first molar.
The radiograph revealed a periapical radiolucency, indicating exacerbated chronic periapical periodontitis.
The access cavity was created with the Safe Access
and Preparation Concept burs set (Nevadent). The
pulp chamber was cleaned with 5.25% NaClO activated
with the SkyPulse laser. Four orifices were located, and
all four canals were shaped in the same sequence
described previously. The LPE enhanced irrigation
was performed with activation by the SkyPulse laser.
In the mesial root, a clean isthmus was visible, and
the irrigants started to flow between the MB1 and MB2
canals in the apical third, which was confirmed with
a micro-suction cannula. In the MB1, MB2 and DB canals, apical preparation was performed with Endostar
E3 Azure files (Poldent) up to size 25/.04 owing to the
apical curvatures. In the DB canal, patency was not
established. The final irrigation protocol was performed
in the same sequence as described before. The periapical radiograph confirmed that the isthmus was filled
with the sealer.

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case report

37

38

39

40

41

42

|

Case 3—Fig. 37: Pre-op radiograph of the maxillary first molar. Fig. 38: The maxillary first molar before treatment. Fig. 39: The maxillary first molar
after creation of the access cavity. Fig. 40: Temporary build-up for increasing the amount of irrigant during the Less-Prep Endo enhanced irrigation protocol.
The isthmus and the orifice of the MB2 canals could be seen. Fig. 41: Chemomechanical preparation before the Less-Prep Endo enhanced irrigation protocol.
Fig. 42: The orifice of the MB2 canal and the cleaned isthmus, seen in the orifice of the MB1 canal.

42

43

44

45

46

Fig. 43: The pulp chamber after root canal obturation. Fig. 44: The MB1 and MB2 canals and isthmus filled with warm gutta-percha. Fig. 45: Post-op radiograph.
Fig. 46: Post-op radiograph, distal shift, showing one isthmus in the coronal part and the second in the apical part.

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| case report

48a

48b

Case 4—Fig. 47: Pre-op radiograph showing the pulp chamber calcification. Figs. 48a & b: Pre-op CBCT image confirming calcification of the pulp chamber.
Fig. 49: The maxillary first molar with the temporary restoration before treatment. Fig. 50: Temporary build-up for increasing the amount of irrigant during
the Less-Prep Endo enhanced irrigation protocol. The pulp chamber calcification could be seen.

Case 4 (Figs. 47–60)
A 35-year-old female patient was referred to the office
owing to the lack of patency in the pulp chamber. The
periapical radiograph and CBCT image confirmed that
the pulp chamber was completely calcified. The calcification of the pulp chamber was removed with diamond-

coated ultrasonic tips. After removing the calcification,
four orifices were located and shaped in the sequence
described previously. The LPE enhanced irrigation protocol with the SkyPulse laser was performed. In this
case, the MB2 canal joined the MB1 canal approximately
4 mm before the apex and was shaped only to this
length. Apical preparation and irrigation were performed

Fig. 51: Removal of the calcification with a diamond-coated ultrasonic tip. Fig. 52: Activation of the sodium hypochlorite between the stages of ultrasonic
preparation. Fig. 53: Partially removed calcification. The orifice of the palatal canal could be seen. Fig. 54: Buccal side of the pulp chamber once
the calcification had been partially removed. No orifices could be seen yet.

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[26] =>

| case report

Fig. 55: Buccal side of the pulp chamber once the calcification had been removed. The orifices were visible but not yet patent. Fig. 56: Buccal side of the
pulp chamber once the calcification had been removed. The orifices were patent. Fig. 57: Scouting the MB2 canal. Fig. 58: View of the pulp chamber,
showing the MB1 and MB2 canals joined in the medial part.

as described previously. The periapical radiograph revealed that the MB2 canal had a separate apical part,
which was cleaned with the irrigants and filled with
the sealer, and that the palatal canal had two portals
of exit.

Discussion
The most important factor in root canal therapy is the
elimination of infection by removing the bacterial biofilm
and disinfecting the dentinal tubules. From many studies,
we know that the antibacterial activity of NaClO is very
high; however, its distribution in a very complex root canal
space can be insufficient. There are various types of

activation devices designed to enhance the penetration
of irrigants into the root canal system and promote better
disinfection.
It is very important to remember that, during root canal
therapy, the clinician has to perform numerous protocols
in the proper order and manner to achieve success. The
clinician needs to maintain apical patency, remove the
hard-tissue debris with rotary or reciprocating files during
shaping and flush the canals with irrigants between
files. After instrumentation, the smear layer has to be
removed, for which the clinician needs to use NaClO and
chelating agents. Finally, the dentinal tubules need to be
disinfected.

Fig. 59: The pulp chamber after obturation of the canals. Fig. 60: Post-op radiograph showing the apical part of the MB2 canal filled with the sealer
and the lateral canal in the palatal root.

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case report

The in vitro trials and in vivo cases, periapical radiographs
and postoperative CBCT images demonstrate that the
laser activation of irrigants allows the clinician to achieve
much better removal of the hard-tissue debris than with
the conventional irrigation methods. The LPE concept
appears promising in terms of the improved removal of
hard-tissue debris. It is important to mention that this
is only a clinical observation. The most important part
of this observation is a very rapid flow of the irrigants
between the root canals located in the same root after the
LPE enhanced irrigation protocol with the SkyPulse laser
but before apical preparation.

Conclusion
The LPE protocol is a modification of the classic root
canal shaping and irrigation protocol and consists of
two stages of irrigation and laser activation with SWEEPS
technology. According to the postoperative periapical
radiographs and CBCT images the number of isthmuses,
lateral canals and portals of exit filled with sealer is visibly
higher than after conventional protocols. This led us to
hypothesise that the amount of hard-tissue debris, infected tissue and necrotic pulp removed is much higher
than with conventional root canal therapy. It needs to be
underlined that no research has yet been performed

“The LPE protocol
is a modification of the
classic root canal shaping
and irrigation protocol.”
comparing the volume of removed hard-tissue debris
between LPE and conventional root canal therapy.
This concept requires further investigation to prove that
this protocol can improve the success rate of root canal
therapy.

contact
Dr Bartlomiej Karaś
MAXDENT
Ul. Hallera 53/2
53-325 Wrocław
Poland
kontakt@bkaras.com
AD

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| case report

The importance of irrigation
in challenging cases
Dr Marco Martignoni, Italy

disease. In fact, it is well known that mechanical instrumentation leaves untreated canal areas ranging from
10 to 50% in individual canals.2–6 In these areas, there
is the possibility for bacteria to replicate, leading to the
failure of the treatment.7 A recent article showed that
the bacterial persistence at the time of filling has a significant influence on the outcome of the treatment, regardless of the irrigating solution and the medication used,8
thus stressing the importance of eradicating as many
microorganisms as possible from the root canal system.
The synergy between mechanical preparation and irrigation is influenced by several factors, such as the fluid
properties and the volume of the irrigant, the irrigant
delivery system and its depth of placement, and the
anatomy of the root canal system.9

1

Introduction
Irrigation of root canals is key to improving the removal of
bacteria, pulp tissue, the smear layer and debris from the
root canal system,1 reducing the risk of post-treatment

Conventional needle irrigation is unable to provide good
disinfection10 because of the risk of the vapour lock effect11
and because needles can have difficulty penetrating
into narrow spaces;12 as a consequence, the difficulty in
reaching the most apical region of the canal with large
volumes of fresh irrigant may result in insufficient replacement and fluid exchange beyond the tip of the needle.13
In order to increase the efficiency of the irrigation,
the literature suggests the use of preheated solutions14

2

3

4

5

6

7

28

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case report

or activation of irrigants1 by means of ultrasonic/sonic
devices15 or negative pressure devices.16

After positioning of the dental dam (Fig. 2), the existing
composite filling in the centre of the crown was removed
using a diamond-coated bur driven by a high-speed
handpiece. In this way, the access cavity was created
and refined in order to see the pulp chamber (Fig. 3).
The existing root canal filling was removed using rotary
instruments specifically designed for retreatment, and
then ultrasonic tips were used to remove the remnants
on the pulp chamber floor. The chamber was filled with
5% sodium hypochlorite (Fig. 4), and the second mesiobuccal canal, which had not been shaped, cleaned or
filled during the initial treatment, was located and shaped
according to the standard protocol.

The closer the needle is to the working length, the greater
the irrigation is. For this reason, using products that follow the anatomy of the prepared root canal can help in
this clinical step. However, the flux must not be violent,
in order to decrease the risk of extruding debris into the
periapical tissue.17
Several articles have described the use of a novel polypropylene needle (IrriFlex, Produits Dentaires) characterised by a back-to-back side vent design that helps
the clinician irrigate the root canal space efficiently and
safely. This product, with its 30-gauge tip, has the advantages of reaching the working length effortlessly and
of bringing a high volume of irrigant close to the apex.
The product has been shown to be effective in curved
canals, but what about challenging cases? The following
case reports demonstrate the use of IrriFlex in two different scenarios: a retreatment and a primary treatment
of a calcified canal.

Case 1
A 62-year-old patient was referred to our clinic for endodontic retreatment. The patient reported swelling of
the maxillary left gingiva. The radiographic examination
revealed the results of a previous endodontic therapy and
the presence of periapical radiolucencies (Fig. 1). Since
the results of the previous therapy could be improved,
we decided to retreat the tooth, passing through the
existing crown.

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Considering the presence of an endodontic lesion
and swelling, a great deal of time was dedicated to
decontamination of the root canal system (Fig. 5).18
The device chosen to deliver the irrigating solution to
the working length was IrriFlex (Figs. 6 & 7) because,
thanks to its flexibility, it would be able to deliver the
irrigant to the apical third of each root, without any effort,
without stopping in case of curvatures. The irrigant was
then activated by means of ultrasonic inserts19 according
to the indications given by Tonini and Cerutti.12

After ensuring that the root canals were dry, they were
filled according to the warm gutta-percha compaction
technique (Figs. 8–10). After that, the access cavity was
filled by means of a direct composite restoration (Fig. 11)
and a postoperative radiograph was taken in order to
check the final result (Fig. 12).

Case 2
A 50-year-old patient came to our office because of
an emergency: while eating, he had broken tooth #22
and he was not able to find the fragment (Fig. 13). The
fracture had exposed the pulp and the patient reported
spontaneous and acute pain. The preoperative radiograph showed that the tooth had a very thin canal lumen
(Fig. 14) and sufficient bone support. It was thus decided
to do an endodontic treatment followed by restoration
with a prosthetic crown.
As a first step of the therapy, a dental dam was positioned
directly around the remaining tooth structure and the
root canal therapy was started. The access cavity was
created, and the root canal opening was located and

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case report

enlarged using ultrasonic tips. Then nickel–titanium rotary
instruments were used to complete the shaping of
this narrow root canal space (Fig. 15). Multiple irrigation
sequences were repeated using IrriFlex and ultrasonic
activation of the sodium hypochlorite, both in order to
have the endodontic instruments work in the presence of
an irrigating solution and to decrease the bacterial load.20
The great advantage of using a polypropylene irrigation
cannula was that, once the last shaping instrument had
reached the working length, the cannula reached the
working length smoothly too (Figs. 16 & 17), allowing
the dentist to bring the irrigant as close as possible to
the apical constriction.1
When the root canal walls looked sufficiently clean and
shiny, obturation with warm gutta-percha was performed.
As a last step of the endodontic treatment, a build-up was
done with composite (Fig. 18) and a periapical radiograph
was taken (Fig. 19).

Conclusion
The same experienced practitioner performed the two root
canal therapies reported in this article. The cases were
extremely different, an initial treatment of a single-rooted
tooth and a retreatment of a multi-rooted tooth, but
both of them were challenging. The instruments and the
sequences used for shaping the root canal system differed
between the cases, since the root canal taper was different and the apical size of the lateral incisor was discernibly
smaller than that of the molar.
The thing that did not change in the approach to these
cases was the attention paid to the irrigation step. In the
retreatment, the eradication of bacteria was the key to
success in a tooth that had already received an endodontic
treatment that had failed, whereas in the lateral incisor,
the presence of a narrow canal made it more difficult to
clean the complexity of the root canal system.21

In both cases, the use of a flexible irrigation cannula that
follows the path created by the endodontic instruments precisely made the treatment easier and reduced operating
times, because it was possible to deliver a large volume of irri
gating solution where it was needed the most. The presence
of length marks on the cannula helped the clinician establish
the needle penetration inside the root canal; the yellow stop
was put on the cannula to emphasise the correspondence
between working length and IrriFlex depth of penetration inside the prepared canal. Obturation with warm gutta-percha
was performed in order to seal the root canal space in 3D,
and the choice to restore both teeth in the same appointment
as that of the root canal therapy was meant to prevent coronal leakage often associated with provisional restorations.
Editorial note: A list of references is available from the publisher.

about
Dr Marco Martignoni graduated
from the Gabriele d’Annunzio University
of Chieti–Pescara in Italy in 1988.
From 1989 through 1991, he completed
continuing education courses at the
Boston University Henry M. Goldman
School of Dental Medicine in the US,
presented by Dr Herbert Schilder.
In 1992, he completed a continuing
education programme presented by Dr Cliff Ruddle in
Santa Barbara in the US. He runs a private clinic in Rome in Italy,
and the practice is dedicated mainly to endodontics,
pre-prosthetic core build-ups and prosthodontics. Dr Martignoni has
conducted and published research on post-endodontic core
build-ups. He is a well-known speaker and has given numerous
lectures and practical workshops in Italy and worldwide on
endodontics, on core build-ups and on the use of the operating
microscope in dentistry. He is founder of the Accademia
Italiana di Odontoiatria Microscopica (Italian academy of
microscopic dentistry) and an honorary member of the
Société Française d’Endodontie (French society of endodontics).

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| case report

Treatment of compromised teeth:
The usual suspects
Drs Robert E. Grover & Kenneth S. Serota, Canada

Introduction
The unceasing innovations and iterations in dental technologies and materials have taken the sophistication of
treatment modalities to a historic level. However, when
we are focused on the newness, the thrill of the outcome,
we fail to pay attention to the purpose of the activity.
A case in point is dental implants. These were initially
considered the gold standard for compromised tooth
replacement despite reports that endodontic therapies
ensured functionality over time to be in the range of
91–97%.1 The newness became tarnished by reports
that peri-implantitis and peri-mucositis showed a mean
weighted prevalence rate of 43% across Europe and 22%
across South and North America.2 A myriad of factors influences the initiation and progression of peri-implant disease; unfortunately, the treatment of peri-implant disease
is at best favourable in the short term, the disease having
a high rate of persistent inflammation and recurrence.3

A study by Guarnieri et al. showed that active periodontal therapy in chronic periodontal patients followed
by long-term regular periodontal maintenance was successful in the retention of the majority of periodontally
compromised teeth.4 In the same patients, a higher
tendency for implant loss than tooth loss was found.
The series of case reports presented in this article will
provide decision guide categories for best practices
which facilitate retention of compromised teeth using
endodontic therapies.

Case report 1: CBCT in endodontics
Perhaps the most important advantage of CBCT in endodontics is that it demonstrates anatomical features in
3D that intra-oral, panoramic and cephalometric images
cannot. In addition, because reconstruction of CBCT
data is performed natively using a personal computer,
data can be reoriented in true spatial relationships.5

Case 1—Fig. 1: An area of periradicular rarefaction was evident along the mesio-proximal aspect of tooth #15. Previous root canal therapy and a pin-retained
post and core supporting a zirconia crown were noted. Fig. 2: The sagittal slice of the CBCT volume showed the lateral lesion extending to the alveolar crest.
Fig. 3: The axial slice of the CBCT volume showed the extent of the rarefaction adjacent to the mesial aspect of the root and the presence of an untreated palatal
canal. Fig. 4: Selective treatment of the palatal canal was performed. Calcium hydroxide was inserted in the canal space. Fig. 5: The extrusion of the interim
calcium hydroxide medicament through the sulcular area of tooth #15 was evident. Fig. 6: A lateral branch of the root canal space containing the obturation
material exited into the interface of the middle and apical thirds of the root. Fig. 7: A periapical radiograph taken four years after treatment showed osseous
regeneration and the reformation of the periodontal ligament. Fig. 8: The coronal slice of the CBCT volume showed the pre-op periradicular radiolucency.
Fig. 9: The coronal slice of the CBCT volume taken four years after treatment showed the resolution of the periradicular radiolucency.

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case report

Case 2—Fig. 10: Loss of bone between tooth #47 and tooth #46 and loss of the periodontal ligament around the apical region of the mesial and distal roots
were evident. Fig. 11: After resection of the distal root, the degree of bone loss appeared to have increased. Fig. 12: A 22-year follow-up showed regeneration
of the lost interproximal bone and cortication of the alveolar crest.

In October 2015, a 55-year-old male patient, previously
seen for treatment in the office, self-referred for a second
opinion regarding the recommended extraction of a
suspected fractured tooth in the maxillary right quadrant.
He reported that a soft swelling had become apparent
over the past week. Clinical examination noted fluctuant
swelling between tooth #15 and tooth #14, and a 12 mm
probing defect was detected along the mesiobuccal line
angle of tooth #15.
The patient provided a periapical radiograph showing
a mesio-proximal periradicular radiolucency associated
with tooth #15 (Fig. 1). The sagittal slice of the CBCT volume (Carestream CS 9000, Carestream Dental) showed
the extent of the lesion (Fig. 2). In the previous root canal
therapy, only the buccal canal had been detected and
treated. The axial slice showed an untreated palatal canal
(Fig. 3). A fibre post placed in the buccal canal had been
used to retain the core. The patient was advised of the
misdirected anchoring pin extending into the periodontal
ligament. With the patient’s consent, it was decided to
selectively treat the palatal canal.
After an interim six-week period of calcium hydroxide therapy (UltraCal XS, Ultradent Products; Figs. 4 & 5),6 the root
canal space was obturated using a warm vertical condensation technique.7 The obturation material was expressed
into a lateral branching portal of exit (Fig. 6). The four-year
follow-up showed resolution of the lateral lesion (Figs. 7–9).
The initial presumption of a fractured root was proven
false, suggesting that diagnosing conditions based on
insufficient data acquisition is unreliable. The use of CBCT
is an imperative in endodontic procedures of any kind provided ALARA (as low as reasonably achievable) principles
regarding radiation dose are followed.

Case report 2: Root amputation
(periodontal and endodontic lesion)
Root resection is a treatment option for molars
with advanced furcation involvement. In a study by

Derks et al., mandibular molars after root resection
showed a survival probability of almost 80% even
20 years later.8
In October 1998, a 39-year-old male patient presented
to the office complaining of gingival tenderness in the
mandibular right quadrant. Extensive bone loss was
noted interproximally between tooth #47 and tooth #46;
however, the periodontal status of the dentition in general was within normal limits. Pulp sensibility testing of
the teeth in the mandibular right quadrant identified
the pulp of tooth #46 to be necrotic (Fig. 10). It was explained to the patient that treatment of periodontal and
endodontic lesions was in general unfavourable and
that success depended on the severity of bone loss,
root trunk length, degree of root separation, curvature of
the root to be resected, ability to eradicate the osseous
defect, pulpal status, and restorative and oral hygiene
procedures required.
With the patient’s consent, the distal root of tooth #46
was resected and the overlying crown portion retained
(Fig. 11). At some point after the amputation procedure,
the referring dentist splinted teeth #47 and 46 with a composite and Ribbond bridge. Twenty-two years after the
initial procedure, osseous regeneration and cortication
in the furcal region were evident between teeth #47
and 46 (Fig. 12).
Advancements in strategies to maintain compromised
teeth in concert with a greater understanding of risk factors associated with dental implants invite a reassessment of the benefits of strategic extraction of a tooth
with a questionable prognosis or of limited strategic
value.9 With the use of hard- and soft-tissue augmentation procedures, platelet-rich fibrin, minimally invasive
flap design and suturing techniques in conjunction with
surgical operating microscopes, it is unreasonable to
sacrifice a tooth for an implant when this venerable
treatment option shows favourable prognosis and
success rates.10

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| case report
Case report 3: Resorptive defect
Progressive internal resorption or those instances with
perforations of the root can be distinguished from external resorption by varied radiographic techniques. In teeth
with internal resorption, the radiolucent lesion moves with
the canal when the radiographs are taken at different angles, whereas in external resorption the radiolucent lesion
moves outside of the canal.11, 12
In March 1999, a 47-year-old female patient presented to
the office with facial swelling, and tooth #11 was tender
to percussion. A periapical radiograph of the maxillary
anterior sextant showed large Class III and IV restorations. Tooth #11 exhibited periapical rarefaction.
Tooth #21 showed internal resorption at the mid-root
level (Fig. 13). The patient reported that tooth #21 had
been traumatised some 35 years before. In the absence
of CBCT imaging, it was assumed that the resorption had
perforated the facial aspect of the root and disrupted
the overlying cortical bone.
Pulpal sensibility testing of the teeth in the anterior determined that tooth #11 was pulpless. The tooth was
endodontically treated and obturated using a warm
vertical condensation technique. Tooth #21 was instrumented to the incisal level of the resorptive defect, and
the canal sealed with white mineral trioxide aggregate
(Fig. 14).13 Were the tooth to be treated today, the choice
of obturation material would be EndoSequence BC
putty (Brasseler). Currently, there is a trend towards the
use of an injectable platelet-rich fibrin regenerative
approach to resolve internal resorptive defects that

shows great potential for long-term healing.14 Follow-up
after 21 years showed that the periradicular radiolucency associated with tooth #11 had resolved and
that the resorptive defect had been reduced in size
(Figs. 15 & 16).

Case report 4: Cracked tooth
In a study of 2,086 cracked teeth by Krell and Caplan,15
the most common teeth demonstrating fracture were
mandibular second molars (36%) followed by mandibular
first molars (27%) and maxillary first molars (18%). There
were no statistically significant differences in treatment
success based on pulpal diagnosis (irreversible pulpitis,
85%; necrosis, 80%; previously treated, 74%), patients’
age or sex, year of treatment, tooth type, restorative
material or number of restored surfaces at the time of
examination.
In July 2014, a 45-year-old female patient presented to
the office with the chief complaint of swelling in the distal
papilla of tooth #14 for a period of ten days. Clinical examination revealed an occlusal amalgam restoration with
a probeable seam in the distal marginal ridge. The probing depths along the distobuccal and lingual line angles
of the tooth demonstrated an infrabony pocket of 8 mm.
The periapical radiograph showed a small amalgam
restoration with a vertically angulated radiolucency interproximally between tooth #14 and tooth #15. A fracture
line extending into the mesial marginal ridge was identified (Figs. 17 & 18). The tooth was assessed for vitality
with thermal and electric pulp tests, which elicited no
response.

Case 3—Fig. 13: The intra-oral periapical radiograph revealed a periradicular radiolucency at the root apex of tooth #11. A large area of internal resorption
was evident mid-root of tooth #21. The resorption had perforated the lateral aspect of the root, causing disruption of the interproximal bone. Fig. 14: A post-op
radiograph showed the endodontic treatment of tooth #11. Tooth #21 was sealed with white mineral trioxide aggregate to the incisal level of the resorptive
defect, as it demonstrated minimal root discoloration. Fig. 15: The periradicular radiolucency associated with tooth #11 had resolved. The resorptive defect
was reduced, and radiolucent deposits were evident within the resorptive crypt. Fig. 16: The sagittal slice of the CBCT volume showed an intact cortical plate.
The presence of calcified deposits was evident in the residual resorptive defect, which had significantly reduced.

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case report

Case 4—Fig. 17: An 8 mm infrabony defect was evident along the distal proximal
aspect of the root of tooth #15. Fig. 18: Debris present in the distal marginal
ridge of the tooth #14 demonstrated a fracture line; however, there was no
indication of cuspal separation. Removal of the amalgam revealed extension
of the fracture into the cuspal stress plane of the buccal and axial line angle.
Fig. 19: The root canal space was obturated using a warm vertical condensation technique. Lateral branches of the root canal system were noted.
Figs. 20 & 21: A post-op periapical radiograph taken in 2020 showed osseous
regeneration and reformation of the periodontal ligament in the infrabony
defect along the distal aspect of the root.

The treatment options were explained to the patient: (1)
extraction and restoration with a three-unit fixed bridge;
(2) extraction, soft- and hard-tissue augmentation, and
implant-retained restoration; or (3) root canal therapy
and restoration with cuspal protection. The patient was
advised that the third option had a questionable prognosis; however, for financial reasons, she chose to proceed
with that option. It should be noted that management of
cracked tooth syndrome varies based on the severity of
the symptoms and depth of tooth structure involved.

“The treatment planning
process demands the
inclusion of a myriad of data
pertaining to the status of the
tooth and root structure.”
21

Endodontic therapy was performed using a warm vertical
condensation technique (Fig. 19). The access preparation was sealed with a flowable and hybrid composite
restoration using the Bioclear Matrix system developed
by Dr David Clark. The radiograph taken at a six-year
follow-up (2020) showed osseous regeneration in the
interproximal area, which had eliminated the periodontal
defect (Figs. 20 & 21).

Conclusion
The treatment planning process demands the inclusion
of a myriad of data pertaining to the status of the tooth
and root structure. The decision guide of the American
Association of Endodontists encourages the clinician
to consider local and systemic case-specific issues,
economics, the patient’s desires and needs, aesthetics,
potential adverse outcomes and ethical factors. The
treatment performed must reflect best practices for the
patient’s needs (www.aae.org/treatmentoptions).
Editorial note: A list of references is available from the publisher.

about
Dr Robert Grover is an assistant
professor in endodontics at the
University of Virginia’s Department
of Dentistry and the Virginia
Commonwealth University
School of Dentistry in the US.
He maintains a private endodontics
practice in Staunton in Virginia.
Dr Kenneth Serota is an ambassador
of the Slow Dentistry Global Network,
the Digital Dentistry Society (Canada)
and the CleanImplant Foundation.
He founded the ROOTS online forum
in 2000 and the NEXUS Facebook forum
in 2015 and practised endodontics in
Ontario in Canada for over 35 years.

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| case report

Endodontic treatment and
the magic lamp
Dr Anne Heinz, Germany

Sensitive or traumatised patients require special attention, whether they are adults or children. Sometimes
both the clinician and the patient share a common anxiety when it comes to root canal therapy—mostly out of
fear of the unknown. To reduce this fear, it helps to break
established habits and to ensure a smooth treatment
process by employing state-of-the-art endodontic assistance systems. The following case report demonstrates
how fears can be successfully reduced and how to trust
the miraculous genie of the magic lamp.
When a child enters the Dentiland dental practice for the first
time, he or she is reminded not of a dentist’s practice but

rather of a fairy tale castle (Fig. 1). This way, we break through
familiar stereotypes to put children in a trance. It is important
for children to be taken seriously and to be treated sympathetically in an environment in which they feel comfortable. Besides providing a feel-good atmosphere in child-oriented treatment rooms, our approach focuses on high-quality treatments.
When it comes to a demanding and time-consuming treatment
such as the root canal therapy of primary teeth, we are fortunate to have systems available which both simplify treatment
and save time. The dental dam has already become standard
in some paediatric dental practices, but mechanical preparation and the use of a microscope are still rare. With ritualised
behavioural guidance and by using an endodontic motor such
as the CanalPro Jeni (COLTENE; Fig. 2), successful treatment
is not a question of magic, even if the name suggests so.

Who else has a friend like me?
Like a car’s navigation system, the Jeni reliably navigates
through the prevailing anatomy of the root canal. A preprogrammed sequence of nickel–titanium (NiTi) files is
Fig. 2: The CanalPro Jeni fully automated endodontic motor. (© COLTENE)

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[37] =>

Fig. 3: Pre-op radiograph of tooth #64. (© Dr Anne Heinz) Fig. 4: The 20/.05 HyFlex EDM file. (© COLTENE) Fig. 5: The 25/~ HyFlex EDM OneFile. (© COLTENE)
Fig. 6: Sequence selection by touchscreen. (© COLTENE) Fig. 7: Post-op radiograph. (© Dr Anne Heinz)

simply selected on the touch screen. Complex algorithms
control the variable movements of the files used at millisecond intervals during this process. Blocking of the file
or wrong turns are virtually impossible with the digital
navigation aids: the software recognises obstacles immediately and sends an acoustic signal when irrigation of
the canal is recommended to rinse debris from the prepared canal. The dentist must always advance with the
contra-angle handpiece from the coronal to the apical
direction. This approach requires a little trust initially, but
makes treatment extremely reliable and efficient, par
ticularly for practice teams.
With COLTENE’s motor, fixed file sequences and key
work steps can be automated quite easily. Newcomers
in particular will benefit from the intuitive operation of
and software-supported analysis of the canal profile by
this fully automated endodontic motor.

Five simple steps
The following patient case illustrates how easy endo
dontic treatment can be using the Jeni. The patient was
a 6-year-old boy who attended Dentiland in spring this
year with complaints concerning his upper jaw. Intra-oral
diagnostics confirmed the need for treatment of tooth #64
(Fig. 3), and Type II early childhood caries was diagnosed. After detailed counselling, the patient and his
parents consented to root canal therapy.
The endodontic treatment in this case followed the five
classic steps:
1. infection control;
2. preparation;
3. irrigation and drying;
4. obturation; and
5. restoration.
Initiating the trance: after anaesthesia and application of the
dental dam, four NiTi files were used in the Jeni endodontic
motor with integrated apex localisation. First, the 25/.12
HyFlex EDM orifice opener (COLTENE) was used to prepare
the access cavity and expand it coronally. It was not necessary to create a glide path. The three subsequent files
were able to follow the natural profile of the canal in an optimal manner. The actual preparation was performed with
the 20/.05 HyFlex EDM file and 25/~ HyFlex EDM OneFile
(Figs. 4 & 5). During this process, the preset Jeni mode

moves the files steadily in the apical direction. As soon
as the beep recommends irrigation, the instruments
are withdrawn from the root canal and then reinserted
deeper than before. This procedure is repeated until
shortly before the apex is reached. In this case, the files
accomplished the working length in a single pass. Finally,
the apical third was prepared with a 40/.04 file, which was
also quickly inserted to the working length.
The parameters for the various file systems from COLTENE
have been saved in the software of the endodontic motor
(Fig. 6). Alternatively, using the Doctor’s Choice program,
individual sequences of up to eight files can be saved.
Overall, the affected tooth was prepared quickly and
reliably with the aid of the fully automated co-pilot—a true
blessing, since compliance during treatment, supported
by a reduced treatment time through a reliable workflow,
is important, particularly with (young) anxious patients.
In combination with a child-friendly and relaxing envi
ronment, this set-up eliminates much of the original
trepidation, even in the case of an endodontic treatment.
After extensive irrigation of the canal with sodium hypochlorite and drying of the canals with the appropriate paper
points, the canals were filled with calcium hydroxide and
a ceramic paediatric crown was inserted adhesively for
restoration. After checking the occlusion and articulation,
the patient was discharged satisfied and pain-free (Fig. 7).

Conclusion
Efficient, fast and reliable restoration is particularly
important for children. The Jeni’s state-of-the-art assistance systems guide the practice team step-by-step
through the preparation process by adjusting the movement of the files.

contact
Dr Anne Heinz
Dentiland
Prenzlauer Chaussee 187
16348 Wandlitz
Germany
info@dentiland.de

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| features

Building a sustainable dental practice
Dr Sanjay Haryana, Sweden

Sustainable dentistry’s two major outcomes, namely
good oral health and reduced environmental impact,
could be achieved by focusing on preventive care and
quality operative care. However, the large amount of
waste produced by the dental office daily is a problem
that needs immediate attention.

take advantage of the trickle-down effect—the spreading
of attitudes and behaviours through the core of the
organisation. The team members must understand
why the change is necessary, feel responsible for their
roles and be inspired to take part in the sustainability
journey.

Reducing emissions—a complex task

For example, switching to green energy leads to a great
impact, requires little effort and minimises interruption to
day-to-day practice. To make sustainable procurement
more manageable, it can be divided into buying less,
wasting less and switching to products and services with
a lower carbon footprint.

Dental caries and periodontitis are two of the most
common diseases globally. Thus, the primary aim of sustainable dentistry is to improve the quality of life through
preventive care and quality operative care. In order to be
able to offer this to the underprivileged part of the global
population, increased emissions are inevitable.
However, from an environmental perspective, we want
the population to have immediate access to dental care,
but we do not want patients to visit the dental practice
too often. After the manufacturing of dental supplies
and the dental waste generated in daily practice, patient
and staff travel are the largest emitters of greenhouse
gases within dentistry. Since dental appointments accumulate over a patient’s lifetime, total emissions end up
being extremely high compared with those resulting from
other healthcare treatments.
In order to decrease emissions, FDI World Dental Federation promotes source reduction through good oral
health or prevention. This is because preventive dentistry
results in fewer appointments, fewer recall visits, a reduction in materials and, consequently, less clinical waste.
Dental diseases that are preventable or are in the early
stages of progression should be targeted using individualised maintenance plans where home care should be
the centre of attention.

Sustainable procurement
Why should dental professionals strive towards sustainable dentistry? Firstly, it is the right thing to do ethically;
secondly, it is a great marketing tool; and finally, it creates
an attractive workplace for new colleagues. Before taking
steps towards creating a green dental practice and
practising green dentistry, the practitioner should understand that sustainability minimises pitfalls and simplifies
the process.
To build a sustainable dental practice, it is essential to
establish the coming change with management and

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“The primary aim of
sustainable dentistry is to
improve the quality of life
through preventive care and
quality operative care.”
Healthcare waste—a major problem
Medical and dental care generate substantial waste. The
healthcare sector is responsible for 5% of all the greenhouse gas emissions in the EU. Dental waste management
has been primarily focused on amalgam disposal, but this
is no longer the main issue. Even though it is well known that
dental practices generate great amounts of waste, there is
limited data available on the effect of this on the environment. Similarly to sustainable dentistry, dental waste management lacks a global consensus on how to tackle certain
environmental issues that are associated with dentistry.
In the day-to-day running of a dental practice, waste is
generated from all parts of the business and can be divided into three categories: household waste, hazardous
waste and clinical waste. Household waste is similar to
that which is generated in a residential environment and
should, if possible, be recycled. Hazardous waste is
considered harmful to people and/or damaging to the
environment and must be disposed of through the appropriate facility. It includes clinical waste, radiographic
solutions, amalgam and gypsum, which generates a toxic
gas during degradation in landfills.

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© IR Stone/Shutterstock.com

Clinical waste is defined as “any waste which consists
wholly or partly of human or animal tissue, blood or other
body fluids, excretions, drugs or other pharmaceutical
products, swabs or dressings, syringes, needles or other
sharp instruments”. It is also classified as hazardous and
should be incinerated.

The four Rs in dentistry
Waste management aims to protect humans and the
environment. If correctly done, it can also reduce costs
since most of the waste produced is clinical waste and
is more expensive to dispose of than household waste.
A popular way to manage waste has been to employ the
four Rs—reduce, reuse, recycle and rethink.
1. Reduce in the surgery
Many practices work with preset trays containing certain
instruments and disposable material, such as plastic
tray liners, gauze, cotton rolls and polishing paste. As
soon as the tray has been contaminated, all materials,
both used and unused, are classified as clinical waste.
Practices should review their set-up routines to minimise
the waste of unused material.
2. Reuse in the surgery
Most of the waste in dentistry consists of single-use
equipment designed to minimise cross-contamination.
There is a need for the development of novel solutions
allowing sterilisation and reuse. However, practices must
consider whether the equipment is safe for patients and
personnel and whether its production and use have
a positive impact on the environment.
3. Recycle in the surgery
This is the most challenging area since clinical waste
cannot be recycled. The most common materials found
in clinical waste are tissues, gloves and sterilisation
pouches. We should be able to establish routines that
allow us to open the pouches with clean gloves, separate

features

|

the plastic from the paper and recycle appropriately.
Small actions like this can have a positive impact on the
environment and save costs for dental practices.
4. Rethink in the surgery
Rethinking is the most important of the four Rs. Even
though reducing, reusing and recycling are the most
discussed, they do not adequately address the clinical
reality of dentistry or medicine. In order to meet the
Sustainable Development Goals of the United Nations as
set out in Agenda 2030, our suppliers must understand
the waste management system and align their dental
products and materials with the most appropriate
end-of-life procedure—incineration, landfill or recycling
(chemical or mechanical).

Moving forward
All clinical waste is destined for incineration and should,
therefore, be bio-based instead of fossil-based to reduce
net emissions. Additionally, a consensus is needed on
how to safely minimise single-use equipment. There are
many different types of plastics used in the healthcare
system, and a circular approach will never be accomplished
if they are recycled together. Our efforts in the clinical
setting will have little impact on sustainability unless there is
an alignment of equipment production, waste management
and end-of-life procedures. Only then can good oral health
and reduced environmental impact be achieved.

about
Dr Sanjay Haryana
is an education and
odontology specialist at
TePe Oral Hygiene Products.

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[40] =>

Study examines public
perceptions
regarding
sustainable dentistry
By Brendan Day, Dental Tribune International

Given the relatively high levels of material waste produced during the course of dental procedures, a more
sustainable approach to dentistry has been advocated
by many within the industry. A study from researchers at
the University of Sheffield has sought to examine how the
general public perceives the push for sustainability within
the profession and to better understand what compromises will be accepted in the name of environmentally
friendly dentistry.
The research team, which is spread across the university’s Department of Psychology and School of Clinical
Dentistry, set up an online questionnaire for participants
recruited via private dental practices and by other means.
Data regarding the participants’ views about sustainable
dentistry, as well as demographic data and information
about the participants’ overall oral health, was collected
between August 2020 and February 2021. In total,
344 adults responded to the survey.

Positive attitudes towards sustainability
Overall, the researchers found that participants responded quite positively to sustainable dentistry and
were “moderately willing to compromise time and convenience”. In addition, they were somewhat likely to agree
to pay more and receive potentially less durable dental
treatment if it meant that the treatment would be more
environmentally conscious. Respondents were least
likely to accept compromises regarding the appearance
of their teeth or their oral health status, whereas those
having better self-rated oral health were more likely to
view sustainable dentistry in a positive light.
“Participants’ ethnicity, level of education and employment status were not found to be associated with their
attitudes towards, or willingness to make compromises
for, sustainable dentistry,” the authors noted. However,
they added that, similarly to the results of previous

40

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studies conducted on attitudes about sustainability, significant differences were present in accordance with age
and gender. Older respondents were less likely to want
to compromise their time and convenience than younger
respondents, whereas women displayed more positive
attitudes regarding sustainable dentistry than men did.
Survey respondents who were registered with a dentist
recorded more positive attitudes towards sustainable
dentistry than those who were unregistered. Whereas
the frequency of dental visits did not appear to affect
these attitudes among participants, the authors found
that those who visited more frequently for routine dental
check-ups stated that they were more likely to pay more
to reduce the ecological footprint of their visits.
In their discussion, the authors recognised a number of
limitations regarding their study, including the relative
homogeneity of respondents, the lack of measuring
household income or socioeconomic status and the
focus on participants’ willingness to make compromises
rather than on their actual behaviour. This focus was justified by the reasoning that “there is currently little choice
for the public when it comes to reducing the impact of
their dental treatments on the environment”.
“[F]uture research may want to use environmental assessment (for example, Life Cycle Assessment), in order to
inform which types of compromises would have a beneficial impact on the sustainability of dental services,”
the authors stated. “Such research would inform what
changes should be made, while our research can inform
whether such changes would likely be accepted by the
public,” they added.
The study, titled “Exploring attitudes towards more
sustainable dentistry among adults living in the UK”,
was published online on 26 August 2022 in the British
Dental Journal.

© Iryna Mylinska/Shutterstock.com

| features

[41] =>

PROFESSIONAL
PRECISE
RELIABLE
ENDODONTIC SOLUTIONS

[42] =>

| manufacturer news
Advanced educational programme

The COLTENE Dental Management Academy again increases
its activities through face-to-face events
for dentists. COLTENE’s endodontics department, in particular, is
constantly expanding its range of training courses, since it has become evident that a growing number of general dentists are increasingly enthusiastic about the supreme discipline of tooth preservation
thanks to the availability of intuitive working aids.

Never stop learning! Further education is important for everyone who
wishes to enhance their professional expertise and personality—
this is the view espoused by international dental specialist COLTENE.
After expanding its digital continuing education offering owing to
pandemic-related restrictions on in-person coaching during the past
two years, the COLTENE Dental Management Academy (DMA) is now
offering face-to-face events again.
Comprehensive range of continuing education
The DMA develops, organises and supervises all events and offerings
of COLTENE’s advanced educational programme worldwide. These
include global summits of dentists, researchers and other dental
experts, as well as webinars, practice-oriented on-site training and
other regional information events of all kinds. Interested individuals
can learn everything they need to know for their everyday practice—
the range of areas covered is extensive, covering disciplines like
restorative dentistry and endodontics and sub-topics such as minimally invasive restorations in the aesthetic zone and safe and easy
automated preparation of a root canal. For those wishing to learn
about the optimal use of the fully automatic CanalPro Jeni endodontic
motor with preprogrammed HyFlex, MicroMega and Remover filing
systems and the ideal use of high-performance composites of the
BRILLIANT product family, DMA workshops are the perfect choice.
Even for self-explanatory products such as a colour-coded irrigation
solution system or the virtually autonomous endodontic motor, inventor Dr Eugenio “Jeni” Pedullà always has new insider tips in store

42

Verified, professional cutting-edge topic content
The training of the respective speakers, who are all proven experts
in their respective fields of specialisation, is also subject to the strict
quality management of the DMA. The number of lecturers who have
passed through the COLTENE educational spectrum with its multilevel
training programme is increasing steadily. This large community of
educators regularly exchanges information about the latest trends and
research results in the dental world. Via the global COLTENE network,
seminar leaders and speakers have access to a wide range of current
publications and studies at all times. As a result, all COLTENE training
content is carefully checked and professionally prepared.
Based on past DMA events, both online and on-site at the company headquarters in Altstätten in Switzerland, Dirk Sommerfeld, education manager
at COLTENE, expressed optimism about the development of the DMA:
“Feedback from all participants has been extremely positive to date and
encourages us to continue developing this programme with even more
commitment and speed. So things remain exciting and we look forward
to expanding the programme further and welcoming new participants.”
In addition to the academy’s internationally recognised training and entertaining social programmes, Sommerfeld regards the networking opportunity
it provides, involving 45 globally recognised speakers from 18 countries, as
being an important point: “Some speakers have heard or read about each
other and appreciate each other, but have never yet met in person. And this
is precisely the framework we wish to offer with the COLTENE DMA.”
Book early
For an overview of the dates for workshops and continuing education
events, please visit COLTENE’s website. In addition, the COLTENE team
of experts will be pleased to help you with any questions you may have
by e-mail (service@coltene.com). Furthermore, numerous case studies
and discussions on the actual use of the company’s dental materials
and working aids are featured on COLTENE’s social media channels.
www.coltene.com

[43] =>

manufacturer news

Faster, safer and more efficient procedures

FKG Dentaire introduces XP-endo Rise

FKG Dentaire has introduced XP-endo Rise, the latest evolution
of the innovative XP-endo shaping solution. Also new is a glide
path file 015/.04—XP-endo Rise Glider, based on the RACE EVO
design—and a new shaper—the XP-endo Rise Shaper.

the XP-endo Rise’s serpentine shape creates a corkscrew effect,
allowing the instrument to encircle gutta-percha and pull it out
of the canal in large pieces. It performs gutta-percha removal up
to two-times faster than conventional competitors.

The XP-endo Rise Shaper has a redesigned tip that increases predictability and control. According to bench test data from FKG
Dentaire, the instrument adapts to the canal’s natural anatomy—
just like the current XP-endo Shaper—and offers superior resistance to cyclic fatigue and superior flexibility compared with
other rotary files. In addition, it offers up to 98.9% debris removal,
increases overall disinfection of the canal with up to 99.5% bacteria reduction and shortens treatment time.

Finisher R features a sickle shape which expands to reach aspects
of the canal previously impossible to reach with instrumentation.
After removing the bulk of the gutta-percha, Finisher R gently
pulsates within the canal, dislodging stubborn gutta-percha tags.
It is up to two-times more effective than passive ultrasonic irrigation
in reducing the remaining root filling material.

www.fkg.ch
A single shaping file that replaces up to five others
To simplify and facilitate initial treatments, FKG has introduced
a new XP-endo Rise Sequence, combining XP-endo Rise Glider
and XP-endo Rise Shaper in the same blister pack. This short
sequence of only two files for glide path and shaping ensures
predictability, a minimum 030/.04 preparation in 8/+3 strokes and
a straightforward procedure. In initial treatment, it also allows
multiple use in up to eight standard root canals.
For retreatment, FKG has introduced a new sequence XP-endo
Rise Retreatment combining D-Race DR1, XP-endo Rise Shaper
and Finisher R. This sequence simplifies retreatments, optimises
removal of root filling material and reduces procedure time.
Unlike traditional solid core NiTi files that burnish gutta-percha into
the canal walls as they bore through the mass of filling material,

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| manufacturer news
The blue power

Safe and predictable shaping with MG3 Blue
PX file (navigator file, 15/.03)
This file is used for glide path preparation. It exhibits austenitic
behaviour, giving it high cyclic fatigue resistance and a long time
to fracture. The controlled memory effect enables the file to
follow the curvatures of the root canal without any restoring
forces, thereby avoiding transportation. The cross section of
this file is parallelogramic, resulting in 50% less contact with
the dentinal walls of the root canal and thus reducing the
torsional load on the file. The debris space is quite large, which,
together with the variable pitch, allows coronal evacuation of
debris.

The MG3 Blue nickel–titanium files are machined with a variable
pitch and helix, allowing efficient coronal evacuation of debris and
preventing a screw-in tendency. This also reduces the torsional
load on the instrument that would otherwise occur because of
debris accumulation or excessive friction with the root canal walls.
File systems like MG3 Blue with controlled memory behaviour and
enhanced fracture resistance allow the clinician to manage different cases with an excellent margin of safety and predictability.
Components of the MG3 Blue file system
SV file (orifice modifier, 20/.10)
This file has a short working segment (9 mm) and 19 mm length.
It is used for mechanical pre-flaring for elimination of coronal
dentine resistance. The cross section of this file is convex tri
angular, which gives the file great strength as well as high cutting
efficiency.

G1 file
The G1 file is a 20/.04 shaping file and particularly beneficial for
shaping complex anatomies, such as deep splits, its controlled
memory properties as well as small tip size allowing it to be directed
precisely into the desired location after prebending. Once the
file has been introduced into the root canal, it does not rebound,
maintaining the original shape of the canal without overcutting
areas of minimal dentine thickness. The cross section of the file
is triangular, which has the advantage of high cutting efficiency
and enhanced flexibility in curved canals, owing to the reduced
metal core.
G2 files
The G2 files, of size 25, have a triangular cross section and come
in two tapers, allowing progressive and gradual preparation of
the root canal whenever needed. The 25/.04 G2 file can be used
for body shaping and as a finishing file in cases with anatomical
limitations, such as severely curved canals. The 25/.06 G2 file
can be used for pressure-less pre-flaring and as a shaping or
finishing file. Owing to the metallurgy of MG3 Blue and cross
section, the 25/.06 G2 file possesses unique flexibility and cyclic
fatigue resistance compared with other files of the same size and
taper.
Additional information
Files are available up to size 50. All the MG3 Blue files are available
in lengths of 21, 25 and 31 mm (except the SV file, which is 19 mm
in length). Precisely calibrated working length markings are
engraved on each instrument shank at 18, 19, 20 and 22 mm for
easy reproduction of the recorded working lengths in each canal,
especially in multi-rooted teeth of different lengths. Taper too is
indicated with markings: one marking for 3%, two for 4% and
three for 6%.
The recommended operation speed is 300–350 rpm, and the
recommended torque is 2 Ncm for the PX, G1 and G2 files and
3 Ncm for the SV file.

www.dental-perfect.com

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[45] =>

|

© YaromirM/Shutterstock.com

meetings

Registration for 2023 Chicago Dental
Society Midwinter Meeting is open
By Dental Tribune International
The Chicago Dental Society (CDS) has recently announced that registration for its 158th Midwinter Meeting
is now open. The premier dental meeting, which attracts
attendees from around the globe, will be held at McCormick
Place West in Chicago on 23–25 February 2023.
“The Midwinter Meeting will once again be the place to
learn from the brightest minds in the industry and earn
valuable CE (continuing education) credit,” CDS President-
elect Dr Michael Durbin said in a press release. “We’ve
scouted and vetted a roster of more than 120 renowned
clinicians and leaders in dental education to deliver hundreds of CE-accredited courses across a variety of topics
to help all members of the dental team advance their
careers and provide the best patient care possible.”
The Midwinter Meeting is known for attracting top-tier
speakers in the field of dentistry from across the country.
The upcoming 158th edition of the event will offer at
tendees more than 240 CE-accredited courses, including
45 workshops. Additionally, it will provide dentists and their
teams with the latest practice management solutions and
evidence-based clinical knowledge.

The expansive exhibition hall will feature hands-on access
to the latest dental products and technologies. Here,
attendees can expect to experience the latest 3D-printing
and laser technologies, as well as practice management
and restorative dentistry solutions, available to help dental teams provide the best care possible for their patients.
“It’s always fascinating to see and test the latest innovations from both the biggest household brands and the
new, up-and-coming companies. You never know what
you’ll find in the exhibition hall, but there’s always something beneficial for every dental practice and team
member,” Dr Durbin added.
Rounding out the Midwinter Meeting experience will be
a series of social and networking events, including
a general session, Brews and Bargains happy hour, an
ice cream social, dedicated networking events for early
career dentists and dental students, a Friday night
concert at Park West headlined by Tributosaurus and
the President’s Dinner Dance.
More information on the event, including registration fees,
can be found at cds.org/mwm.

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2 2022

45

[46] =>

| meetings

More than 23,000 trade show visitors from 114 countries attended the International Dental Show 2021 in Cologne, Germany.

IDS organisers herald beginning of
post-COVID-19 era
By Dental Tribune International

46

The countdown to the International Dental Show (IDS)
2023 has begun, and the organisers have set the bar
high by stating that the forthcoming IDS will return to
its pre-pandemic form and size. IDS 2023 is set to take
place on 14–18 March next year in the western German
city of Cologne.

IDS 2023 will be the 40th instalment of the event, and it
will mark 100 years since the establishment of the trade
fair in 1923. The organisers commented on the forthcoming event during a press conference on 8 October
in Singapore, where co-organiser Koelnmesse was
holding IDS’s sister event, the International Dental
Exhibition and Meeting (IDEM).

“IDS 2023 will be the
40th instalment of the event,
and it will mark 100 years
since the establishment
of the trade fair in 1923.”

Dr Markus Heibach of the Association of the German
Dental Industry (VDDI) opened the press conference
by explaining that the dental industry in Germany and
abroad had recovered well during the first half of this
year, despite economic fallout from the war in Ukraine.
“Overall, there are very positive signals, both domes
tically and also abroad across all areas,” Dr Heibach
explained. He added: “In particular, we see an increased
demand for high-quality restorations, for ‘high-end’

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2 2022

[47] =>

meetings

dentistry.” Dr Heibach drew a connection between the
pandemic and an increased awareness of oral health
and general appearance, stating: “Clearly, the constant
preoccupation with health issues has reminded many
people of the value of personal health and quality
of life.”
The exhibition floors at IDEM were open as Markus
Oster, vice president for trade fair management at

Koelnmesse, took to the podium. According to Oster,
his experiences with IDEM 2022 were significant for the
forthcoming 40th IDS. Oster said: “Although the pandemic situation has not yet been overcome, I associate
this trip and developments in general with the beginning
of the post-corona era and a return to normality. I am
also completely convinced that the IDS, as the world’s
most important industry platform, will once again take
place in the coming year with the dimensions we were
last able to experience at the 2019 edition.”
Oster said that he expects IDS 2023 to operate under
“normal” conditions with a proven hygiene concept in
place. It will also be a hybrid event, offering remote participation through the virtual trade fair platform IDSconnect.
Oster pointed out that the Koelnmesse trade fair grounds

“IDS 2023 will be staged
across seven halls, and a total
exhibition space of 180,000 m²
will make it larger than
pre-pandemic events.”
were reachable by more than 1,500 daily rail connections and that travel between Cologne and surrounding
metropoles like Düsseldorf, Essen or Dortmund is free
of charge for holders of a valid IDS ticket.
IDS 2023 will be staged across seven halls, and a
total exhibition space of 180,000 m² will make it larger
than pre-pandemic events. In 2019, the 38th IDS
covered 170,000 m² of exhibition space and featured
2,260 vendors from more than 60 countries. In 2021,
the 39th IDS was downsized to 115,000 m² and took
place without a number of its stalwarts. It featured
830 exhibitors from 59 countries. IDS is organised by
Koelnmesse and VDDI.

From left to right: Prof. Christoph Benz, Mark Stephen Pace, Gerald Böse, mayor Henriette Reker, Dr Markus Heibach, Dr Gerhard Seeberger, Oliver Frese
and Lutz Müller. Opening ceremony IDS 2021. (All images: © Koelnmesse)

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2 2022

[48] =>

| meetings

International events

CIOSP 2023—40 Sao Paulo
International Dental Meeting

AAE23—
American Association of
Endodontists Annual Meeting

25–28 January 2023
Sao Paulo, Brazil
https://www.ciosp.com.br/pt

3–6 May 2023
Chicago, USA
https://www.aae.org

AEEDC Dubai 2023
7–9 February 2023
Dubai, UAE
https://aeedc.com/
see-you-at-aeedc-dubai-2022

The British Dental Conference
& Dentistry Show

23–25 February 2023
Chicago, USA
www.cds.org/midwinter-meeting

12–13 May 2023
Birmingham, UK
https://birmingham.dentistryshow.co.uk

IDS 2023

ESE Biennial Congress

14–18 March 2023
Cologne, Germany
www.ids-cologne.de

6–9 September 2023
Helsinki, Finland
https://www.e-s-e.eu

13–15 April 2023
Sydney, Australia
www.icoi.org/events

48

2 2022

4–7 May 2023
Antalya, Turkey
https://cnridentex.com

158th Chicago Dental Society
Midwinter Meeting

ICOI World Congress

roots

18th IDENTEX—
International Oral and
Dental Health Exhibition

FDI World Dental Congress
24–27 September 2023
Sydney, Australia
www.fdiworlddental.org/
world-dental-congress-2023

© 06photo/Shutterstock.com

th

[49] =>

|
© 32 pixels/Shutterstock.com

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2 2022

49

[50] =>

| about the publisher

Imprint
Publisher and
Chief Executive Officer
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t.oemus@dental-tribune.com

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International Headquarters

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50

roots
2 2022

[51] =>

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[cover] => roots international No. 2, 2022

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