Endo Tribune U.S. No. 10, 2012
ADA meeting offers plenty for endodontists / What defines success in endodontics? / Industry
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ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
november 2012 — Vol. 7, No. 10
www.dental-tribune.com
ADA
meeting
offers
What defines
success in
plenty
for
endodontists
endodontics?
Clinical opinion
By Barry Musikant, DMD
M
ost of us would agree that
well-cleansed, non-distorted shaping is a significant
factor in producing endodontic success. The research states that
preparations to a minimum of 35 are
necessary for an adequate volume of our
irrigants to be effective.1 In other words,
success is defined as setting the biologic
conditions within the treated canal to
eliminate the bacteria that may be present and to create a seal so they cannot reestablish themselves and that those that
have not be removed are entombed.
What I have observed recently is a subtle de-emphasis of these biologic requirements as factors for success replaced by
a growing enthusiasm for reciprocating
NiTi instruments that remain intact
during the shaping procedure. The fact
that the incidence of separation is reduced is taken as an act of progress that
will lead to higher success rates. Where
the biologic needs of the tooth must
rightly be considered primary, it is being
displaced by the simplistic notion that a
NiTi instrument remaining intact after
it shapes the canal walls is proof of a superior result. While a separated instrument can certainly reduce success rates,
an intact instrument is only as good as
the job it does in adequately cleansing
the root, while maintaining its original
shape without producing any internal
defects.
Putting myself into the shoes of rotary NiTi users, I can appreciate the
positive emotions that result from an
instrument that remains intact when
for so many years unpredictable instrument separation was intimately associated with the use of NiTi as it relates to
varying degrees of canal curvature, taper and tip size of the NiTi instrument
used, whether it is landed or not and the
speed of rotations. In short, rotary NiTi
requires attention to detail in technique,
at times a good deal of recapitulation
and careful case selection.
The introduction of a NiTi system that
largely reduces unpredictable separation decreases these concerns, simplifies the shaping procedure and reduces
the costs associated with rotary NiTi. Yet
these improvements have little to do
with the biologic requirements for effective endodontic treatment.
While reciprocating NiTi is a twist on
rotary NiTi, to be effective it must still
cleanse the canal walls. Yet like their rotary predecessors, reciprocating NiTi sys-
” See SUCCESS, page C3
Tom Bender, left,
and Gunnar Wallin
of Wykle Research
had plenty to talk
about at the recent
ADA meeting in
San Francisco:
new products for
endodontic
treatment.
Photos/Fred
Michmershuizen,
Dental Tribune
Nick Snow, left, and Sarah Tzdepski of Coltene show off some of the company’s products for
endodontic treatment.
Dave Lage of Essential Dental Systems.
By Fred Michmershuizen, Managing Editor
cone backfilling and many more. Most of
the video clips were chosen from recent
clinical cases.
In Buchanan’s hands-on course, attendees were able to use the new TrueTooth™
3–D printed training replicas, available
from Dental Education Laboratories. The
replicas allow dentists to practice again
and again until they get consistently
good results with a given technique in a
The American Dental Association held
its 153rd Annual Session and World Marketplace Exhibition in San Francisco in
October. For endodontists, the meeting
offered an opportunity to learn from
leaders in clinical practice, research, academia and industry. There was also plenty of new technology to discover.
In the lecture halls, Dr. L. Stephen Buchanan, one of the featured speakers at
the meeting, presented an all-day lecture
and a hands-on course. In the lecture,
“The Art of Endodontics: Everything Has
Changed but the Anatomy,” attendees
were able to see fresh clinical footage shot
with a state-of-the-art HD1080p video
camera. The images were painted onto
a screen at a resolution that resembled
looking through a microscope. Attendees were able to see new procedures, such
as rotary negotiation, guided-bur access
preps, single-file GTX shaping, single-
” See ADA, page C2
[2] =>
C2
news
Endo Tribune U.S. Edition | November 2012
“ ADA, Page C1
given anatomic challenge. There is also
a patent-pending process for these TrueTooth replicas to have simulated pulp
tissue that dissolves with sodium hypochlorite irrigating solutions.
On the exhibit hall floor, many companies offered products and resources of
value to endodontists.
Wykle Research offered new products
for endodontic treatment. Calasept irrigation needles are dual-side-vented,
luer-lock irrigation needles that are designed to provide for safe and effective
irrigation. The dual side vents optimize
cleansing of canals, creating a “swirl”
effect. The closed tip safely protects the
apex. Also available from Wykle are new
Calasept color-coded irrigation syringes
that are designed to eliminate risk when
using multiple irrigation liquids.
Jordco, a company that continues to refine its product line, offered a wide range
of products for treatment, diagnosis, organizing, storage, safety and convenience.
For treatment, the Endoring II hand-held
endodontic assistant, EndoGel endodontic lubricating gel, e-Ruler endodontic file
measuring instrument and Pure Bond
Dispensers bonding agent and composite
dispenser were available. Also popular was
the Jordco e-Foam endodontic foam and
the FileCaddy bulk file storage system.
Taken together, the offerings comprise
what the company calls the Jordco System. The system works on the premise
AD
ENDO TRIBUNE
Publisher & Chairman
Torsten Oemus t.oemus@dental-tribune.com
Chief Operating Officer
Eric Seid e.seid@dental-tribune.com
Group Editor
Robin Goodman r.goodman@dental-tribune.com
Editor in Chief ENDO Tribune
Frederic Barnett, DMD barnettF@einstein.edu
Managing Editor ENDO Tribune
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Managing Editor Show Dailies
Kristine Colker k.colker@dental-tribune.com
Managing Editor
Sierra Rendon s.rendon@dental-tribune.com
Managing Editor
Robert Selleck, r.selleck@dental-tribune.com
Account Manager
Humberto Estrada h.estrada@dental-tribune.com
Meeting attendees crowd the aisles of the ADA exhibit hall in San Franciso.
that Jordco products complement each
other and work in concert from diagnosis
through all phases of treatment.
Coltene Endo showcased its HyFlex CM
NiTi files with Controlled Memory, which
the company says are up to 300 percent
more resistant to cyclical fatigue compared to other NiTi files, which substantially helps reducing the incidence of file
separation. According to Coltene Endo,
HyFlex CM NiTi files have been manu-
Marketing director
Anna Kataoka-Wlodarczyk
a.wlodarczyk@dental-tribune.com
factured utilizing a unique process that
controls the material’s memory, making
the files extremely flexible but without
the shape memory of other NiTi files.
For those who prefer not to use rotary
files, Essential Dental Systems (EDS) offered its Endo-Express reciprocating
handpiece and its SafeSiders, designed to
eliminate the fear of fracture associated
with crown-down systems and the typical
shortcomings of the step-back process.
C.E. DIRECTOR
Christiane Ferret c.ferret@dtstudyclub.com
Journal explores
pulp hyperthermia
Tribune America cannot assume responsibility for
the validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names or statements made by advertisers. Opinions expressed by authors are their own
and may not reflect those of Tribune America.
The September issue of the Journal of
the California Dental Association covers
a range of topics, including a discussion
of the different reasons for the rise in
pulp temperature during various modalities of tooth preparation.
“Pulp Hyperthermia During Tooth
Preparation: the Effect of Rotary Instruments, Lasers, Ultrasonic Devices, and
Airborne Particle Abrasion” discusses
how the rise in pulp temperature during
restorative therapy can compromise vitality of the dental pulp. This article also
comments on the measures that need to
be taken to avoid the risk of pulp hyperthermia during tooth preparation.
In an additional article, titled “Atypical
Odontalgia — An Update,” authors describe the current understanding of the
etiology and pathophysiology of atypical tooth pain and provides appropriate
diagnostic and management approaches
for this condition.
Tribune America, LLC
116 West 23rd Street, Suite 500
New York, NY 10011
Phone (212) 244-7181
Fax (212) 244-7185
Published by Tribune America
© 2012 Dental Tribune America, LLC
All rights reserved.
Tribune America strives to maintain the utmost accuracy in its news and clinical reports. If you find a
factual error or content that requires clarification,
please contact Managing Editor Fred Michmershuizen
at f.michmershuizen@dental-tribune.com.
Editorial Board
Frederic Barnett, Editor in Chief
Dr. Roman Borczyk
Dr. L. Stephen Buchanan
Dr. Gary B. Carr
Prof. Dr. Arnaldo Castellucci
Dr. Joseph S. Dovgan
Dr. Unni Endal
Dr. Frnando Goldberg
Dr. Vladimir Gorokhovsky
Dr. Fabio G.M. Gorni
Dr. James L. Gutmann
Dr. William “Ben” Johnson
Dr. Kenneth Koch
Dr. Sergio Kuttler
Dr. John T. McSpadden
Dr. Richard E. Mounce
Dr. John Nusstein
Dr. Ove A. Peters
Dr. David B. Rosenberg
Dr. Clifford J. Ruddle
Dr. William P. Saunders
Dr. Kenneth S. Serota
Dr. Asgeir Sigurdsson
Dr. Yoshitsugu Terauchi
Dr. John D. West
(Source: California Dental Association)
Tell us what you think!
Corrections
Endo Tribune strives to maintain the
utmost accuracy in its news and
clinical reports. If you find a factual
error or content that requires
clarification, please report the
details to Managing Editor
Fred Michmershuizen at
f.michmershuizen@dental-tribune.
com.
Do you have general comments or criticism
you would like to share? Is there a particular
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Endo Tribune? Let us know by e-mailing
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to process.
[3] =>
Endo Tribune U.S. Edition | November 2012
Clinical opinion
C3
“ SUCCESS, Page C1
tems have been proven to be ineffective
in cleansing all the walls of oval canals.
NiTi, be it used in a rotary or reciprocating fashion, tends to shape centrally with
little ability to touch what are most often
the buccal and lingual walls of oval canals.
This has been amply demonstrated by
the micro CT scans of Versiani, Pecora
and Neto (Figs. 1,2). Note the pulp tissue
prior to its removal by a NiTi reciprocating single instrument system (Fig. 1) and
the tissue remaining after instrumentation (Fig. 2). This is hardly an adequate result although as seen from a mesio-distal
X-ray it would produce a pleasing picture.
The remaining tissue is visible from a
bucco-lingual perspective, one not seen
from a mesio-distal orientation. Remaining tissue in fact would not be seen at all
on an X-ray because it lacks radiopacity. We
would only see the radiopaque gutta-percha and cement that gives the illusion of a
job well done, an inaccurate presentation
that gives us no appreciation of the tissue
left behind. Yet, given this well-documented information, too many of us are taking
the final X-ray as proof of effectiveness.
This is despite the fact that at best most
preparations are no greater than a 25/08
and often more conservative. As mentioned earlier, the literature states a minimum of a 35 preparation is required for effective irrigation, a degree of irrigation that
can dissolve chemically the tissue that was
not removed mechanically, something else
the literature clearly shows remains after
NiTi instrumentation.
The standards for effective canal cleansing are not directly related to an instrument remaining intact. Those who use
this property as a guide for its effectiveness are not focusing on what is essential.
An instrumentation system must be able
to shave dentin away from all the circumferential walls throughout the length of
the canal. Failing that, it must at a minimum prepare the canals to dimensions
that give the irrigants particularly when
they are activated, the best chance of digesting any remaining tissue. Only in this
way can we predictably remove the tissue
that supports bacterial growth and prevents a hermetic seal when still present.
Up to now we have limited the discussion to inadequate shaping of oval canals.
However another factor that dentists
should consider when using a single file
reciprocating NiTi system is the stress to
the walls of the canals. In the past three
years a number of studies have implicated rotating instruments as the main
cause of micro-fractures along the length
of the canal occurring anywhere from
25 to 60 percent of the time depending
upon the system employed. Hand instrumentation and short amplitudes of engine-generated motion have been shown
not to cause micro-fractures.
A secondary cause of micro-fractures is
directly related to the taper of the instrument. The greater the taper the greater
the incidence of micro-fracture.2–5 A
single instrument system employing an
0.08 tapered file will engage the walls
of the canal along length, producing far
greater contact than a sequence of crowndown preparations that are purposely
designed to minimize engagement along
length by any one instrument.
By simplifying the system down to
one instrument, the burden of shaping
is placed on one instrument alone with
all the stresses and strains concentrated
Fig. 1: This CBCT image shows canals before being instrumented with
a single rotary file system. Images/Courtesy of rootcanalanatomy.blogspot.com
Fig. 2: The canals after being instrumented with single rotary file
system. Please note the green areas are not cleansed.
AD
Unlike rotary users, Endo-Express reciprocating users don’t
fear instrument separation or dentin micro-fractures!
SafeSiders are the only instruments designed specifically to work in
reciprocation. The flat along the entire length:
- Creates more efficient cutting
- Reduces engagement for faster advancement
- Reduces instrument stress improving durability
- Increases instrument flexibility without sacrificing strength
Increase your quality while reducing your costs!
Schedule a FREE In-Office Demo.
FREE In-Office Demo, Visit: www.edsdental.com/demo
Visit www.edsdental.com for promotional offers!
Learn More - Visit the EDS booth during the upcoming dental meeting!
*Research available upon request.
89 Leuning St, S. Hackensack, NJ 07606 • 1-800-22-FLEXI • www.edsdental.com
[4] =>
C4
in that one instrument. That one instrument goes through repeated oscillations
of 150 degrees and reverse 30 degrees,
producing a net 120-degree advance with
every full cycle. Every three cycles produce a full rotation (Fig. 3). At a frequency
of 600 cycles per minute, 200 full rotations are generated every minute, about
the same as that generated by the prior
generation of rotary NiTi instruments
and noted to predictably produce microfractures.
If looked at with a critical eye, single file
NiTi reciprocating systems de-emphasize
cleansing as the essential that it is without necessarily reducing the incidence
of micro-fracture. The advances claimed
for these systems are reduced rates of
breakage, lower costs and reduced time
requirements, none of which address the
limitations of inadequate cleansing, irrigation, and centered preparations that
remove too much tooth structure centrally and too little laterally in the case of
oval canals.
By comparison, we employ a series
of 0.02 tapered stainless steel relieved
reamers (a flat along the entire working
length) (Fig. 4) that negotiate apically
with minimal resistance, shaving dentin
effectively whether used manually with a
short watch-winding stroke or in a 30-degree reciprocating handpiece. Please note
that the 30-degree oscillation generated by the handpiece does not drive the
reamer deeper. That is accomplished by
the relieved reamer’s vertically oriented
flutes that shave dentin away laterally,
AD
Clinical opinion
Endo Tribune U.S. Edition | November 2012
Fig. 4: Stainless-steel relieved reamers (top, flat along the entire working length) with the
vertically oriented flutes compared to the horizontally oriented flutes of a file (bottom).
Fig. 3: This figure demonstrates the ‘rotary’
action of some single file reciprocating
systems. Images/Barry Musikant, DMD
reducing the resistance against further
apical progress.
Oscillating at between 3,000 and
4,000 cycles per minute, full apical negotiation is most often accomplished
with a few up-and-down hand strokes.
With the concerns of separation nonexistent, the dentist has no problems
in aggressively working any of these instruments against all the lateral walls of
canals, be they round or oval and in the
vast majority of cases, the canals are routinely shaped to a minimum of 35 at the
apex and to a 40, 1 mm further back.
While the system we advocate has been
proven to adapt to just about any situation one can encounter, the intent of this
discussion is to shed light on the shortcomings of a single file NiTi reciprocating
system that is not designed to address
the tissue in the extensions of oval canals and does not ultimately reduce the
rotations and tapered instruments associated with micro-fractures.
This entire discussion brings up the
larger issue of marketing as an obstacle
to learning. The major companies spend
large sums of money in developing techniques to influence dentists to buy their
products. One can clearly see the impact
in marketing in developing a technique
that is less likely to break, costs less and
takes less time for the dentist to do.
These are all wonderful marketing
goals, but they do nothing to improve
the clinical conditions that are the basis
for increased success. A broad discussion
of the impact of marketing and the adverse effects it has on our decision-making would be a worthy effort. For those
” See SUCCESS, page C5
[5] =>
Endo Tribune U.S. Edition | November 2012
industry
C5
Wykle Research expands its Calasept Endo line
Wykle Research has announced the release of two new Calasept Endo products,
which it distributes for Nordiska Dental
of Sweden, the manufacturer of Calasept
and Calasept Plus.
Calasept Irrigation Needles are highquality, double-side-vented, luer-lock
irrigation needles that optimize the
cleansing of canals, creating a “swirl effect.”
The needles are available in 27 g or 31 g,
in packs of 40 needles.
Features include the following:
• Bendability
• Luer-lock hub
• Sterile and disposable
• Designed for ease in cleaning roots
• High-quality stainless steel
interested in such an exercise please
contact me and perhaps we can get something started.
References
2.
3.
4.
5.
Zand V, Lotfi M, Rahimi S, Mokhtari H, Kazemi A, Sakhamanesh V. A comparative
scanning electron microscopic investigation of the smear layer after the use of sodium hypochlorite gel and solution forms
as root canal irrigants. J Endod. 2010;
36(7):1234–1237.
Yoldas O, Yilmaz S, Atakan G, Kuden C,
Kasan Z. Dentinal Microcrack Formation
during Root Canal Preparations by Different
NiTi Rotary Instruments and the Self-Adjusting File. J Endodont 2012;38(2):232–235.
Kim HC, Lee MH, Yum J, Versluis A, Lee CJ,
Kim BM. Potential relationship between
design of nickel-titanium rotary instruments and vertical root fracture. J
Endodont 2010;36(7):1195–1199.
Bier CA, Shemesh H, Tanomaru-Filho M,
Wesselink PR, Wu MK. The ability of different nickel-titanium rotary instruments to
induce dentinal damage during canal preparation. J Endodont 2009;35(2):236–238.
Shemesh H, Bier CA, Wu MK, TanomaruFilho M, Wesselink PR. The effects of canal
preparation and filling on the incidence
of dentinal defects. Int Endod J. 2009;
42(3):208–213.
Barry Lee Musikant,
DMD, is a member
of the American Dental Association, American Association of Endodontists, Academy
of General Dentistry,
the Dental Society of
New York, First District
Dental Society, Academy of Oral Medicine,
Alpha Omega Dental
Fraternity and the American Society of Dental Aesthetics. He is also a fellow of the American College
of Dentistry (FACD). He is a partner in the largest
endodontic practice in Manhattan. Musikant’s 35plus years of practice experience have established
him as one of the top authorities in endodontics. To
find more information from Musikant, visit www.
essentialseminars.org, email info@essentialseminars.
org or call (888) 542-6376.
These new products complement
Wykle’s popular Calasept line, which
includes Calasept and Calasept Plus calcium hydroxide paste for temporary filling of root canals, which is sold in packages of four syringes with 20 needles.
Calasept EDTA is 17 percent EDTA solu-
Calasept Irrigation Needles
Calasept Irrigation Syringes
Photographs provided by Wykle Research
tion. Calasept CHX is 2 percent chlorhexidine solution for irrigation. Both solutions are packaged with a luer adaptor for
easy filling of syringes.
Wykle Research distributes Calasept
Endo products by Nordiska Dental, a Swed-
ish manufacturer of Dental supplies.
Wykle Research and Nordiska Dental will
continue to provide new endo products.
For more information, contact Wykle
Research at (800) 859-6641 or visit www.
wykleresearch.com.
AD
“ SUCCESS, Page C4
1.
Calasept Irrigation Syringes are 3 ml
luer-lock, single-use syringes. They are
color coded to eliminate risk when using multiple irrigation liquids. They
are available in packs of 20 syringes, 10
white and 10 green.
Features include the following:
• High-quality, three-part syringe
• Color coded
• Luer lock
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