roots C.E. No. 1, 2018

Cover / Editorial / Content / The dental operating microscope in endodontics / "He brought a world of enthusiasm and knowledge to the global endodontic community" / Ready-to-use bioceramic materials in apical resorption: A clinical case / Minimally invasive root canal treatment uses fluids, acoustics / The importance of irrigation and PUI in modern endodontics / There is a better way (and LVI can show you how to get there) / About the publisher - imprint

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Table of contents

1

roots

2016

International Edition • Vol. 8 • Issue 1/2018

issn 2161-6558

the international C.E. magazine of

1

endodontics

2018

_C.E. article

_tribute

_research

The dental operating
microscope

Remembering
Fred Weinstein

Bioceramic materials
in apical resorption

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editorial _ roots

Remembering
Dr. Fred Weinstein
He was wearing a Royal Canadian Mounted Police uniform the first time I met him. It was 2007, and I
had just started a new job as an editor with Dental Tribune, covering the specialty of endodontics. With his
red blazer, hat and tall boots he looked genuine — and approachable. I just had to talk with him. After all,
how often does one get a chance to meet a Mountie?
He turned out to be none other than Dr. Fred Weinstein, and he was dressed up to promote the IFEA
meeting, which was being held that year in his hometown of Vancouver, British Columbia. Over the next
decade I got to know him quite well. He was always generous with his time, and he was always helpful to
me, a non-dentist, with information on the specialty and also about key personalities, tools and equipment,
and the industry in general.
Weinstein had already retired after a long and successful career in private practice and as an educator
and product innovator, but in 2012 he agreed to serve as editor in chief of roots magazine. Over the years
we not only worked together on the publication, but we also became friends. We would often meet up at
various dental meetings, where I was busy on the exhibit hall floor taking pictures for our show daily. He
would be there to partake in the various educational sessions and to visit with his many friends. It seemed
he knew almost everybody.
The last time we were together was at last year’s AAE in New Orleans. Weinstein and his wife, Heather,
and I met up before the meeting got underway for dinner and a stroll in the French Quarter. At this year’s
AAE gathering in Denver, Weinstein, who passed away last October, will be missed. I sure will miss him. Turn
to page 11 of this issue of roots for a tribute to Weinstein in which a number of prominent endodontists
share their fond memories.
The centerpiece of this publication, however, is an article by Dr. Frank C. Setzer, “The dental operating
microscope in endodontics,” which originally appeared in AAE’s ENDODONTICS: Colleagues for Excellence
newsletter. The article is being made available in this issue of roots with the permission of the AAE. By
reading this article, and then taking a short online quiz at www.DTStudyClub.com, you will gain one ADA
CERP-certified C.E. credit.
You can also access the vast library of C.E. articles published in the AAE’s clinical newsletter by visiting
www.aae.org/colleagues.
I can imagine that taking time away from your practice to pursue C.E. credits is costly in terms of lost
revenue and time, and that is another reason roots is such a valuable publication. I hope you will enjoy this
issue and that you will take advantage of the C.E. opportunity.

Fred Michmershuizen,
Managing Editor

Sincerely,

Fred Michmershuizen, Managing Editor
f.michmershuizen@dental-tribune.com

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I content_ roots

page 11

page 06

page 14

I C.E. article

I about the publisher

06

18

 he dental operating microscope
T
in endodontics

_imprint

_Frank C. Setzer, DMD, PhD, MS

I tribute
11	‘He brought a world of enthusiasm and
knowledge to the global endodontic
community’
_Fred Michmershuizen, Managing Editor

I research

1

roots

2016

International Edition • Vol. 8 • Issue 1/2018

issn 2161-6558

the international C.E. magazine of

14	Ready-to-use bioceramic materials in
apical resorption: A clinical case

1

endodontics

2018

_Ricardo Affonso Bernardes

industry
15	Minimally invasive root canal treatment
uses fluids, acoustics
16	The importance of irrigation and PUI in
modern endodontics

industry education
17	There is a better way (and LVI can show
you how to get there)
_Mark Duncan, DDS, FAGD, LVIF, DICOI, FICCMO

page 15

_C.E. article

_tribute

_research

The dental operating
microscope

Remembering
Fred Weinstein

Bioceramic materials
in apical resorption

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I on the cover

A diaphonized mesial root of a lower left second molar,
showing the vascularity stained within the demonstration
of the pulp canal system, as prepared and photographed
by Craig Barrington, DDS. Barrington may be contacted
at cbdds002@yahoo.com. You may also follow him on
Facebook, Craig Barringtondds.

page 16

page 17

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I C.E. article_ microscopes

The dental operating
microscope in endodontics
Author_Frank C. Setzer, DMD, PhD, MS

_c.e. credit
This article qualifies for C.E.
credit. To take the C.E. quiz, log
on to www.dtstudyclub.com.
Click on ‘C.E. articles’ and
search for this edition (Roots
C.E. Magazine — 1/2018). If
you are not registered with the
site, you will be asked to do so
before taking the quiz. You may
also access the quiz by using
the QR code below.

_The practice of endodontics requires precision
and great attention to detail. These depend on the
training, skills and experience of the clinician. Most
endodontic procedures are carried out in dark and
confined places, and fractions of millimeters may
decide the outcome of treatment. Over the past
decades, endodontics has gained not only basic
and clinical scientific knowledge, but also has taken
technological quantum leaps. Due to the intricate
nature of endodontic treatment, practitioners have
always sought to improve their vision of the operational field.

_Advantages of dental microscopes

Fig. 1_Highmagnification
inspection of caries
below crown margin.
Courtesy of Dr.
Francesco Maggiore,
Aschaffenburg, Germany.
(Photos/Provided by
American Association
of Endodontists)

Fig. 1

Better vision requires enhanced magnification
and illumination, and both microscopes and loupes
have been widely adopted. Operating microscopes
have a number of advantages compared with loupes.
Loupes are worn on the head and may be used with
or without external light sources. This necessitates
weight limitations and restricts the oculars to the
bare minimum of lenses needed for magnification.
By contrast, the microscope is a self-supported unit;
therefore, additional lenses or prisms are not a concern. This has meaningful implications with regard to
ergonomics and visualization.
The attachment of loupes to glasses dictates a
design that angles the binoculars inward in order
for the viewer to focus on the object. As a result, the
practitioner’s eyes also rotate medially. This is similar
to near object accommodation by the naked eye,
which can lead to
eye muscle strain
and fatigue. By
contrast, microscope binoculars
are arranged in a
parallel orientation. This arrangement is facilitated
by prisms that let
the incoming light

beams reach the eyes also in a parallel direction.
This simulates the observation of a distant object:
a straight, forward-looking gaze that causes less
muscle stress and fatigue. In addition, from an ergonomic perspective, working correctly with a dental
microscope improves overall body posture and may
reduce neck and back pain.
Commercially available microscopes provide adjustable magnification ranging from approximately
4x-25x magnification, while most loupes provide
fixed magnification between 2.5x-6x. Magnification
can be divided in low magnification (~2x-8x), mid
magnification (~8x-16x), and high magnification
(~16x-25x). Low, mid and high magnification are
applicable for different procedural steps throughout
nonsurgical and surgical endodontic treatment. Low
magnification is mainly applicable for an overview of
the operating field.
Mid magnification is used for the main procedural
steps throughout root canal therapy and endodontic
surgery. High magnification is used for the identification of minute structures and documentation of
the finest details. Using a microscope significantly
increases a practitioner’s accuracy.1 However, it must
be mentioned that there is a learning curve and working at both mid and high magnification will require
the practitioner to slow down movements to avoid
unintended actions on the smallest of anatomical
structures. As a result of working in a small-scale
environment, new types of micro-instruments also
were introduced to the dental profession.

_History of microscopes in endodontics
The idea of using microscopes in dentistry is not
new. Bowles suggested and used a dental microscope
as early as 1907!2 In endodontics, dental operating
microscopes were first introduced by individual
clinicians3,4 and then adopted by endodontic specialty programs throughout the United States. The
American Association of Endodontists was an early
proponent of training in microscopes for endodontic
residents and successfully advocated for the Com-

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C.E. article_ microscopes

mission on Dental Accreditation to add a microscope proficiency standard to the CODA educational
standards for postgraduate endodontic programs in
1998. The latest standard requires the teaching of
magnification devices “beyond that of magnifying
eyewear” at an in-depth level, which is the highest
of the levels of knowledge prescribed by CODA.5
Based on two surveys, in 1999 and 2008, the accessibility and use of the microscope by endodontists
increased from 52 percent to 90 percent.6,7 It is now
also increasingly being used by other specialties8 and
in dental education.9

Fig. 2

Fig. 3

Fig. 4a

Fig. 4b

_Microscope use for nonsurgical procedures
For the endodontic practitioner, the dental microscope is useful for diagnosis and clinical procedures. The microscope may aid diagnostically in
identifying caries, insufficient crown or restorative
filling margins (Fig. 1), or assessing craze or fracture
lines. During root canal therapy, magnification and
illumination provided by the operating microscope
aids with caries removal, access preparation, removal of pulp chamber calcifications, identification
of root canal orifices, identification of cracks and
fracture lines (Fig. 2), and the treatment of internal
resorptions. Under the microscope, subtle changes
in dentin color and texture become apparent, such
as developmental lines on the pulp floor guiding the
practitioner toward root canal orifices, or the darker
color of the pulp floor itself, allowing the practitioner
safer dentin removal.
High magnification can help in the localization
and instrumentation of obstructed and calcified
canals, the identification of canal bifurcations (Fig. 3),
the removal of canal obstructions such as denticles
and calcifications, and obturation (Figs. 4a,b). Additional primary endodontic procedures benefiting
from microscope use include vital pulp therapy and
regenerative endodontics by allowing careful and
gentle manipulation of the pulpal tissues or a blood
clot, respectively. Enhanced vision also aids in the
treatment of dental anomalies, such as dens invaginatus, or fused teeth.
In endodontic retreatments, the microscope is
helpful in identifying and removing leftover filling
materials, such as sealer remnants, pastes or guttapercha,10 silver points and carrier-based materials,
posts or fractured instruments11 (Figs. 5a-d). It also
aids in nonsurgical perforation repair, allowing the
practitioner to clean the perforation site and place
the perforation repair material more precisely.12,13

_Microscope use for surgical procedures
Surgical endodontics has been completely transformed by microscopic procedures. For many years

surgical burs and amalgam for root-end fillings
were the standard of care. The incorporation of
the microscope, and also to a certain degree the
endoscope, together with the use of ultrasonic tips
and biocompatible filling materials, has evolved
the classical apicoectomy into modern endodontic
microsurgery.14 All steps of endodontic microsurgery are carried out under varying degrees of magnification, including flap preparation, osteotomy,
identification of root apices, root-end resection,
inflammatory tissue removal, observation of the
resected root surface (Fig. 6), root-end preparation,
root-end filling, and suturing.15 The microscope is
also helpful for cervical or external resorption or
perforation repairs.

_Treatment effects

Fig. 3_Deep canal bifurcation.
Microscope-controlled filling of first
canal just below split (arrow).
Fig. 4a_Situation after irreversible
pulpitis of left maxillary first molar
two weeks after delivery of fixed
partial denture. High magnification
allowed for identification and
treatment of three mesio-buccal
canals through existing restoration.
Fig. 4b_Post-operative radiograph.

There has been great debate over whether the
use of magnification would actually increase the
success rate of endodontic procedures. It is an
accepted fact in endodontics that microbes and
their endotoxins are responsible for the majority of
inflammatory periapical lesions. Healing of these
lesions in cases of a diagnosis of pulp necrosis has
been associated with disinfection of the root canal
system, reduction of the microbial content, filling of
the root canal system and the permanent restoration of the tooth.
It is thus assumed that the identification and
treatment of all parts of the root canal system increase the chances of a successful treatment and
good long-term prognosis. Ample literature has been
published with regard to the identification of additional canals with the help of higher magnification

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Fig. 2_Evaluation of extent of
mesial fracture line (arrows) in left
second maxillary molar. Microscopic
inspection confirmed restorability.

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I C.E. article_ microscopes
ment was performed by dental students recently
instructed in microscope use.22

_Nonsurgical treatment outcomes

Fig. 5a

Fig. 5b

Fig. 5c

Fig. 5d

Fig. 5a_Separated instrument in
second mesio-buccal canal of left
maxillary first molar (arrow). Situation
after uncovering of fragment with
ultrasonic tips and debris removal.
Fig. 5b_Pre-operative radiograph.
Fractured instrument in mesial root
of lower left first molar. Patient was
referred for fragment removal and
continuation of treatment.
Fig. 5c_Access to instrument
fragment (arrows) in mesiobuccal
canal using ultrasonic tips. Note
loosely placed gutta-percha in
mesiolingual canal to prevent any
fragments or debris from accidentally
blocking the canal.
Fig. 5d_Radiograph verifying complete
instrument removal. Temporary after
first appointment. Canals are filled with
non-radiopaque calcium hydroxide.
Fig. 6_Highmagnification
inspection of
resected root surface
of left maxillary
lateral incisor using
a micro-mirror. Note
leakage of previous
root filling stained
with methylene blue.

Fig. 6

and illumination.16,17 The effectiveness of vision enhancement for the detection of second mesio-buccal
canals (MB2) in maxillary molars was assessed both
in vitro and in vivo. The detection rate of MB2 canals
in vitro was shown to be 90 percent with the operating microscope and 52 percent without aided vision.
Gorduysus et al.18 demonstrated that the percentage
of MB2 canal negotiation increased with the aid of
higher magnification.
Burley et al.19 described the successful identification of MB2s in 312 maxillary first and second molars
in 57.4 percent of the cases when using the operating
microscope, 55.3 percent with dental loupes and 18.2
percent with unaided vision. In first maxillary molars,
the incidences of MB2 identification were 71.1 percent, 62.5 percent and 17.2 percent for the microscope, dental loupes and no magnification groups,
respectively. Stropko20 treated a total 1,732 maxillary molars working at times with unaided vision
and at times with a dental microscope. With more
experience and a dental microscope, the incidence
of locating MB2 canals increased from 73.2 percent
to 93.0 percent in first molars and from 50.7 percent
to 60.4 percent in second molars. Microscope use
also increased the
number of root canal orifices located
in mandibular molars,21 and significantly increased the
quality of access
cavity preparation
and the accuracy
of canal identification when treat-

It was long uncertain if microscope usage resulted in improvements in nonsurgical treatment
outcomes. Del Fabbro et al. conducted two Cochrane
Reviews, in 200923 and 2015,24 to identify randomized
controlled trials and quasi-randomized controlled
trials comparing endodontic therapy performed
with or without one or more magnification devices.
Neither in 2009, nor in 2015, were the authors able
to identify a single study reporting the outcome of
either nonsurgical or surgical endodontic therapy
matching the strict criteria put forward in their study.
Hence, the authors concluded that it was unknown if
and how any magnification device affected the treatment outcome, in particular, since a great number of
factors besides the microscope can have a significant
impact on the success of endodontic procedures. The
authors suggested future long-term, well-designed
randomized clinical trials.
Recently, however, a study published by Monea et
25
al. assessed the impact of the operating microscope
on the outcome of nonsurgical treatments of a consecutive series of 184 comparable teeth diagnosed
with pulp necrosis and chronic apical periodontitis
performed by postgraduate students. Success was
defined as a decrease or disappearance of the radiolucency following the recommendations of the
European Society of Endodontology. After follow-up
periods of six months and 18 months, there were significant differences between microscope and control
groups, with 94.8 percent versus 87.5 percent (healed
and improved) at six months, and 95.9 percent and
91.9 percent at 18 months. At 18 months, 89 percent
of cases available for follow-up in the microscope
group were classified as completely healed.

_Surgical treatment outcomes
Another systematic review by del Fabbro et al.26
to investigate the use of magnification devices in
endodontics identified three prospective clinical trials evaluating the outcomes of endodontic surgery.
The authors were unable to identify significant differences in outcomes depending on treatment with
loupes, microscope or an endoscope and suggested
that different magnification devices could only
minimally affect the outcome. In two meta-analyses,
Setzer et al. described the differences in outcome of
three techniques for endodontic surgery.27,28 Investigated were clinical studies that applied traditional
endodontic surgical techniques (TRS), including 12
studies with a total sample size of 925 teeth using
no magnification, straight surgical handpieces and

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C.E. article_ microscopes

amalgam root-end filling and a cumulative success
rate of 59.0 percent; seven studies using contemporary surgical procedures (CRS) with a collective sample size of 610 teeth, employing magnifying loupes,
ultrasonic root-end preparation and biocompatible
filling materials and a cumulative success rate of 88.1
percent; and nine studies on endodontic microsurgery (EMS) with a total of 699 teeth using the identical techniques as CRS with the only differences being
the use of high-power magnification devices such as
microscopes or endoscopes instead of loupes and a
cumulative success rate of 93.5 percent.
The cumulative success rate of the EMS group was
significantly higher than the CRS group, which only
employed loupes, and the TRS group, which used
no magnification. The EMS group combined studies that employed both the dental microscope and
the endoscope. It needs to be mentioned that these
studies are comparable as both microscopes and
endoscopes provide high-power magnification and
illumination and also because the microscope is used
for the majority of the steps of the surgical procedure
in the studies where an endoscope was used during
root-end preparation.
The endodontic microsurgery procedures demonstrated significantly better cumulative success
rates than the studies that only employed loupes
when all 16 studies with a total of 1,309 teeth were
compared. Seven of 16 studies provided information
on the individual tooth type (four for CRS and three
for EMS), demonstrating a significant difference in
probability of success between the groups for molars.
Tsesis et al.29 provided an updated systematic review
on endodontic surgery in 2013 and also confirmed a
statistically significant difference in successful outcomes of both microscope and endoscope-assisted
procedures compared with loupes.

_Microscope features and upgrades
Modern dental microscopes have evolved considerably with regard to features and options available
to the dental clinician. Depending on personal preferences and possible locations in the operatory, floorstanding, wall- or ceiling-mounted units are available. While standard microscopes come with basic
optics and light options, certain accessory features
are recommended for endodontic purposes. Surgical
procedures will require greater angulations to view
resected root surfaces and other surgical details. At
a minimum, a microscope should be equipped with
180-degree-tiltable binoculars to address the angulation requirements and an eyepiece with a reticle.
A reticle is a set of fine lines, most commonly in the
shape of crosshairs or concentric rings, that provides
proper centering on the object in focus and allows
for easier individual calibration (parfocaling) of the

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

microscope. It also is an indispensable tool for documentation. Since light and the object image reach
the binoculars virtually free of shadows, microscope
photography and recording allow for excellent image
quality for documentation and clinical operations.
However, this requires perfect calibration with an
external monitor and a reticle to center the image.
Full high-definition and three-chip cameras are the
gold standard for video recording and available as external or internal solutions. Screenshots from video
recordings can be obtained at higher quality by using
post-processing software applications that allow for
image stacking.30 For still photography, new generation digital mirrorless cameras have demonstrated
advantages compared with DSLRs.
There is a variety of additional upgrades for
core microscope functions. Instead of fixed focal
distances that limit the microscope to an object distance of 200 mm, 250 mm or 300 mm, variable focal
distance adapters have become available, allowing
for easier switching between practitioners and easier
adjustment to patients of different statures. These
are offered in top-of-the-line microscopes, often in
conjunction with electrical zoom and fine focus options that allow smooth and stepless adjustments of
both magnification and focus. Extendable (foldable)

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Fig. 7_Pre-op image of a mandibular
right first molar in which nonsurgical
root canal treatment had been
completed five years ago. (Photos/
Provided by Dr. Frank C. Setzer)
Fig. 8_Clinical image shows
previously treated canals with
infected gutta-percha filling.
Fig. 9_A furcation canal is visible
under high magnification (arrow).
Fig. 10_A third distal canal is also
located under magnification.
Fig. 11_Post-operative radiograph
shows the retreated tooth with five
main canals.
Fig. 12_The one-year follow-up
radiograph demonstrates the
complete resolution of the
periradicular radiolucencies and
permanent restoration of the tooth.

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I C.E. article_ microscopes
binoculars were introduced for better ergonomics.
Magnetic arrest functions (clutch) are available
for increased stability, particularly for microscopes
with several documentation ports and attachments.
The practitioner can choose from a variety of light
sources. The traditional standard is still halogen (yellowish hue, peak at 600-700 nm, ~3300K) and the
brightest option is xenon (like daylight, homogeneous spectrum 400-700 nm, ~5500K), making it most
useful for the identification of fine details in deeper
areas of the root canal system and documentation.
Recently LED lights (green part of emission spectrum,
low at 450 nm and 550 nm, ~5700K) became available and offer a significantly longer lifetime, however, at a reduced brightness compared with xenon.

_Case study
Mandibular right first molar. Nonsurgical root
canal treatment had been completed five years
ago. Originally, a new crown restoration had been
planned. However, the periapical radiograph revealed periradicular radiolucencies (periapical and
in the furcation area) (Fig. 7). The patient received a
recommendation to extract the tooth due to the bone
loss in the furcation.
There were no symptoms, and periodontal probing depths were within normal limits, suggesting an
endodontic problem as the origin of the furcation
defect. Nonsurgical retreatment was initiated. The
clinical image shows the previously treated four canals with infected gutta-percha filling (Fig. 8). Under
high magnification, a furcation canal (Fig. 9, arrow)
and a third distal canal (Fig. 10) were located.
The post-operative radiograph shows the retreated tooth with five main canals (Fig. 11). The
one-year follow-up radiograph demonstrates the
complete resolution of the periradicular radiolucencies and permanent restoration of the tooth (Fig. 12).

_Conclusion
The dental operating microscope has become
an integral part of endodontic practice. For both
nonsurgical and surgical endodontic therapy it is
indispensable for excellency. Besides the obvious
benefits for clinical practice, evidence has become
available that demonstrates better outcomes compared with treatment without vision enhancement
or magnifying eyewear. Treatment rendered using
the dental operating microscope results in superior
care for patients, and modern endodontic therapy is
more effective because of its use._
This article originally appeared in ENDODONTICS:
Colleagues for Excellence, Winter 2016. Reprinted
with permission from the American Association of

Endodontists, ©2016. The AAE clinical newsletter is
available at www.aae.org/colleagues.
The following exclusive online bonus materials
associated with this article are also available at www.
aae.org/colleagues:
• Full-text article: Monea M, Hantoiu T, Stoica A,
Sita D, Sitaru A. The impact of operating microscope
on the outcome of endodontic treatment performed
by postgraduate students. Eur Sci J. 2015;305-311.
• Full-text article: Setzer FC, Shah S, Kohli M, Karabucak B, Kim S. Outcome Of Endodontic Surgery: A
Meta-Analysis Of The Literature - Part 1: Comparison
Of Traditional Root- End Surgery And Endodontic
Microsurgery. J Endod. 2010;36:1757-1765.
• Full-text article: Setzer FC, Kohli M, Shah S, Karabucak B, Kim S. Outcome of Endodontic Surgery: A
Meta-analysis of the Literature - Part 2: Comparison
of Endodontic Microsurgical Techniques With and
Without the Use of Higher Magnification. J Endod.
2012;38:1-10.
A complete list of references is available from the
publisher, and also at www.aae.org/colleagues.

_about the author

roots

Frank C. Setzer, DMD, PhD,
MS, is a diplomate of the
American Board of Endodontists, and an assistant
professor at the Department of Endodontics at the
University of Pennsylvania
School of Dental Medicine.
He teaches undergraduate
students and post-doctoral
residents. Setzer specializes
in root canal therapy, trauma
and surgical root canal procedures. He received his first
dental degree from the Dental School of the FriedrichAlexander-University Erlangen-Nuremberg, Germany, in
1995, where he also received his doctoral degree in 1998. He
pursued his endodontic specialty training at the University
of Pennsylvania after working for nine years in a multispecialist private practice as associate and partner. Setzer
graduated from the endodontic program of the University
of Pennsylvania in 2006, receiving the Louis I Grossman
Postdoctoral Award in Endodontics. He earned a master
of science in oral biology and a DMD degree in 2008 and
2010, respectively. Setzer is teaching as clinic director and
pre-doctoral program director at the Department of Endodontics of the University of Pennsylvania. Setzer lectures
frequently nationally and internationally, has published in
peer-reviewed journals and serves, among others, as the
associate editor for endodontics for Quintessence International and on the editorial advisory board of the Journal
of Endodontics and the Journal of the American Dental
Association. He can be contacted at fsetzer@upenn.edu.

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tribute_ Dr. Fred Weinstein

‘He brought a world of
enthusiasm and knowledge to the
global endodontic community’
Author_Fred Michmershuizen, Managing Editor
_He will be remembered as a friend, a teacher and
a healer. Fred Weinstein, DMD, a retired endodontist
from Vancouver, British Columbia, died Oct. 15,
2017, at the age of 78, after a brief illness. His fellow specialists expressed sadness at his passing and
acknowledged how his passion for the profession
rubbed off on them through many decades of friendship. Many are also remembering him for his ability to
have fun — especially when it came time to promote
an international endodontic conference hosted in his
native country.
“Fred has been an inspiration for me for all these
years, ever since we met over 30 years ago,” said
Gerald N. Glickman, DDS, MS, professor and chair

at Texas A&M College of Dentistry in Dallas, one of
many endodontists who shared fond memories of
Weinstein.
“What a remarkably kind and insightful individual
he was — always inquiring about me and others
and never letting on about himself,” Glickman remembered. “He brought a world of enthusiasm and
knowledge to the global endodontic community. I
will miss him dearly.”
“Fred was that special kind of person who would do
anything he could to help out when needed. He cared
for everyone and was a dear friend,” said John J. Stropko,
DDS, of Prescott, Ariz. “Fred was a teacher, always
encouraging others to use the latest technology to

Roots2018_01.indd 11

Fred Weinstein, DMD,
MRCD(C), FICD, FACD,
who passed away Oct. 15,
2017, at the age of 78,
is pictured in Anaheim,
Calif., at the California
Dental Association meeting,
CDA Presents the Art and
Science of Dentistry, in 2012.
A retired endodontist from
Vancouver, British Columbia,
Weinstein often traveled to
dental meetings to keep his
knowledge of the specialty
current and to visit with his
many friends. (Photo/
Fred Michmershuizen,
Managing Editor)

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I tribute_ Dr. Fred Weinstein
Left to right: In a print ad
published in the August
2007 issue of Endo Tribune,
Dr. Fred Weinstein dressed
as a Royal Canadian
‘Mountie’ to promote the
IFEA meeting, held that
year in Vancouver, British
Columbia.
Dr. Fred Weinstein
with ‘Queen Elizabeth,’
at the IFEA meeting
in 2007. (Photo/Fred
Michmershuizen,
Managing Editor)
Dr. Fred Weinstein
in Hamburg, Germany,
in the summer of 2017.
(Photo/Haye Hinrichs)

deliver better treatment
results for their patients.
During the process, he
went to great lengths
to clearly communicate
his beliefs in an easy-tounderstand manner. Our
specialty has lost one of
its great members.”
“I knew Fred for
more than 25 years,
and I always found it
entertaining to be in his
company,” said Anne
Lauren Koch, DMD. “We
went to hockey games,
basketball games and
endodontic meetings
together. Fred was a character, but in the best sense
of the word. He was entertaining, charming and
unpredictable. That was Fred. But to those of us who
knew and loved him, he was much more than that.
He was a loyal friend who made a maximum effort to
understand each of us in a personal and supportive
way. Really, at the end of the day, Fred was a mensch.
He will be very much missed.”
Weinstein was born in 1939 in Winnipeg, Manitoba. He graduated from the University of Manitoba
at the age of 22 with a degree in general dentistry,
and then he went on to study endodontics at the
University of Pennsylvania School of Dental Medicine in Philadelphia, under the tutelage of Dr. Louis
Grossman, known as the “Father of Endodontics.”
After receiving his Certificate in Endodontics from
the University of Pennsylvania in 1969, he moved his
family to Vancouver and established an office in the
Fairmont Medical Building, where he would go on to
practice for more than 40 years.
“He loved his patients, and he equally enjoyed
teaching and lecturing throughout the world to advance the learning within dentistry,” his family wrote
in an obituary published in the Vancouver Sun.
Weinstein’s accomplishments within the profession were notable. He served as an assistant clinical
professor at the University of British Columbia and
was a past president of the Canadian Academy

of Endodontics, the British Columbia Society of
Endodontics, the Interspeciality Society of British
Columbia and the International Federation of Endodontic Associations (IFEA). He was a member of the
Royal College of Dentists, and he was a fellow of the
American College of Dentists and the International
College of Dentists.
He served on advisory boards for several leading
dental manufacturers, and he lectured extensively
throughout the world. He also served as a volunteer
endodontist at the 2010 Vancouver Winter Olympics,
and performed root canal treatment on world boxing
champion Sugar Ray Leonard in the 1980s.
He was especially proud to have served as the general chairman for the 2007 IFEA World Congress in
Vancouver. To drum up excitement for that meeting,
he dressed as a Royal Canadian “Mountie” at several
events leading up to it — something that friends and
colleagues remembered for years.
“Fred always had a smile and was known as ‘the
Canadian Mountie’ for his outfit that he wore at every
dental meeting to promote the IFEA meeting in Vancouver in 2007,” remembered Samuel O. Dorn, DDS.
“He was truly dedicated to the Canadian Academy of
Endodontics and its place in global endodontics. His
passion for endodontics and his friendship will never
be forgotten.”
“I cherish my photo of us with him dressed as a
Mountie when he was president of IFEA,” said Dr.
William Ben Johnson. “Fred and I started out as endodontic colleagues, then became friends. So much
so he would go snow skiing with me even when he
didn’t care for skiing, and I would drink wine with him
when I preferred scotch. I’ve lost a friend.”
After his retirement from practice, Weinstein
continued to travel to dental meetings to keep his
knowledge of the specialty current and to visit with
his many friends.
For many years, Weinstein was editor in chief of
roots magazine, the international C.E. magazine of
endodontics, published by Dental Tribune America.
“Above all of Fred’s accomplishments and titles,
his family remained his number one priority in his life,
always,” his family wrote in the Sun. “He had a gentle
heart of gold, compassion and sincerity and a smile
that would illuminate a room.”_

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[14] =>

I research_ bioceramics

Ready-to-use bioceramic materials
in apical resorption: A clinical case
Author_Ricardo Affonso Bernardes

_Introduction: Bioceramic materials, with their
biocompatible type and excellent physic-chemical
properties, are frequently used in endodontics. They
can be used as cements, root repair materials, root
canal sealers and filling materials, which have the
advantages of greater biocompatibility, antibacterial
properties and sealing capacity. A further advantage
of these materials is their ability to form hydroxyapatite and ultimately create a bond between dentin
and the material.1
Calcium phosphate silicate cement (CPSC) is a new
generation of biological cement first proposed in 2006.
It contains phosphate salts in addition to hydraulic
calcium silicates. The purpose of its development was
the hope that the hydration method would improve the
Fig. 1_A) Initial radiography;
cement’s mechanical properties and biocompatibility.
B) Cone beam CT tooth #8;
As examples of CPSCs, Endosequence Root Repair
C) Cone beam CT tooth #9;
Material Putty and Endosequence Root Repair Material
D) Calcium hydroxide.
Paste (ERRM Paste; Brasseler, Savannah, Ga.) have been
(Photos/Provided by
industrialized as ready-to-use, premixed bioceramic
Ricardo Affonso Bernardes)
materials. Their main inorganic components include
C3S, C2S and calcium phosphates. The institution of
Fig. 2_A) Teeth #8, 9; B) Bio-C
premixed CPSCs eliminates the possibility of heterorepair; C) Applied Bio-C repair in
geneous consistency during on-site mixing. Because
apical buffer; D) Bio-C sealer;
the material is premixed with non-aqueous but waterE) Cones and Bio-C sealer;
miscible carriers, it will not set during storage and
F) Final radiography.
hardens only on exposure to an
aqueous environment.1,2
Objective: The aim of this
study was to show the ability and facility to use a novel
line of bioceramic endodontic
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
materials.
Method: A 67-year-old female after orthodontics treatment with a symptomatic
right upper central incisor was
assessed at a private endodontic clinic. She complained
Fig. 2a
Fig. 2b
Fig. 2c
of spontaneous pain. Clinical
examination showed a buccal
abscess with fistula. The tooth
was sensitive to percussion
and to palpation. Cold test was
Fig. 2d
Fig. 2e
Fig. 2f
negative. Radiographic exami-

nation demonstrated an apical resorption. Cone beam
CT showed apical resorption in both central incisors,
bigger in #8. The root canals were instrumented with
Root Zx 2 (J Morita Corp., California) and Endossequence Rotary limes 35.04 until 50.04 (Brasseler) using
2.5 percent sodium hypochlorite and EDTA, as well
as with the tip 20.01 (Helse Ultrasonic Ocoee, USA).
Calcium hydroxide was used as root canal dressing for
14 days and, after remission of symptoms, the apical
buffer was performed with the new, ready-to-use
Bioceramic BIO-C REPAIR cement (Angelus, Londrina,
Brazil), and root canals were filled with the new, readyto-use BIO-C SEALER (Angelus, Londrina, Brazil) and
single gutta-percha cones 50.04 (Tanari Amazonas,
Brazil). The cones were then cut with touch heat and
condensed.
Conclusion: Both products showed the ability and
efficiency to be used in repair of resorptions and filling root canals, respectively._

_References
1.

Physical properties and hydration behavior of a fast-setting
bioceramic endodontic material. Ya-juan Guo. Tian-feng
Du, Hong-bo Li, Ya Shen, Christophe Mobuchon, Ahmed
Hieawy, Zhe-jun Wang, Yan Yang, Jingzhi Ma, and Markus
Haapasalo. BMC Oral Health. 2016; 16: 23.
Bioceramic materials in Endodontics. Zhejun Wang.
Endodontic Topics 2015, 32, 3-30.

_about the author

roots

Ricardo Affonso Bernardes
graduated in dentistry from
the University of Uberaba in
1990. He graduated in endodontics from Bauru Dental
School at the University of
Sao Paulo in 1994. He received a master of science
in endodontics in 2002 and
a PhD in endodontics from
the Bauru Dental School at
the University of Sao Paulo
in 2013. He is a visiting professor and post doctoral at
University of British Columbia, Vancouver, 2013. He is
teacher and chairman, Endodontics Department, School of
Dentistry, Brazilian Association of Dentistry, Brasilia DF.

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[15] =>

industry_ Sonendo

I

Minimally invasive root canal
treatment uses fluids, acoustics
Author_Sonendo Staff

_The GentleWave® System offers a minimally invasive1 alternative to standard root canal treatment,
employing patented Multisonic Ultracleaning® technology to deliver fluids throughout the entire root
canal system.1
The advanced combination of fluid dynamics and
broad-spectrum acoustic technology2 enables the
GentleWave Procedure to reach into the deepest,
most complex portions of the root canal system1,2 to
remove tissue, debris and bacteria.2
The result is a more thorough, more effective
cleaning that potentially helps reduce the need for
retreatments over time.3
The GentleWave procedure also helps preserve
the integrity and functionality of the tooth by leaving
more of the dentin structure intact3 and can typically
be completed in just one session.3
For more information, you can contact Sonendo®
at (844) 766-3636 or visit www.Sonendo.com._

_References
1
2.
3.

Molina B et al. (2015) J Endod. 41:1701-1705.
Vandrangi P et al. (2015) Oral Health 72-86.
Sigurdsson A et al. (2016) J Endod. 42:1040-1048.

(Photo/Provided by Sonendo)

		

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[16] =>

I industry_ Vista Dental Products

The importance of irrigation
and PUI in modern endodontics
Author_Vista Dental Products Staff

Chlor-XTRA and SmearOFF 2-in-1
are ideal with the EndoUltra cordless
activation device. (Photo/Provided by
Vista Dental Products)

_The goal of root canal cleaning and shaping is
the removal of vital or necrotic tissue, microorganisms and their byproducts while providing space
for placing obturation material. The ultimate goal
being the complete removal and disinfection of the
endodontic space.
The tools used in mechanical enlargement of
the root canal space are unable to conform to the
intricate root canal anatomy. It has been shown
that conventional instrumentation leaves as much
as 35 percent of the canal anatomy untouched.
Instrumentation and irrigation, although important
factors in canal disinfection, cannot in themselves
be relied upon for optimal canal cleanliness. As the

market trends toward fewer required instruments,
there is a resulting negative impact and consequence
of less associated irrigation. This has impacted endodontic retreatment rates.
Acoustic streaming and cavitation have been
proven to significantly enhance cleaning of difficult
anatomy. When ultrasonic activation is introduced,
irrigant streaming and cavitation occur, resulting in
significantly improved debridement of canal spaces,
disruption of biofilm and improved penetration of
irrigants into dentinal tubules. The ultrasonic activation of irrigants greatly reduces bacteria levels and
improves root sealing.
EndoUltra™ is the only cordless, activation device available. Not tied to a wall, the cordless device
is easily incorporated into one’s existing irrigation
protocol. Incorporating this product as well as enhanced irrigants into irrigation protocol is an effective, predictable method of improving endodontic
care, according to the company.
Vista Dental Products asserts that its patented
solutions Chlor-XTRA™ and SmearOFF™ 2-in-1 are
great options when developing a predictable irrigation regiment. Chlor-XTRA™ is an enhanced NaOCl.
Proprietary chemistry gives this 6 percent NaOCl a
lower surface tension, allowing for improved penetration into canal anatomy and significantly faster
tissue dissolution compared with standard NaOCl.
SmearOFF is an EDTA-based formula enhanced
with chlorhexidine. SmearOFF not only effectively
removes the smear layer, but also kills bacteria in one
easy step. Unlike other two-in-one mixes, SmearOFF
is compatible with sodium hypochlorite and will not
form a precipitate, eliminating steps and saving time
with each procedure.
Enhanced irrigants paired with ultrasonic activation is key to thoroughly cleansing canal anatomy.
Vista Dental Products asserts that it offers a fantastic
product line to not only simplify the irrigation process,
but to more predictably achieve endodontic success.
For more information, call Vista Dental Products
at (877) 418-4782 or visit www.vista-dental.com._

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industry education_ LVI

There is a better way
(and LVI can show you
how to get there)
Author_Mark Duncan, DDS, FAGD, LVIF, DICOI, FICCMO, Clinical Director, LVI
_You know how those days go — all morning long,
it felt like you were struggling to keep on track with
the schedule. Your team is frustrated because they
haven’t had their full hour lunch more than one day
a week in as long as they can remember. You walked
by the sterilization room 15 minutes ago, and it sure
sounded like they were complaining to each other
because you said to work in that emergency, and they
were struggling to figure out how to pick up their kid
from daycare on time. Again.
You want them to enjoy working here, but you
have to be able to pay the bills. And your best assistant
asked you again if she can have that raise you have
been promising her. Don’t they understand?
Today will be another day of three chairs and
patient after patient asking you questions about
treatment, all eager to get started with getting their
mouth fixed, but yet you still won’t see any of them
show up on the schedule. They said they wanted to
do the work, but for some reason, they never seem to
come back and do it.
They say insurance doesn’t cover it, or they ask for
a pre-determination. Too bad they don’t know the
pre-determination doesn’t mean much.
Today, you have 27 patients on your schedule and
will work your butt off and still not have a chance to
pee. It looks like you should be able to be done by 5,
but today will finish worse than yesterday.
It feels like half of your patients are crankier than
you are, and your team isn’t really talking to you
today, and you know when you get home, all you will
want to do is go to sleep and wake up on Saturday —
except it’s still Tuesday!
It doesn’t make sense — you have taken C.E. courses
every time they come to town. The new insurance plan
was supposed to make things easier. You bought a
bunch of new equipment to save money on taxes — of
course now you have to pay for it every month — but

why does it seem like the harder you work, the further
behind you get? There has to be a simple reason.
Well, it turns out there actually is — and it’s something that you learned when you were about 5! Do
unto others. More specifically, build systems in your
office so that you can treat your patients the way you
would want to be treated — comprehensively and with
exceptional information to make good decisions — and
produce a consistent experience time after time.
While doing that, add exceptional care — esthetic
adhesive excellence like you see in the journals. But how?
Well, the answer happens to be the foundation that LVI
was built upon — building the excellence in a patientcentered practice. And the programs at LVI have been
teaching clinical excellence and communication and
business systems for almost 20 years to help doctors
do a better job of not only seeing the patient but, more
importantly, connecting with them. Two decades of not
only communication but comprehensive diagnosis and
clinical excellence. As a result, the doctors at LVI have a
statistically higher professional satisfaction and income.
Isn’t it time you go find out what they are doing
differently? Yes. Yes it is — and congratulations on the
journey you are about to start._

Roots2018_01.indd 17

The Las Vegas Institute for Advanced
Dental Studies. (Photo/Sierra
Rendon, Dental Tribune)

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about the publisher _ imprint

roots

the international C.E. magazine of endodontics

U.S. Headquarters
Tribune America
116 West 23rd Street, Ste. 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
feedback@dental-tribune.com
www.dental-tribune.com
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
President/Chief Executive
Officer
Eric Seid
e.seid@dental-tribune.com
Group Editor
Kristine Colker
k.colker@dental-tribune.com

Roots Managing Editor
Fred Michmershuizen
f.michmershuizen
@dental-tribune.com
Managing Editor
Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor
Robert Selleck
r.selleck@dental-tribune.com
Education Director
Christiane Ferret
c.ferret@dtstudyclub.com
Client Relations Coordinator
Leerol Colquhoun
l.colquhoun@dental-tribune.com

Product/Account Manager
Humberto Estrada
h.estrada@dental-tribune.com
Product/Account Manager
Maria Kaiser
m.kaiser@dental-tribune.com
Product/Account Manager
Jordan McCumbee
j.mccumbee@dental-tribune.com
Feedback & General Inquiries
feedback@dental-tribune.com

Editorial Board

Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
Daniel Heysselaer, Roeland de Moor, Julia
Kamenova, T. Dostalova, Christliebe Pasini,
Peter Steen Hansen, Aisha Sultan, Ahmed
A Hassan, Marita Luomanen, Patrick Maher,
Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit
Sahar-Helft, Lajos Gaspar, Paolo Vescovi,
Marina Vitale, Carlo Fornaini, Kenji Yoshida,
Hideaki Suda, Ki-Suk Kim, Liang Ling Seow,
Shaymant Singh Makhan, Enrique Trevino,
Ahmed Kabir, Blanca de Grande, José Correia
de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep
Arnabat, Ahmed Abdullah, Boris Gaspirc,
Peter Fahlstedt, Claes Larsson, Michel Vock,
Hsin-Cheng Liu, Sajee Sattayut, Ferda Tasar,
Sevil Gurgan, Cem Sener, Christopher Mercer,
Valentin Preve, Ali Obeidi, Anna-Maria
Yannikou, Suchetan Pradhan, Ryan Seto, Joyce
Fong, Ingmar Ingenegeren, Peter Kleemann,
Iris Brader, Masoud Mojahedi, Gerd Volland,
Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz,
Herbert Deppe, Friedrich Lampert, Jörg
Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert

Tribune America is the official media partner of:

roots_Copyright Regulations
_the international C.E. magazine of roots published by Tribune America is printed quarterly. The magazine’s articles and illustrations are
protected by copyright. Reprints of any kind, including digital mediums, without the prior consent of the publisher are inadmissible and liable
to prosecution. This also applies to duplicate copies, translations, microfilms and storage and processing in electronic systems. Reproductions,
including excerpts, may only be made with the permission of the publisher.
All submissions to the editorial department are understood to be the original work of the author, meaning that he or she is the sole copyright
holder and no other individual(s) or publisher(s) holds the copyright to the material. The editorial department reserves the right to review all
editorial submissions for factual errors and to make amendments if necessary.
Tribune America does not accept the submission of unsolicited books and manuscripts in printed or electronic form and such items will
be disposed of unread should they be received.
Tribune America strives to maintain the utmost accuracy in its clinical articles. If you find a factual error or content that requires clarification, please contact Group Editor Kristine Colker at k.colker@dental-tribune.com. Opinions expressed by authors are their own and may
not reflect those of Tribune America and its employees.
Tribune America cannot assume responsibility for the validity of product claims or for typographical errors. The publisher also does not
assume responsibility for product names or statements made by advertisers.
The responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability
arising from inaccurate or faulty representation are excluded. General terms and conditions apply, and the legal venue is New York, New York.

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Table of contents

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