roots C.E. No. 2, 2014

Cover / Editorial / Content / Endodontic irrigants and irrigant delivery systems / Control the anatomy; control procedural training / LVI Core I three-day course is designed for doctors and their teams to learn together / Sonendo: Root canals clean at the speed of sound / Introducing Grey MTA Plus — ‘Reshaping’ root canal practices everywhere / Imprint

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Table of contents

roots
issn 2161-6558

the international C.E. magazine of

2

2014

_C.E. article

Endodontic irrigants
and irrigant delivery
systems

_education

Control the anatomy;
control procedural training

_industry education

LVI Core I three-day course
is designed for doctors and
their teams to learn together

North America Edition • Vol. 5 • Issue 2/2014

endodontics

[2] =>

[3] =>

editorial _ roots

New ways
to learn
When it comes to dentistry in general, and the specialty of endodontics in particular, there is always
a lot to learn. That’s why dental meetings like the AAE Annual Session are so important. The dental literature is valuable as well — especially a C.E. magazine like the one you are holding now (more on that
in a moment).
In this issue of roots, you can find articles on new ways to learn. Namely, there are new 3-D training
replicas, available from Dr. L. Stephen Buchanan and his team at Dental Education Laboratories. (These new
tooth models, I’m told, are a delight to work with.) There’s an article about a three-day course available at
the Las Vegas Institute for Advanced Dental Studies. This issue also contains a report by Dr. Gary Glassman
on endodontic irrigation. He reveals the results of research on various irrigation systems and their efficacy.
By reading the article by Dr. Glassman, then taking a short online quiz about his article at www.
DTStudyClub.com, you will gain one ADA CERP-certified C.E. credit. Keep in mind that because roots
is a quarterly magazine, you can actually chisel four C.E. credits per year out of your already busy life
without the lost revenue and time away from your practice.
To learn more about how you can take advantage of this C.E. opportunity, visit www.DTStudyClub.
com. You need only register at the Dental Tribune Study Club website to access these C.E. materials free of
charge. You may take the C.E. quiz after registering on the DT Study Club website.
I know that taking time away from your practice to pursue C.E. credits is costly in terms of lost revenue
and time, and that is another reason roots is such a valuable publication. I hope you will enjoy this issue
and that you will take advantage of the C.E. opportunity.
For those of you attending the AAE Annual Session this spring in Washington, D.C., be sure to say hello
in person. I’ll also be at the spring CDA Presents the Art and Science of Dentistry meeting in Anaheim, Calif.
As always, I welcome your comments and feedback.

Fred Weinstein, DMD, MRCD(C),
FICD, FACD

Sincerely,

Fred Weinstein, DMD, MRCD(C), FICD, FACD
Editor in Chief

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I content_ roots

page 14

page 06

page 19

I C.E. article
06	Endodontic irrigants and irrigant
delivery systems
_Gary Glassman, DDS, FRCD(C)

I education
14	Control the anatomy; control
procedural training

_L Stephen Buchanan, DDS, FICD, FACD

I industry education
19	LVI Core I three-day course is designed for
doctors and their teams to learn together

_Mark Duncan, DDS, FAGD, LVIF, DICOI, FICCMO

I industry
20

Sonendo: Root canals clean at the speed of sound

21	Introducing Grey MTA Plus — ‘Reshaping’ root
canal practices everywhere

I about the publisher
22

_imprint

page 20

04 I roots
2_ 2014

roots

North America Edition • Vol. 5 • Issue 2/2014

issn 2161-6558

the international C.E. magazine of

2

endodontics

2014

_C.E. article

Endodontic irrigants
and irrigant delivery
systems

_education

Control the anatomy;
control procedural training

_industry education

LVI Core I three-day course
is designed for doctors and
their teams to learn together

I on the cover

The image is of a TrueTooth™ training replica. Designed
by Dr. L. Stephen Buchanan and re-created by a 3-D
printer, these are authentic replicas of the internal and
external anatomy of CT-scanned extracted teeth, with
bleach-dissolvable material in the root canal passageways.
TrueTooth training replicas are available exclusively from
www.DELendo.com and are patent pending. (Image/
Provided by L. Stephen Buchanan, DDS, FICD, FACD)

page 20

page 21

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I C.E. article_ irrigation

Endodontic irrigants
and irrigant delivery
systems
Author_Gary Glassman, DDS, FRCD(C)

_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 — 2/2014). 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.

Figs. 1a,b_Root-canal complex.
(Images/Dr Ronald Ordinala Zapata,
Brazil, www.facebook.com/
TheInternalAnatomy
OfTheHumanTeeth)

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_Endodontic treatment is a predictable procedure with high success rates. Success depends
on a number of factors, including appropriate
instrumentation, successful irrigation and decontamination of the root-canal space to the apices
and in areas such as isthmuses. These steps must be
followed by complete obturation of the root canals,
and placement of a coronal seal, prior to restorative
treatment.
Several irrigants and irrigant delivery systems
are available, all of which behave differently
and have relative advantages and disadvantages.
Common root-canal irrigants include sodium
hypochlorite (NaOCl), chlorhexidine gluconate,
alcohol, hydrogen peroxide and ethylenediaminetetraacetic acid (EDTA). In selecting an irrigant and

technique, consideration must be given to their
efficacy and safety.
With the introduction of modern techniques,
success rates of up to 98 percent are being
achieved.1 The ultimate goal of endodontic treatment per se is the prevention or treatment of apical
periodontitis, such that there is complete healing
and an absence of infection,2 while the overall
long-term goal is the placement of a definitive,
clinically successful restoration and preservation
of the tooth. For these to be achieved, appropriate
instrumentation, irrigation, decontamination and
root-canal obturation must occur, as well as attainment of a coronal seal.
There is evidence that apical periodontitis is a
biofilm-induced disease.3 A biofilm is an aggregate

Fig. 1a

Fig. 1b

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C.E. article_ irrigation

of microorganisms in which cells adhere to each
other and/or to a surface. These adherent cells are
frequently embedded within a self-produced matrix
of extracellular polymeric substance. The presence of
microorganisms embedded in a biofilm and growing in the root-canal system is a key factor for the
development of periapical lesions.4–7 Additionally,
the root-canal system has a complex anatomy that
consists of arborisations, isthmuses and cul-de-sacs
that harbor organic tissue and bacterial contaminants (Figs. 1a,b).8
The challenge for successful endodontic treatment has always been the removal of vital and
necrotic remnants of pulp tissue, debris generated
during instrumentation, the dentin smear layer,
microorganisms, and micro-toxins from the rootcanal system.9
Even with the use of rotary instrumentation, the
nickel-titanium instruments currently available only
act on the central body of the root canal, resulting
in a reliance on irrigation to clean beyond what may
be achieved by these instruments.10 In addition, Enterococcus faecalis and Actinomyces prevention or
treatment of apical periodontitis such as Actinomyces israelii — which are both implicated in endodontic
infections and in endodontic failure — penetrate
deep into dentinal tubules, making their removal
through mechanical instrumentation impossible.11,12
Finally, E. faecalis commonly expresses multidrug
resistance,13–15 complicating treatment.
Therefore, a suitable irrigant and irrigant delivery
system are essential for efficient irrigation and the
success of endodontic treatment.16 Root-canal irrigants must not only be effective for dissolution of
the organic of the dental pulp, but also effectively
eliminate bacterial contamination and remove the
smear layer — the organic and inorganic layer that
is created on the wall of the root canal during instrumentation. The ability to deliver irrigants to the
root-canal terminus in a safe manner without causing harm to the patient is as important as the efficacy
of those irrigants.
Over the years, many irrigating agents have
been tried in order to achieve tissue dissolution and
bacterial decontamination. The desired attributes of
a root-canal irrigant include the ability to dissolve
necrotic and pulpal tissue, bacterial decontamination and a broad antimicrobial spectrum, the ability to
enter deep into the dentinal tubules, biocompatibility
and lack of toxicity, the ability to dissolve inorganic
material and remove the smear layer, ease of use, and
moderate cost.
As mentioned above, root-canal irrigants currently in use include hydrogen peroxide, NaOCl,
EDTA, alcohol and chlorhexidine gluconate. Chlorhexidine gluconate offers a wide antimicrobial
spectrum, the main bacteria associated with en-

I

dodontic infections (E. faecalis and A. israelii) are
sensitive to it, and it is biocompatible, with no tissue
toxicity to the periapical or surrounding tissue.17
Chlorhexidine gluconate, however, lacks the ability
to dissolve necrotic tissue, which limits its usefulness. Hydrogen peroxide as a canal irrigant helps
to remove debris by the physical act of irrigation,
as well as through effervescing of the solution.
However, while an effective anti-bacterial irrigant, hydrogen peroxide does not dissolve necrotic
intra-canal tissue and exhibits toxicity to the surrounding tissue.
Cases of tissue damage and facial nerve damage
have been reported following use of hydrogen peroxide as a root-canal irrigant.18 Alcohol-based canal
irrigants have antimicrobial activity too, but they do
not dissolve necrotic tissue.
The irrigant that satisfies most of the requirements for a root-canal irrigant is NaOCl.19,20 It has
the unique ability to dissolve necrotic tissue and
the organic components of the smear layer.19,21,22 It
also kills sessile endodontic pathogens organized in
a biofilm.23,24 There is no other root-canal irrigant
that can meet all these requirements, even with
the use of methods such as lowering the pH,25–27 increasing the temperature28–32 or adding surfactants
to increase the wetting efficacy of the irrigant.33,34
However, although NaOCl appears to be the most
desirable single endodontic irrigant, it cannot dissolve inorganic dentine particles and thus cannot
prevent the formation of a smear layer during
instrumentation.35
Calcifications hindering mechanical preparation
are frequently encountered in the root-canal system, further complicating treatment. Demineralizing agents such as EDTA have therefore been recommended as adjuvants in root-canal therapy.20,36
Thus, in contemporary endodontic practice, dual
irrigants such as NaOCl with EDTA are often used as
initial and final rinses to circumvent the shortcomings of a single irrigant.37–39 These irrigants must be
brought into direct contact with the entire canalwall surfaces for effective action,20,37,40 particularly
in the apical portions of small root canals.9
The combination of NaOCl and EDTA has been
used worldwide for antisepsis of root-canal systems. The concentration of NaOCl used for rootcanal irrigation ranges from 2.5 to 6 percent,
depending on the country and local regulations; it
has been shown, however, that tissue hydrolyzation
is greater at the higher end of this range, as demonstrated in a study by Hand et al. comparing 2.5 and
5.25 percent NaOCl.
The higher concentration may also favor superior
microbial outcomes.41 NaOCl has a broad antimicrobial spectrum,20 including but not limited to E.
faecalis. NaOCl is superior among irrigating agents

		

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I C.E. article_ irrigation
that dissolve organic matter. EDTA is a chelating
agent that aids in smear layer removal and increases
dentine permeability,42,43 which will allow further
irrigation with NaOCl to penetrate deep into the
dentinal tubules.44

_General safety precautions
Regardless of which irrigant and irrigation system is employed, and particularly if an irrigant with
tissue toxicity is used, there are several general precautions that must be followed. A rubber dam must
be used and a good seal obtained to ensure that no
irrigant can spill from the pulp chamber into the oral
cavity. If deep caries or a fracture is present adjacent
to the rubber dam on the tooth being isolated, a
temporary sealing material must be used prior to
performing the procedure to ensure a good rubber
dam seal. It is also important to protect the patient’s
eyes with safety glasses and protect clothing from
irrigant splatter or spill.
It is very important to note that while NaOCl
has unique properties that satisfy most requirements for a root-canal irrigant, it also exhibits
tissue toxicity that can result in damage to the
adjacent tissue, including nerve damage should
NaOCl incidents occur during canal irrigation.
Furthermore, Salzgeber reported in the 1970s
that apical extrusion of an endodontic irrigant
routinely occurred in vivo.45 This highlights the
importance of using devices and techniques that
minimize or prevent this. NaOCl incidents are
discussed later in this article.

_Irrigant delivery systems
Root-canal irrigation systems can be divided
into two categories: manual agitation techniques
and machine-assisted agitation techniques.9
Manual irrigation includes positive-pressure irrigation, which is commonly performed with
a syringe and a sidevented needle. Machineassisted irrigation techniques include sonics and
ultrasonics, as well as newer systems such as
the EndoVac (SybronEndo), which delivers apical
negative-pressure irrigation,46 the plastic rotary F
File (Plastic Endo),47,48 the Vibringe (Vibringe),49 the
Rinsendo (Air Techniques),9 and the EndoActivator
(DENTSPLY Tulsa Dental Specialties).9
Two important factors that should be considered
during the process of irrigation are whether the irrigation system can deliver the irrigant to the whole
extent of the root-canal system, particularly to the
apical third, and whether the irrigant is capable of
debriding areas that could not be reached with mechanical instrumentation, such as lateral canals and
isthmuses. When evaluating irrigation of the apical

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third, the phenomenon of apical vapor lock should
be considered.50–52

_Apical vapor lock
Because roots are surrounded by the periodontium, and unless the root-canal foramen is open, the
root canal behaves like a closed-ended channel. This
produces an apical vapor lock that resists displacement during instrumentation and final irrigation,
thus preventing the flow of irrigant into the apical
region and adequate debridement of the root-canal
system.53,54
Apical vapor lock also results in gas entrapment
at the apical third.9 During irrigation, NaOCl reacts
with organic tissue in the root-canal system, and the
resulting hydrolysis liberates abundant quantities of
ammonia and carbon dioxide.55 This gaseous mixture
is trapped in the apical region and quickly forms a
column of gas into which further fluid penetration is
impossible. Extension of instruments into this vapor
lock does not reduce or remove the gas bubble,56 just
as it does not enable adequate flow of irrigant.
The phenomenon of apical vapor lock has been
confirmed in studies in which roots were embedded
in a polyvinylsiloxane impression material to restrict
fluid flow through the apical foramen, simulating a
closed-ended channel. The result in these studies was
incomplete debridement of the apical part of the canal walls with the use of a positive-pressure syringe
delivery technique.57–60
Micro-CT scanning and histological tests conducted by Tay et al. have also confirmed the presence
of apical vapor lock.60 In fact, studies conducted
without ensuring a closed-ended channel cannot be
regarded as conclusive on the efficacy of irrigants
and the irrigant system.61–63 The apical vapor lock may
also explain why in a number of studies investigators
were unable to demonstrate a clean apical third in
sealed root canals.59, 64–66
In a paper published in 1983 based on research,
Chow determined that traditional positive-pressure
irrigation had virtually no effect apical to the orifice
of the irrigation needle in a closed root-canal system.67 Fluid exchange and debris displacement were
minimal. Equally important to his primary findings,
Chow set forth an infallible paradigm for endodontic irrigation: “For the solution to be mechanically
effective in removing all the particles, it has to: (a)
reach the apex; (b) create a current (force); and (c)
carry the particles away.”67 The apical vapor lock and
consideration for the patient’s safety have always
prevented the thorough cleaning of the apical 3 mm.
It is critically important to determine which irrigation
system will effectively irrigate the apical third, as well
as isthmuses and lateral canals,16 and in a safe manner that prevents the extrusion of irrigant.

[9] =>

C.E. article_ irrigation

EndoVac® Setup

_Manual agitation techniques
By far the most common and conventional set
of irrigation techniques, manual irrigation involves
dispensing of an irrigant into a canal through needles/cannulae of variable gauges, either passively or
with agitation by moving the needle up and down
the canal space without binding it on the canal
walls. This allows good control of needle depth and
the volume of irrigant that is flushed through the
canal.9,63 However, the closer the needle tip is positioned to the apical tissue, the greater the chance
of apical extrusion of the irrigant.67, 68 This must be
avoided; were NaOCl to extrude past the apex, a
catastrophic accident could occur.69

Fig. 2_EndoVac setup. (Images/
Provided by Gary Glassman,
DDS, FRCD(C))

Macro cannula and
Micro cannula tubing

Multiport Adaptor

High-volume suction

Master delivery
tip (MDT) suction
tubing

_Manual-dynamic irrigation

Fig. 2

Manual-dynamic irrigation involves gently moving a well-fitting gutta-percha master cone up and
down in short 2- to 3-mm strokes within an instrumented canal, thereby producing a hydrodynamic
effect and significant irrigant exchange.70 Recent
studies have shown that this irrigation technique
is significantly more effective than automateddynamic irrigation and static irrigation.9,71,72

geous to apply ultrasonics after completion of
canal preparation rather than as an alternative to
conventional instrumentation.9,20,77 PUI irrigation
allows energy to be transmitted from an oscillating
file or smooth wire to the irrigant in the root canal by
means of ultrasonic waves.9 There is consensus that
PUI is more effective than syringe needle irrigation
at removing pulpal tissue remnants and dentine debris.78–80 This may be due to the much higher velocity
and volume of irrigant flow that are created in the
canal during ultrasonic irrigation.9,81 PUI has been
shown to remove the smear layer; there is a large
body of evidence with different concentrations of
NaOCl.9,80–84 In addition, numerous investigations
have demonstrated that the use of PUI after hand
or rotary instrumentation results in a significant
reduction in the number of bacteria,9,85–87 or achieves
significantly better results than syringe needle irrigation.9,84,88,89
Studies have demonstrated that effective delivery
of irrigants to the apical third can be enhanced by
using ultrasonic and sonic devices that demonstrate
acoustic micro-streaming and cavitation.79,81,90,91
Acoustic micro-streaming is defined as the movement of fluids along cell membranes, which occurs as
a result of the ultrasound energy creating mechanical pressure changes within the tissue. Cavitation
is defined as the formation and collapse of gas and
vapor-filled bubbles or cavities in a fluid.
The Apical Vapor Lock theory, proven in vitro by
Tay, has been clinically demonstrated92 to also include the middle third by Vera: “The mixture of gases
is originally trapped in the apical third, but then it
might grow quickly by the nucleation of the smaller
bubbles, forming a gas column that might not only
impede penetration of the irrigant into the apical
third but also push it coronally after it has been delivered into the canal.” However, more recently Munoz93
demonstrated that both passive ultrasonic irrigation

_Machine-assisted agitation systems
Sonic irrigation
Sonic activation has been shown to be an effective method for disinfecting root canals, operating
at frequencies of 1–6k Hz.73, 74 There are several sonic
irrigation devices on the market. The Vibringe allows delivery and sonic activation of the irrigating
solution in one step. It employs a two-piece syringe
with a rechargeable battery. The irrigant is sonically
activated, as is the needle that attaches to the syringe.
The EndoActivator is a more recently introduced
sonically driven canal irrigation system.9,75 It consists
of a portable handpiece and three types of disposable
polymer tips of different sizes. The EndoActivator has
been reported to effectively clean debris from lateral
canals, remove the smear layer and dislodge clumps
of biofilm within the curved canals of molar teeth.9
Ultrasonics
Ultrasonic energy produces higher frequencies
than sonic energy but low amplitudes, oscillating at
frequencies of 25–30 kHz.9,76 Two types of ultrasonic
irrigation are available. The first type is simultaneous
ultrasonic instrumentation and irrigation, and the
second type is referred to as passive ultrasonic irrigation operating without simultaneous irrigation (PUI).
The literature indicates that it is more advanta-

		

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I C.E. article_ irrigation
(PUI) and EndoVac are more effective than the conventional endodontic needle in delivering irrigant to
WL of root canals.”
This raises the efficacy question. Two recently
published studies examined this issue with both
systems by testing their ability to eliminate microorganisms during clinical treatment from infected root
canal systems.94,95 Paiva fund that after a supplementary irrigation procedure using PUI with NaOCl that
23 percent of the samples produced positive cultures.
Cohenca’s study examining the clinical efficacy of
the EndoVac fund no microbial growth either after
post instrumentation irrigation or at the one92 week
obturation appointment.
When questioning these diverse results, one must
remember that microbial hydrolysis via NaOCl is an
equilibrium reaction. Hand demonstrated that a 50
percent reduction of NaOCl concentration resulted in
a 300 percent reduction in dissolution activity.
Accordingly, one must consider both the delivery
of the irrigant to full working length, via PUI or apical
negative pressure and the total volume of NaOCl exchanged. The volume of an instrumented root canal 19
mm long shaped to a #35 with a 6 percent instrument
equals 0.014 cc. Paiva described placement of NaOCl
via a NaviTip (Ultradent) at WL — 4 mm during instrumentation and discussed using PUI with #15 K file at
WL — 1 mm. Prior to PUI, 2 ml of NaOCl was injected
into the canal; however, this could not have filled the
apical 4 mm95 due to the apical vapor lock. According
to Munoz, the canal was most likely immediately filled
with ultrasonically activated NaOCl for one minute,92
but as just described — only about 0.014 cc would
have been effectively available for this exchange and
activation. In contrast, the Apical Negative Pressure
protocol described by Cohenca et al. approximately 2 ml
of NaOCl actively passes through the complete WL for
one92 minute.96 The difference in volumetric exchange
equals 2/0.014 = 14, 200 percent and likely explains the
disinfection differential.

_The plastic rotary F File
Although sonic or ultrasonic instrumentation is
more effective at removing residual canal debris than
rotary endodontic files are,104 and irrigation solutions
are often unable to remove this during endodontic
treatment, many clinicians still do not incorporate it
into their endodontic instrument armamentarium.
The common reasons given for not using sonic or
ultrasonic filing are that it can be time-consuming to
set up, an unwillingness to incur the cost of the equipment, and lack of awareness of the benefits of this
final instrumentation step in endodontic treatment.
It is for these reasons that an endodontic polymerbased rotary finishing file was developed. This new,
single-use, plastic rotary file has a unique file design

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with a diamond abrasive embedded into a non-toxic
polymer. The F File will remove dentinal wall debris and
agitate the NaOCl without enlarging the canal further.

_Pressure-alternation devices
Rinsendo irrigates the canal by using pressuresuction technology. Its components are a handpiece,
a cannula with a 7 mm exit aperture, and a syringe
carrying irrigant. The handpiece is powered by a
dental air compressor and has an irrigation speed of
6.2 ml per minute. Research has shown that it has
promising results in cleaning the root-canal system,
but more research is required to provide scientific
evidence of its efficacy. Periapical extrusion of irrigant has been reported with this device.101, 102

_The EndoVac apical negative-pressure
system
The EndoVac apical negative-pressure irrigation
system has three components: the Master Delivery
Tip, MacroCannula and MicroCannula. The Master
Delivery Tip simultaneously delivers and evacuates
the irrigant (Fig. 2). The MacroCannula is used to suction irrigant from the chamber to the coronal and
middle segments of the canal. The MacroCannula or
MicroCannula is connected via tubing to the highspeed suction of a dental unit. The Master Delivery Tip
is connected to a syringe of irrigant and the evacuation hood is connected via tubing to the high-speed
suction of a dental unit.56 The plastic MacroCannula
has an open end of ISO size 0.55 mm in diameter with
a 0.02 taper and is attached to a handpiece for gross,
initial flushing of the coronal and mid-length parts of
the root canal. The MicroCannula contains 12 microscopic holes and is capable of evacuating debris to full
working length.102
The ISO size 0.32 mm diameter stainless-steel
MicroCannula has four sets of three laser-cut, laterally positioned offset holes adjacent to its closed
end, 100 μ in diameter and spaced 100 μ apart. This
is attached to a finger piece for irrigation of the apical part of the canal when it is positioned at working
length. The MicroCannula can be used in canals that
are enlarged with endodontic files to ISO size 35.04
or larger.
During irrigation, the Master Delivery Tip delivers irrigant to the pulp chamber and siphons off the
excess irrigant to prevent overflow. Both the MacroCannula and MicroCannula exert negative pressure
that pulls fresh irrigant from the chamber, down the
canal to the tip of the cannula, into the cannula, and
out through the suction hose. Thus, a constant flow
of fresh irrigant is delivered by negative pressure
to working length. A recent study showed that the
volume of irrigant delivered was significantly higher

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C.E. article_ irrigation

than the volume delivered by conventional syringe
needle irrigation within the same period,46 and resulted in significantly more debris removal at 1 mm
from working length than did needle irrigation.
During conventional root-canal irrigation, clinicians must be careful when determining how far an
irrigation needle is placed into the canal. Recommendations for avoiding NaOCl incidents include not
binding the needle in the canal, not placing the needle
close to working length, and using a gentle flow rate
when using positive-pressure irrigation.103 With the
EndoVac, in contrast, irrigant is pulled into the canal
at working length and removed by negative pressure.
Apical negative pressure has been shown to enable irrigants to reach the apical third and help overcome apical vapor lock.46,104 In addition, with respect to isthmus
cleaning, although it is not possible to reach and clean
the isthmus area with instruments, it is not impossible
to reach and thoroughly clean these areas with NaOCl
when the method of irrigation is safe and efficacious.
In studies comparing the EndoActivator,105 passive
ultrasonic,105 the F File,105 the manual-dynamic Max-iProbe (DENTSPLY Rinn),105,106 the Pressure Ultrasonic111
and the EndoVac,106 only the EndoVac was capable of
cleaning 100 percent of the isthmus area.
Apart from being able to avoid air entrapment, the
EndoVac system is also advantageous in its ability
to deliver irrigants safely to working length without
causing their undue extrusion into the periapex,46,102
thereby avoiding NaOCl incidents. It is important to
note that it is possible to create positive pressure in
the pulp canal if the Master Delivery Tip is misused,
which would create the risk of a NaOCl incident. The
manufacturer’s instructions must be followed for
correct use of the Master Delivery Tip.

_Sodium hypochlorite incidents
Although a devastating endodontic NaOCl incident is rare,107 the cytotoxic effects of NaOCl on vital
tissue are well established.108 The associated sequelae
of NaOCl extrusion have been reported to include
life-threatening airway obstructions,109 facial disfigurement requiring multiple corrective surgical
procedures,110 permanent paraesthesia with loss of
facial muscle control,69 and — the least significant
consequence — tooth loss.111
Although the exact etiology of the NaOCl incident
is still uncertain, based on the evidence from actual
incidents and the location of the associated tissue
trauma, it would appear that an intravenous injection may be the cause. The patient shown in Figure
3 demonstrates a widespread area of tissue trauma
that is onsistent with the characteristics of NaOCl
incident trauma reported by Pashley.108,112
This extensive trauma, and particularly involving
the pattern of ecchymosis around the eye, could

I

Fig. 3_Irrigation accident with
widespread trauma.

Fig. 3

have occurred only if the NaOCl had been introduced
intravenously to a vein close to the root apex through
which extrusion of the irrigant occurred and the irrigant then found its way into the venous complex. This
would require positive pressure apically that exceeded
venous pressure (10mg of Hg). In one in-vitro study,
which used a positive-pressure needle irrigation technique to mimic clinical conditions and techniques, the
apical pressure generated was found to be eight times
higher than the normal venous pressure.113
This does not imply that NaOCl can or should be
excluded as an endodontic irrigant; in fact, its use is
critical, as has been discussed in this article. What this
does imply is that it must be delivered safely.

_Safety first
In order to compare the safety of six current intracanal irrigation delivery devices, an in-vitro test was
conducted using the worst-case scenario of apical
extrusion, with neutral atmospheric pressure and an
open apex.102 The study concluded that the EndoVac
did not extrude irrigant after deep intra-canal delivery
and suctioning of the irrigant from the chamber to
full working length, whereas other devices did. The
EndoActivator extruded only a very small volume of irrigant, the clinical significance of which is not known.
Mitchell and Baumgartner tested irrigant (NaOCl)
extrusion from a root canal sealed with a permeable
agarose gel.114 Significantly less extrusion occurred
using the EndoVac system compared with positivepressure needle irrigation. A well-controlled study
by Gondim et al. found that patients experienced
less postoperative pain, measured objectively and

		

roots
2
I 11
_ 2014

[12] =>

I C.E. article_ irrigation
subjectively, when apical negative-pressure irrigation
was performed (EndoVac) than with apical positivepressure irrigation.115

_Efficacy
In vitro and in vivo studies have demonstrated
greater removal of debris from the apical walls and
a statistically cleaner result using apical negative
pressure irrigation in closed root-canal systems with
sealed apices. In an in vivo study of 22 teeth by Siu and
Baumgartner, less debris remained at 1 mm from working length using apical negative pressure compared
with use of traditional needle irrigation, while Shin
et al. found in an in vitro study of 69 teeth comparing
traditional needle irrigation with apical negative pressure that these methods both resulted in clean root
canals, but that apical negative pressure resulted in
less debris remaining at 1.5 and 3.5 mm from working
length.46,104,116
When comparing root-canal debridement using
manual dynamic agitation or the EndoVac for final
irrigation in a closed system and an open system, it
was found that the presence of a sealed apical foramen adversely affected debridement efficacy when
manual-dynamic agitation was used, but did not
adversely affect results when the EndoVac was used.
Apical negative-pressure irrigation is an effective
method to overcome the fluid-dynamic challenges
inherent in closed root-canal systems.117

_Microbial control
Hockett et al. tested the ability of apical negative
pressure to remove a thick biofilm of E. Faecalis, finding that these specimens rendered negative cultures
obtained within 48 hours, while those irrigated using
traditional positive-pressure irrigation were positive
at 48 hours.99
One study found that apical negative-pressure
irrigation resulted in similar bacterial reduction to
use of apical positive-pressure irrigation and a triple
antibiotic in immature teeth.118 In a study comparing
the use of apical positive-pressure irrigation and
a triple antibiotic that has been utilized for pulpal
regeneration/revascularisation in teeth with incompletely formed apices (Trimix = Cipro, Minocin, Flagyl)
versus use of apical negative-pressure irrigation with
NaOCl, it was found that the results were statistically
equivalent for mineralized tissue formation and the
repair process.119 Using apical negative pressure and
NaOCl also avoids the risk of drug resistance, tooth
discoloration and allergic reactions.120,121

_Conclusion
Since the dawn of contemporary endodontics,

12 I roots
2_ 2014

dentists have been syringing NaOCl into the root
canal space and then proceeding to place endodontic instruments down the canal in the belief
that they were carrying the irrigant to the apical
termination.
Biological, scanning electron microscopy, light
microscopy and other studies have proven this belief
to be in error. NaOCl reacts with organic material in
the root canal and quickly forms micro-bubbles at
the apical termination that coalesce into a single
large apical vapor bubble with subsequent instrumentation. Because the apical vapor lock cannot be
displaced via mechanical means, it prevents further
NaOCl flow into the apical area.
The safest method yet discovered to provide fresh
NaOCl safely to the apical terminus to eliminate the
apical vapor lock is to evacuate it via apical negative
pressure. This method has also been proven to be
safe because it always draws irrigants to the source
via suction — down the canal and simultaneously
away from the apical tissue in abundant quantities.122
When the proper irrigating agents are delivered
safely to the full extent of the root-canal terminus,
thereby removing 100 percent of organic tissue and
100 percent of the microbial contaminants, success
in endodontic treatment may be taken to levels never
seen before._
Editorial note: A complete list of references is
available from the publisher.
This article has been reprinted in part from G.
Glassman, Safety and Efficacy Considerations in
Endodontic Irrigation (PenWell, January 2011).

_about the author

roots

Dr. Gary Glassman graduated from the University of
Toronto, Faculty of Dentistry
in 1984. He graduated from
the Endodontology Program at Temple University
in 1987, where he received
the Louis I. Grossman Study
Club Award for academic
and clinical proficiency in
endodontics. The author
of numerous publications,
Glassman lectures globally on endodontics, is on staff at
the University of Toronto, Faculty of Dentistry in the graduate department of endodontics, and adjunct professor of
dentistry and director of endodontic programming for the
University of Technology, Kingston, Jamaica. He is a fellow
of the Royal College of Dentists of Canada, fellow of the
American College of Dentists, and the endodontic editor for
Oral Health Dental Journal. He maintains a private practice,
Endodontic Specialists, in Toronto, Ontario, Canada. He can
be reached at gary@rootcanals.ca.

[13] =>

[14] =>

I education_ training replicas

Control the anatomy;
control procedural training
New teaching paradigms from 3-D printed
procedural training replicas
Author_L. Stephen Buchanan, DDS, FICD, FACD
_We buy “New Tech” when we perceive that
some part of our personal or professional lives
could be managed more easily with this new tool.
We bought billions of cordless and then wireless
phones because we wanted to talk to anybody, any
time, regardless of where we happened to be when
the spirit moved us. And it was good. Beyond good
was when Steve Jobs shoved computing power,
endless content and the whole wide-world Internet

Fig. 1_Clear, radio-opaque
TrueTooth replica overlaid by its
X-ray image. (Photos/Provided by L.
Stephen Buchanan,
DDS, FICD, FACD)

14 I roots
2_ 2014

Fig. 1

through our mobile phones. Who knew?
That’s how I have experienced every one of
my New Tech adventures. First I use it to imitate
what we did before — i.e., replacing slide carousels
with computers — only later to find creative possibilities never imagined. In my example, it was
discovering the power that clinical video footage
can bring to lectures.
In that transition, my first concern was how
to fill a 10-by-30-foot screen with a single video
projector, without the three side-by-side stacks
of slide projectors we used before. After worrying that one to death, I realized that the greatest
storytellers on earth — Hollywood, Bollywood,
etc. — pitched their $100 million stories on a single
screen — so why did I need three? After that small
epiphany, I concentrated my efforts on how to
do what they do, and now I can do much of what
these masters of the entertainment universe do,
in ultra-high-def, with just a laptop computer.
So has been my experience with 3-D printed tooth
replicas. I went into stereolithography looking for a
simpler method of teaching endodontic procedures,
a way around the grossness — they are discarded
body parts, after all — as well as the unpredictable
nature of teaching RCT in the random anatomic
forms found inside the extracted teeth that course
attendees gather. What I encountered was much
more profound than just having a training model
that didn’t smell.
After about six months of experimentation, numerous experiments in polymer chemistry and a
seemingly endless series of plugged-up print heads,
we learned how to make clear TrueTooth® replicas
that were radio-opaque with a pulp-colored medium
inside each canal space that can be digested with
sodium hypochlorite. TrueTooth procedural training
replicas were born (Fig. 1).

[15] =>

[16] =>

I education_ training replicas

Figs. 2a–c

Figs. 2a–c_The tactile feedback is
scrape, ‘click,’ advance.

Here are the things I have learned about their use in
the past year of teaching hands-on courses with them:
1) We can now, for the first time, teach RCT to
dental students and dentists in an iterative manner,
the same way astronauts are trained, by repetition.
Previously, in extracted teeth, a student faced
with an anatomic endo challenge only got a single
chance to get it right. No repeat attempt was possible,
because no other tooth would ever be found with the
same challenge, so procedural endodontic training
had always been a random walk through the endo
anatomy of patients’ teeth. In the endodontic training era that just expired, it took about 250 to 500 RCT
cases (me too) before the frequency of getting surprised by a new anatomic challenge began to wane.
Now, students can launch themselves at the same
anatomic challenge as many times as it takes for
them to have it nailed. Attack the same 90-degree
apical impediment in a DB root canal of an upper
molar 15 to 20 times — with the same, exact challenge
every time — and you will be the king of 90-degree
apical canal curvatures thereafter. Now, even orthodontists can learn to do a mean RCT. This is a serious
game changer for endodontic educators.

bend K-files to enter and traverse that accessory
canal, and I have seen this particular use of these
replicas shorten students’ timeline to competence as
they watch all the idiosyncrasies of file function while
working in an anatomically accurate canal space.
Students are able to see the bent file tip snapping
past the accessory canal orifice at the same time
they distinctly feel the attendant “click” of the file tip
dropping into the secondary canal, and after a couple
of tries they become proficient in negotiating into
accessory canals with visual and tactile feedback.
The next challenge is to remove the visual feedback
loop by changing to an opaque TrueTooth replica, and
invite the student to enter the same secondary canal
anatomy by just feel instead of vision and feel. After
conquering that challenge, they know how to correctly bend files and blindly sneak them into secondary anatomy using mental imaging to interpret the
tactile feedback coming through the handle of the file.
After this exercise, it is a relatively short path to
accomplishment of the same in a patient’s root canal
system. Mental imaging is the most important skill a
dentist can bring to bear during RCT. For the first time
we have a reproducible method of transferring this
critical skillset. A game changer for sure.

2) TrueTooth replicas are very effective when used
in clear and then opaque form to teach mental imaging skills.
I begin each of my hands-on courses with a mental imaging exercise in a clear TrueTooth replica of a
maxillary central incisor that has an apical canal bifurcation. I teach course attendees how to accurately

3) While softer than extracted teeth, the heatresistant polymer used to print TrueTooth replicas
cuts crisply with high-speed handpieces — without
gumming up burs.
At Dental Education Laboratories, we set the HS
handpieces at one-third the typical RPM — giving
the participant more authentic tactile resistance

‘This new technology can easily replace extracted teeth and
unauthentic models in endodontic training.’

16 I roots
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[17] =>

[18] =>

I education_ training replicas

Fig. 3_Endodontics — chasing the
worm.

through a range of anatomic challenges they could
not meet in five years of practice.
Now, course objectives met by each student are
easily documented, a necessity for accreditation
review.
5) Replicas can be designed and printed for surgical training , complete with soft tissue that can be
incised, reflected and sutured; hard and soft bone tissues, as well as roots and their canals — all printed together with no assembly required — are encountered
exactly as they are in a surgical procedure (see “A new
paradigm in surgical training,” roots, Issue 1, 2014).

Fig. 3

during access procedures. Also, while the TrueTooth
replicas are more easily ledged than extracted teeth,
I have found they are the equivalent of swinging two
baseball bats on deck before going up to the plate
against a pitcher.
If you can navigate these anatomically authentic
replica canals without ledging any of the natural
irregularities contained within, you are ready for
prime time in real teeth, as you will have developed
the requisite light touch all successful endodontists
have. This is a more subtle advantage than those
mentioned above, but no less helpful to educators,
nonetheless.
When students use training models with canals
that resemble a soda straw, students gain no experience in ledge avoidance — a vital skill they desperately
need as they move from pre-clinical lab to clinic and
start invading their patient’s teeth. These replicas
deliver anatomically accurate training in a way never
previously possible.
4) Now, educators can develop a procedural training curriculum around a series of classic anatomic
tooth forms that walk undergraduate dental students through the most common endodontic challenges they will encounter in practice, as well as
more difficult cases that can lead graduate students

18 I roots
2_ 2014

6) Replicas can be created with multiple versions
at the same level of difficulty to provide a diversity of
experience for students, and still other versions for
testing replicas that are only available to educators
and examining boards. For procedural testing to be
fair to students, educators and examiners, they are
all served by authentic, reproducible 3-D printed
replicas.
With our modeling engineers and our new multiink printer, our goal is to build replicas of quadrants
and full arches with a different TrueTooth replicas in
every tooth position.
I’ve made the case that this new technology
can easily replace extracted teeth and unauthentic
models in endodontic training. Dental education just
got better, but the home run of this new tool will inevitably bring educational applications never before
imagined. Dental education will never be the same.
The Dental Education Laboratories website,
DELendo.com, has a complete catalog of the 30plus different TrueTooth replicas currently available; however if you don’t see a TrueTooth replica
that rings your chimes — whatever the need — let
us know._

_about the author

roots

L. Stephen Buchanan, DDS,
FICD, FACD, is a diplomate
of the American Board of
Endodontics and an assistant clinical professor at the
postgraduate endodontic
programs at USC and UCLA.
He maintains a private practice limited to endodontics
and implant surgery in Santa
Barbara, Calif., and is the
founder of Dental Education
Laboratories, a hands-on training center serving general
dentists and endodontists who want to upgrade their skills in
new endodontic and implant technology. Dr. Buchanan can
be reached through his business, Dental Education Laboratories, www.DELendo.com, info@endobuchanan.com.

[19] =>

industry education_ LVI

LVI Core I three-day
course is designed for
doctors and their teams
to learn together
Author_Mark Duncan, DDS, FAGD, LVIF, DICOI, FICCMO, Clinical Director, LVI
_As a patient, I expect the best care I can find. As
a doctor, I want to deliver the best care possible. That
takes us to the power of continuing education, and as
doctors we are faced with many choices in continuing education.
As a way to introduce you to the Las Vegas Institute for Advanced Dental Studies, or LVI, I want
to outline what LVI is about and what void it fills
in your practice. The alumni who have completed
programs at LVI were given an independent survey,
and unlike the typical surveys, 99.7 percent said they
love practicing dentistry, and of those surveyed, 92
percent said they enjoy their profession more since
they started their training at LVI. That alone is reason
enough to go to LVI and find out more.
While the programs at LVI cover the full breadth
of dentistry, the most powerful and life-changing
program is generally reported as being Core I, or
Advanced Functional Dentistry — The Power of
Physiologic-Based Occlusion. This program is a
three-day course that is designed for doctors and
their teams to learn together about the power of
getting their patients’ physiology on their side. In
this program, doctors can learn how to start the
process of taking control of their practice and start
to enjoy the full benefits of owning their practice
and providing high-quality dentistry.
Whether he or she works in a solo practice or in a
group setting, every doctor can start the process of
creating comprehensive care experiences for his or
her patients.
We will discuss why some cases that doctors are
asked by their patients to do are actually dangerous
cases to restore cosmetically. We will discover the
developmental science behind how unattractive
smiles evolve and what cases may need the help of
auxiliary health care professionals to get the patient

feeling better. The impact of musculoskeletal signs
and symptoms will be explored and how the supporting soft tissue is the most important diagnostic
tool you have. Not simply the gingiva, but the entire
soft-tissue support of the structures not just in the
mouth but also in the rest of the body.
A successful restorative practice should not be
built on insurance reimbursement schedules. An
independent business should stand not on the whims
and distractions of a fee schedule but rather on the
ideal benefits of comprehensive care balanced by the
patients’ needs and desires.
Dentistry is a challenging and thankless business, but it doesn’t have to be. Through complete
and comprehensive diagnosis, there is an amazing
world of thank-yous and hugs and tears that our
patients bring to us, but only when we can change
their lives. The Core I program at LVI is the first step
on that journey.
That’s why when you call, we will answer the
phone, “LVI, where lives are changing daily!”_

Las Vegas Institute for Advanced
Dental Studies offers Core I, a threeday course for doctors and their
teams. (Photo/Provided by Las Vegas
Institute for Advanced Dental Studies)

roots
2
I 19
_ 2014

[20] =>

I industry_ Sonendo

Sonendo: Root canals
clean at the speed of sound
Author_Sonendo staff

_Introducing GentleWave

_About Sonendo and Sound Science

Scheduled to make its debut at the 2014 AAE
Annual Session, the GentleWave™ System utilizes
patented Multisonic Ultracleaning™ technology that
is designed to quickly, easily and safely loosen and
remove pulp tissue, debris, decay and bacteria within
minutes. The system is designed to clean the entire
canal system, automatically and simultaneously.

Sonendo’s commitment to Sound Science® ensures that its product development is based on
sound scientific research and extensive proof source.
Furthermore, the company will continue to leverage
its innovative approach to sound — and its use in endodontics — as it works to bring this new technology
to the endodontic community.
In summary, Sonendo is focused on bringing to market a device that will provide an endodontic treatment
that is highly predictable for every procedure, more comfortable for the patient, faster and more efficient for the
practice, and offering a significantly cleaner disinfected
treatment area compared with current standards.

_New paradigm

Fig. 3_SEM showing apical cleaning
with GentleWave.

Because the GentleWave System has the ability to
clean in such a comprehensive way, less traditional
instrumentation is required, creating the potential to
dramatically reduce procedure time. The minimally
invasive procedure also allows the opportunity to
remove less structural dentin, helping to preserve the
structural integrity of the tooth.
Bjarne Bergheim, president and CEO of Sonendo,
has been directly involved in the development of the
GentleWave since its early inception.
“Very soon, endodontists performing root canal
therapy will have the ability to provide an ultraclean
environment for their patients in a more comprehensive, efficient and predictable way,” Bergheim
said. “We remain focused on creating a new standard of care for the patient as well as improving the
clinical quality and business performance of doctors performing root canal therapy.”

Fig. 1

Fig. 2

Fig. 1_GentleWave patented
handpiece design. (Photos/Provided
by Sonendo Inc.)
Fig. 2_GentleWave System.

20 I roots
2_ 2014

_Come see Sonendo
Those doctors attending the AAE Annual Session
in April will have a chance to learn more. Dr. Mehrzad
Khakpour will offer a presentation on Sonendo’s
Multisonic Ultracleaning technology on Wednesday,
April 30, from 2 to 3 p.m. in the exhibit hall. AAE
attendees will also be able to view the system and
take part in demonstrations as Sonendo unveils the
GentleWave at booth No. 823. For more information,
visit www.sonendo.com._
Sonendo’s system is not yet commercially available for sale or distribution.

Fig. 3

[21] =>

industry_ Avalon Biomed

Introducing Grey MTA
Plus — ‘Reshaping’ root
canal practices everywhere
Author_Avalon Biomed staff
_Avalon Biomed Inc. is introducing its first dental
product, Grey MTA Plus®. The bioactive root and pulp
treatment material helps heal injured vital pulp and
also treats various endodontic conditions. Grey MTA
Plus represents the next generation of the tricalcium
silicate materials and is composed of a fine, non-gritty
powder and a unique gel. While most other MTAs include water, the MTA Plus gel enables the MTA powder
to set faster and be washout-resistant within five
minutes. The gel and fine powder allow the clinician to
easily create the consistency desired. The powder-togel ratio can be varied so that the clinician can create
putty-like, creamy paste or a sealer consistency.
The benefits of MTA (tricalcium silicate)-based
products are well established for a multitude of endodontic procedures, ranging from perforation repair
to root-end filling, and also for vital pulp therapy.
Grey MTA Plus is indicated for vital pulp procedures,
including pulp-capping, cavity lining and use as a
base. Additionally, Grey MTA Plus can be used for
root-canal sealing, revascularization or for obturation when extraction is the only alternative.
The silvery color of Grey MTA Plus is beneficial for
distinguishing the material when placed, and the color
makes the material slightly more radiopaque than
other white MTA materials. The product was tested
internationally beginning in 2011, and case reports
show the healing effect that results from the bioactive
tricalcium silicate of MTA. When implanted, the material was equal to the best-known MTA.
The material is non-cytotoxic and is antibacterial when tested in vitro against common endodontic bacteria including E. faecalis. All components of
the product are already used in dentistry and pulpal
procedures. Articles on Grey MTA Plus are available
at avalonbiomed.com. The Grey MTA Plus powder
is packaged in a desiccant-lined bottle to keep the
powder dry and allows the clinician to dispense
only what is needed, avoiding waste. The dropper
tip gel bottle is suitable for mixing small amounts.

‘I like how the Grey MTA Plus
mixes. The fine, particle-size
powder combined with the special
gel creates a material that has
superior handling properties.’
— Prof. Karl F. Woodmansey,
asst. professor, Department of Endodontics,
Baylor College of Dentistry
Two kit sizes are available: 2.5 and 8 gram.
Avalon Biomed offers a superior product in a
convenient format at an excellent price that enables
each dose (about 0.1 gram per scoop) to be economical. With this product, a clinician can offer “more
healing.” Spontaneous comments from customers
show that the Grey MTA Plus material is “head and
shoulders” above other MTAs.
Feeling is believing; when you mix the powder and
gel, the scratchy, gritty sound and feel is absent, and
the handling of Grey MTA Plus is as easy as with IRM®.
It’s designed to be an affordable, convenient MTA
that performs for you and the patient._

Photo/Provided by
Avalon Biomed Inc.

roots
2
I 21
_ 2014

[22] =>

I 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

Roots Managing Editor
Fred Michmershuizen
f.michmershuizen
@dental-tribune.com
Managing Editor
Sierra Rendon
s.rendon@dental-tribune.com

Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com

Managing Editor
Robert Selleck
r.selleck@dental-tribune.com

President/Chief Executive
Officer
Eric Seid
e.seid@dental-tribune.com

Education Director
Christiane Ferret
c.ferret@dtstudyclub.com

Group Editor
Kristine Colker
k.colker@dental-tribune.com

Marketing Director
Anna Kataoka
a.kataoka@dental-tribune.com

Product/Account Manager
Humberto Estrada
h.estrada@dental-tribune.com
Product/Account Manager
Will Kenyon
w.kenyon@dental-tribune.com
Feedback & General Inquiries
feedback@dental-tribune.com

Editorial Board

Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
Daniel Heysselaer, Roeland de Moor, Julia
Kamenova, T. Dostalova, Christliebe Pasini,
Peter Steen Hansen, Aisha Sultan, Ahmed
A Hassan, Marita Luomanen, Patrick Maher,
Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit
Sahar-Helft, Lajos Gaspar, Paolo Vescovi,
Marina Vitale, Carlo Fornaini, Kenji Yoshida,
Hideaki Suda, Ki-Suk Kim, Liang Ling Seow,
Shaymant Singh Makhan, Enrique Trevino,
Ahmed Kabir, Blanca de Grande, José Correia
de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep
Arnabat, Ahmed Abdullah, Boris Gaspirc,
Peter Fahlstedt, Claes Larsson, Michel Vock,
Hsin-Cheng Liu, Sajee Sattayut, Ferda Tasar,
Sevil Gurgan, Cem Sener, Christopher Mercer,
Valentin Preve, Ali Obeidi, Anna-Maria
Yannikou, Suchetan Pradhan, Ryan Seto, Joyce
Fong, Ingmar Ingenegeren, Peter Kleemann,
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.

22 I roots
2_ 2014

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[cover] => roots C.E. No. 2, 2014

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Table of contents

[toc_titles] =>

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