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RO0110_01_Titel
issn 1616-6345
roots
international magazine of
Vol. 7 • Issue 4/2011
endodontology
4
2011
| case report
Minimally invasive crown lengthening
| practice management
The passive income practice
| meetings
Ten years of DGEndo and the launch of DGET
[2] =>
RO0110_01_Titel
[3] =>
RO0110_01_Titel
editorial _ roots
I
Dear Reader,
_The single most important development that was a giant leap for endodontics is
micro-computed tomography, which gives us a 3-D view. Without this technology, the
basis for many endodontic procedures was just empirical, like enlarging the root canal three
sizes beyond the first file that binds during hand instrumentation, or arbitrarily deciding the
final apical size with tapered rotary use.
Prof Marco Versiani’s root-canal anatomy project on micro-CT study guide has demystified many old concepts. Now we know that all root canals are curved, apical diameters are
not as small as perceived, and root canals do not have large tapers.
Prof Beena Rani Goel
Regenerative endodontics, though in the infant stage, can hold significant implications
for the management of necrotic immature teeth. These treatment protocols can result in
radiographic and clinical evidence of healing and subsequent root development. Tyler
Lovelace et al. have demonstrated that the evoked-bleeding step in regenerative procedures
triggers a significant accumulation of undifferentiated stem cells in the canal space, leading to the regeneration of pulpal tissues. Future developments may see wider application of
these tissue-engineering principles, revolutionising the field of endodontics.
The use of lasers in endodontics may be common procedure soon with a number of applications in access preparation, root-canal shaping, and decontamination of the root-canal
system. The improved technology has introduced endodontic fibres and tips of a calibre and
flexibility that permit insertion up to 1 mm from the apex. Laterally emitting conical fibre tips
were found to be safe under defined conditions for intra-canal irradiation without harmful
thermal effects on the periodontal apparatus.
The EndoVac irrigation system (SybronEndo) is one of the best things that has happened
to endodontics in recent years. While sodium hypochlorite significantly eliminates the
biofilm associated with endodontic infections, it can cause catastrophic tissue damage
when extruded. With EndoVac, fortunately, it can now be safely delivered to full working
length. Research shows that EndoVac usage can result in a significant reduction of postoperative pain levels in comparison with conventional needle irrigation.
Micro-CT studies show that the apical thirds are not cleaned with tapered systems of
small tip size. In addition, they showed that instruments with a flat widened tip determine
apical diameter better than round tapered instruments. The coming years are bound to see
an increased acceptance of LightSpeed LSX instruments (SybronEndo) to obtain biologically
optimal preparations.
At a time when dental professionals have a choice between root-canal treatment and
implant placement after extraction, it is heart-warming to see that recent developments in
endodontics, if incorporated into the surgery, can maintain the tooth in a functional state
for many years.
Yours faithfully,
Prof Beena Rani Goel
President of the International Academy for Rotary Endodontics
roots
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I content _ roots
page 6
I editorial
03
page 10
I news
Dear Reader
26
| Prof Beena Rani Goel, Guest Editor
Minimally invasive crown lengthening as an
alternative to implant treatment
| Prof Marcel Wainwright
28
Vital amputation of permanent teeth
| Dr Robert Teeuwen
I meetings
34
The passive income practice
| Dr Phillip Palmer
36
Ten years of DGEndo and the launch of DGET
| Oscar von Stetten
I opinion
40
Critical thinking:
The missing link in endodontic education
| Dr Barry Lee Musikant
24
Dental symposium at home? AMED goes virtual
| Dr Terrell F. Pannkuk
I practice management
20
FKG Dentaire introduces iRaCe and Scout-RaCe
| FKG
I research
18
An interview with Dr Emanuele Ambu
I industry news
32
10
Dental X-rays can predict fractures
I feature
I case report
06
page 20
International Events
I about the publisher
41
42
| submission guidelines
| imprint
Rubber dam hazards?
| Dr Kenneth S. Serota
Cover image courtesy of
Produits Dentaires SA.
page 24
04 I roots
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page 32
page 36
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I case report _ crown lengthening
Minimally invasive crown
lengthening as an alternative
to implant treatment
Author_ Prof Marcel Wainwright, Germany
Fig. 1
Fig. 2
Fig. 1_Single-tooth radiograph
showing the fractured tooth #22.
Fig. 2_Thermoplastic root filling in
tooth #22.
Fig. 3_Radiograph of the orthograde
root filling, found to be lege artis.
_Crown fractures frequently force the treatment provider to make a clear-cut treatment choice
between tooth preservation and dental implant treatment. Speakers at implantological congresses tend to
present impressive implant/prosthodontic solutions
for anterior fracture cases, to the point where the
audience could be tempted to believe that this was the
only appropriate treatment alternative. The following
case report documents a tooth preservation option
that is simple to perform, minimally invasive and
successful.
_Case report
A 66-year-old male patient presented at our office
with a fractured upper left lateral incisor (tooth #22).
The clinical crown of this tooth had fractured in the
marginal region, with the pulp of the tooth slightly
exposed in one location; the pulp tissue vitality test
showed a weak positive result. The patient was completely free of pain symptoms. There was no root
mobility. Available treatment options were discussed
with the patient based on a single-tooth radiograph
(Fig. 1). The neighbouring teeth #21 and 23 had been
06 I roots
4_ 2011
Fig. 3
restored with all-ceramic crowns two years previously. However, a three-unit fixed prosthetic denture
was rejected by the patient, as was surgical treatment
with immediate implant placement following extraction.
Conservative tooth preservation was therefore
the treatment of choice for patient and treatment
provider alike. The patient was informed that tooth
preservation could only be successful if the required
orthograde root-canal instrumentation was possible,
the tooth was symptom free and biological width
could be restored prior to the fabrication of a crown
restoration. If these requirements turned out not to
be met, an implant/prosthodontic solution would
have to be resorted to as an alternative.
Treatment sequence
Following extensive patient education and pretherapeutic discourse, the patient received local
anaesthesia, and tooth #22 was instrumented. This
was initially difficult, as the root canal turned out
to be slightly obturated. Following instrumentation
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I
to ISO 20, the tooth was prepared for a root filling.
Instrumentation to more than ISO 20 did not appear
advisable, as the reduced diameter of tooth #22
already constituted an increased fracture hazard
during preparation of the endodontic post or in the
presence of lateral forces. At the same visit, an orthograde endodontic filling was placed using a thermoplastic restorative technique (Thermafil; DENTSPLY
DeTrey) and Sealapex (SybronEndo; Fig. 2). The control
radiograph showed that the root-canal filling had
been placed lege artis (Fig. 3).
Surgical crown lengthening was planned for
four weeks later. Like all surgical interventions at our
clinic, this crown lengthening was performed using
ultrasonic surgical instruments (Acteon). In this protocol, the surgeon employs a surgical kit containing
multiple calibrated diamond instruments (Fig. 4).
A minimal circumferential incision was performed
under local anaesthesia, completely dispensing with
extensive flap elevation procedures or relieving incisions. The marginal bone was prepared approximately
2mm farther apically to provide sufficient biological
width for a subsequent crown (Berglundh 1992). The
use of ultrasonic surgical instruments allows the surgeon to proceed quickly while protecting the tissue,
as these instruments help reduce the risk of iatrogenic
damage to the root dentine, a risk that is elevated
when using conventional rotary instruments (Fig. 5).
The site was sutured closed using a synthetic monofilament thread (Trofilene 8-0, Stoma; Fig. 6). Microsurgical suturing is indispensable in the anterior region.
If it is neglected, this will result in tissue recession and
impaired aesthetics.
The sutures were removed one week later. Wound
healing was uneventful, and the patient was completely free of pain and other symptoms throughout
the entire treatment. After an additional week, a postand-core build-up was performed using the Fibrapost and Sealacore system (Produits Dentaires;
Fig. 7). The root canal was prepared with reamers,
which are available in four different diameters (Fig. 8).
The option to use the depth stop to pre-calibrate the
reamer to the desired length was helpful, not least
Fig. 4
Fig. 5
as a precaution against excessive preparation depths
(Figs. 9 & 10).
The root canal was prepared under copious irrigation and conditioned with a self-etching bonding
system (Sealacore; Fig. 11). The UDMA-based resin
cement (Sealacore) was introduced into the root canal
with a syringe and application tip (Fig. 12). The Fibrapost is a fibreglass-reinforced resin endodontic post
(Fig. 13) with retentive grooves. Our clinic uses metalfree endodontic post systems exclusively, as their
biomechanical properties are clearly superior to those
Fig. 6
Fig. 4_Crown lengthening kit
(Acteon).
Fig. 5_Ultrasonic crown lengthening
of tooth #22 using minimally invasive
incisions.
Fig. 6_Microsurgical 8-0 suture.
Fig. 7_Fibrapost and Sealacore
system.
Fig. 8_Endodontic reamers.
Fig. 7
Fig. 8
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I case report _ crown lengthening
Fig. 9_Defining preparation depth
using the adjustable stop.
Fig. 10_Endodontic preparation
using a reamer.
Fig. 9
Fig. 10
Fig. 11
Fig. 12
of metal posts. One important aspect is the absorption of the vertical lateral masticatory forces, which
is better for the resin posts than for the metal posts
because the former have material characteristics
resembling those of natural dentine. In addition, the
optical properties of the system (translucency, transparency) facilitate highly aesthetic anterior solutions
while eliminating the risk of corrosive discolouration.
native to implant/prosthodontic treatment, provided
that the tooth is free of pain, that the preconditions
for endodontic treatment are met, and that the
root is stable. Today’s post-and-core systems are
expected to be metal free and to offer easy handling
and aesthetic long-term results. Our experience with
the Fibrapost and Sealacore system has been positive
throughout; they have produced excellent results and
suit our procedures well._
Fig. 11_Conditioning the lumen
of the root canal for accepting
the endodontic post.
Fig. 12_Applying the resin cement.
Fig. 13_Fibrapost with
retention groups.
Fig. 14_Core placement
and preparation.
Fig. 15_All-ceramic crown in situ.
Note the healthy and complete papillae and periodontal tissues.
Fig. 13
Following core shaping and preparation (Fig. 14),
a polyether impression was taken for an all-ceramic
crown (e.max, Ivoclar Vivadent). The definitive crown
was delivered a week after tooth preparation and
cemented with a dual-curing self-adhesive cement
(RelyX Unicem, 3M ESPE; Fig. 15).
_Summary
When the clinical crown of a tooth is lost due
to fracture, surgical crown lengthening and tooth
restoration based on a post and core is a viable alter-
Fig. 14
08 I roots
4_ 2011
roots
_contact
Prof Marcel Wainwright
Dental Specialists and White Lounge Kaiserswerth
Kaiserswerther Markt 25–27
40489 Düsseldorf
Germany
www.dentalspecialists.de
Fig. 15
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I research _ vital amputation
Vital amputation
of permanent teeth
Author_ Dr Robert Teeuwen, Germany
_The vital amputation (VA) of deciduous teeth
with the goal of maintaining their functionality for
a limited period is a widely accepted measure. Vital
amputation of permanents, however, is only approved for limited indications. While therapeutic
agents such as calcium hydroxide (Ca(OH)2) and mineral trioxide aggregate (MTA) are recommended for
VAs, formaldehyde (CH2O) containing agents are a
controversial subject.
1. treatment of deciduous teeth;
2. treatment of permanents with incomplete root
growth; and
3. emergency measure.
Indications 2 and 3 include the option of a later
definitive root-canal treatment (RCT).
The European Society of Endodontology (ESE)
defines pulp amputation as a procedure during which
part of the exposed vital pulp tissue is removed with
the aim of maintaining vitality and function of the
remaining parts of the pulp.1 ESE recognises the following indications for VAs (i.e. pulpotomy):
Seidler recommends VA for the accidentally
opened pulp of young molars and extremely curved,
narrow root canals.2 Stern considers difficulty in
opening the mouth an indication for VAs as well.3
McDougal et al. extend the indication for pulpotomy
when there are economic concerns, as some patients
are unable or unwilling to bear the expense of a RCT.4
According to Swift et al., a successful VA may be
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
Figs. 1a–d_24-year-old patient,
VA 16 (16 July 1993): before VA (a);
heavy bleeding from the pulp after N2
VA, 16 July 1993 (b); after VA and
amalgam filling (c); X-ray control,
29 September 1999 (d).
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expected following traumatic or mechanical carious
pulp exposure.5 We consider predictable success with
the following prerequisites:
_non-inflamed pulp;
_bacteria-proof closure; and
_use of a pulp-compatible capping material.
Seidler states the following regarding the success
of VA:2
_A higher rate of success is observed in cases of
iatrogenic pulp exposure.
_Treatment success is reduced in cases of complete
root growth.
_Molars are more successfully treated than incisors.
For a pulpotomy with Ca(OH)2, Jensen presupposes that there is no pain existent anamnestically.6
Teixeira et al. corroborate the significance of pain
prior to VA.7 In their study of 41 Ca(OH)2 vitally amputated permanent teeth, anamnestic pain existed in
12 cases. The pulpotomy of these aching teeth led to
failure after six to eight months in 50% of the cases
(n = 6), while all other vitally amputated teeth were
considered successfully treated.
McDougal et al. report on 73 eugenol pulpotomies
on aching permanent molars and premolars.4 A
clinical success rate of 90% after six months and
78% after 12 months was observed. The teeth, which
were free of pain at check-up, were radiologically
controlled and it was shown that 49% of the teeth
were free of pathological findings after six months
and 42% after 12 months.
According to Jensen, pulpotomy is an attempt to
stimulate hard tissue healing at the area of amputation.6 Fountain and Camp point out that a pulpotomy
may result in canal calcification, internal resorption
or necrosis of the pulp.8 Kozlow and Massler refer
to literature that reports the formation of a dentine
bridge in rat teeth under non-calcium-containing
materials, such as wax, amalgam, acrylic resin and
zinc oxide eugenol.9 In human teeth, the bridging
under Ca(OH)2 was successful in 43% of the cases and
under antibiotics in 23% of the cases. During their
own tests on rat teeth, the authors assessed good
reparative reactions with complete bridging following pulpotomy with Ca(OH)2, zinc oxide eugenol,
cortisone and silver amalgam.
According to Alacam, various materials are recommended for pulpotomy: Ca(OH)2, formocresol,
glutaraldehyde, ferrous sulphate, zinc oxide eugenol
and polycarboxylate cement.10 Salako et al. compared MTA, formocresol, ferrous sulphate and bioactive glass with regard to their pulpotomy compat-
I
ibility and found MTA to be the ideal pulpotomy
agent.11
Agents that contain CH2O and Ca(OH)2 are historically established VA agents for deciduous and permanent teeth. Massler et al. report a clinical success
rate of 92% following VA with Ca(OH)2.12 Taking postoperative X-rays into account, the success rate was
reduced to 75% after one year and dropped to 65%
after two to five years. The authors suggest several
reasons for this failure:
_pulp already heavily inflamed initially;
_too much pressure applied during application; and
_disposal of the blood coagulum via haemostatic
agents.
1st group (31 teeth)
2nd group (6 teeth)
(no pathological findings radiographically, no anamnestic pain)
17 teeth with complete root growth,
14 teeth with incomplete root growth
3 with periodontal gap enlargement –
2 of them with pain,
3 with apical ostitis,
5 teeth with complete root growth,
1 tooth with incomplete root growth.
Table I
Mejàre and Cvek performed partial pulpotomies
using Ca(OH)2 on 37 permanent teeth (35 molars,
2 premolars).13 The patients were six to 15 years old
and their pulpotomy had to be performed at least two
years prior to inclusion in the study. Check-ups were
performed at an average of 56 months (24 to 140). The
teeth were separated into two groups (Table I). Two
failures occurred in the first group, in teeth with incomplete root growth (after ten days and 48 months).
The other 29 teeth (93.5%) were treated successfully.
In the second group, two failures occurred (after
10 and 24 months) in teeth with periodontal gap
enlargement (one tooth with complete root growth
and the other with incomplete root growth).
Molven states that there were no pathological
findings in 1,391 root-filled roots in 51.6% of the
cases and in 236 pulpotomized roots in 65% of the
cases.14 Asgary and Eghbal report the successful use
of a new VA agent called CEM, a cement mixture
enriched with Ca, in 205 pulpotomies on molars.15
For comparison, 202 molars were extirpated vitally.
The root-canal filling (RCF) was performed via lateral
condensation with AH Plus (DENTSPLY DeTrey) as
sealant. After seven days, 38% of the pulpotomytreated and 60% of the root-canal-treated patients
reported needing analgesics. After six months, 88.94%
of the patients underwent a radiological check-up.
The pulpotomy patients revealed a significantly higher
success rate (p < 0.001).
The most frequently used VA agent for deciduous
teeth is formocresol, a mix of CH2O, cresol, glycerine
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Fig. 2a
Fig. 2b
Figs. 2a–c_ 30-year-old patient, VA
28 (3 May 1993): prepared cavity (a);
after VA and amalgam filling (b);
X-ray control, 17 December 1994 (c).
Fig. 2c
and water. A survey showed that formocresol pulpotomies on deciduous teeth were performed by general
dentists in 73% of the cases and by paediatric dentists in 98.2% of the cases.16 The frequency of use on
permanent teeth was lower: 18.9% for general and
55.4% for paediatric dentists.
Powder
Zinc oxide 63.0 %
Titanium dioxide 3.6 %
Bismuth subcarbonate 10.0 %
Bismuth subnitrate 15.0 %
Paraformaldehyde 7.0 %
Red lead (lead oxide) 1.4 %
Liquid
Eugenol 77.0 %
Rose oil 1.8 %
Lavender oil 1.2 %
Peanut oil 20.0 %
Table II
Fisch published the results of pulp amputations of
600 teeth, which were performed with the CH2O-containing preparation Triopaste.17 Check-ups were done
between six months and 18 years after amputation.
Examination of the X-ray controls revealed a pathological apex in 9%. Eleven teeth were histologically
examined. Hard substance formation was observed
in the form of apical foramen closures and apposition
at the lateral canal walls, which partially led to obliteration of the canal lumen.
During an accelerated test lasting up to 2.5 months,
Overdiek tested N2 as CH2O-containing VA agent on
human teeth. He observed that for several weeks following N2 application there was a possibility of a hard
substance barrier forming.18
Over a period of 12 years, Stern3 carried out 175
N2 pulpotomies under relative isolation on teeth
with complete root growth, regardless of possible
anamnestic pain. Fifteen per cent of the patients
experienced increased pain after treatment, which
subsided within 48 hours. Four patients, however,
developed pulpitis, which resulted in the extraction of
three teeth and conservative RCT of one tooth. Stern
was able to track the outcome of 35 vitally amputated
teeth over a longer period. During the course of
check-ups, two teeth were extracted, one of them due
to a fracture. Five years after treatment, Stern observed advancing calcification of the nerve channels.
12 I roots
4_ 2011
Frankl considers the advantage of pulpotomy
compared with RCT as there being no instrument
fractures or perforations during pulpotomy.19 A possible failure could always be countered with a RCT. He
asserts that Ca(OH)2 pulpotomies can be successful
only if teeth are asymptomatic prior to treatment and
for accidentally opened pulp and, therefore, bleeding
from the pulp.
According to the literature, N2 VA on deciduous
teeth renders significantly better results than Ca(OH)2
pulpotomy. Therefore, Frankl performed N2 pulpotomies on permanents as well.19,20 He selected only
asymptomatic teeth whose pulp had been accidently
exposed for treatment. The treatment was performed
under a rubber dam and thus pulp bleeding did not
have any effect. Two hundred and fifty cases were
re-examined for up to 13 years. The age of the patients
ranged between 22 and 55 years. Failures manifested
by pain within 48 hours amounted to 2%. The aim of
the following study was to analyse the success and
failure rates of N2 VAs on permanent molars, and to
compare these rates with vital molar extirpations done
within the same period.
_Material and method
The study was conducted in my dental practice,
which is located in a rural area. Between 1992 and
1998, 795 VAs and 945 vital extirpations (VEs) were
performed on molars. After treatment, 85 VA and
93 VE patients did not return to the practice and were
thus excluded from the study, leaving 710 VAs and
852 VEs for analysis.
During the treatment period, only N2, which
was approved by the district president of Düsseldorf,
Germany, on 8 February 1990, was used as therapeutic agent (see Table II for composition).
The root canals were prepared according to the
N2 method: relative isolation, no root-canal rinsing
and root-canal preparation with reamers only.21 For
the RCF, N2 mixed to a creamy consistency was applied
with a lentulo spiral. The VA cavities were prepared
1 to 2mm into the canals. N2 mixed to a paste was
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inserted into the cavity with a filling instrument and
lightly pressed with cotton. Minor bleeding was irrelevant. In cases of heavier bleeding, the inserted N2
was removed after a few minutes and then replaced
with freshly mixed N2. A synthetic closure of the cavity performed within the same sitting required a lining,
which is not necessary for an amalgam closure. X-ray
controls were later viewed at double and sevenfold
magnification. The apical condition was differentiated
as follows: apically without pathological findings,
apically uncertain and apically pathological. The root
with the worst apical findings was evaluated. This was
also applicable for the classification of RCF levels.
Failures without accompanying X-rays were
termed Mi1 and failures with accompanying X-rays
were termed Mi2. The total failure percentage was not
determined by simply adding Mi1 and Mi2, but by
adding the number of Mi1s to the number of X-rays
taken. The percentage of failures was then determined
from this sum. The statistical analysis was performed
using SPSS (version 18).
_Results
Of the VA patients 47.6% were male and of the VE
patients 52.4% were male. The practice owner treated
70.1% (n = 498) of the VA patients and 49.1% (n = 418)
of the VE patients and all the rest were treated by an
assistant. The average age of VA patients was 34.6 years
and that of VE patients was 30.6 years. The average
observation period was 53.8 months (max. 165) for VAs
and 49.4 months (max. 169) for VEs. Of the 710 VA cases
504 (71%) and of the 852 VE cases 496 (58.1%) were
subject to follow-up X-ray controls.
Table III_Summarised VE results.
Tooth
⌺
A total of 61 VA and 77 VE failures were registered
and classified as without accompanying X-ray (Mi1) or
with accompanying X-ray (Mi2). Fifty-one of the 61 VA
I
II
III
Recall
Extraction
X-ray
post VE
failures were followed-up with X-rays. Not all of the
accompanying X-rays of the Mi2 failures revealed a
failure.
Two VA failure X-rays and ten VE failure X-rays were
wrongly evaluated as negative. Ten VA Mi1 cases were
removed because of pain, three of them within a few
hours after VA.
In two cases, a granuloma at an extracted root was
indicated in the patient files. In two additional cases,
the extraction followed after six and 11 days. In 12 of
the 16 VE cases, extractions were performed because
of pain (one day to 21 months after VE). Patients who
visited the practice after pulpotomy made positive a
negative reference to anamnestic symptomatic pain
241 times and 157 times, respectively. Subsequently,
the failure rate was 10.8% (n = 26) in the first case and
7.0% (n = 11) in the latter case. The difference was insignificant statistically (p = 0.114).
The failure diagnosis after VA was most frequently
made for the lower second molar (18.5%) and after VE
for the lower first molar (19%). The lower wisdom
teeth were conspicuous because the failure rate was
only 4.7% after VA, and no failure at all was observed
after VE. Not every failure diagnosis led to therapeutic
consequences such as extractions.
Altogether, 206 (28.6%) VA and 123 (14.4%)
VE teeth were extracted during the follow-up phase
(very statistically significant difference; p = 0.000).
The largest number of extractions, namely 51.9%
(n= 107) of the VAs and 46.3% (n= 57) of the VEs, were
performed because the teeth had been destroyed
or fractured. The lower wisdom teeth were the most
frequently affected in the case of pulpotomy (61.8%;
n = 21) and the upper second molars in the case of
VE (64%; n = 16).
Failure IV
IV a
Mi 1
IV b
Mi 2
V
VI
IV c
Mi 3
X-ray
+ Mi 1
Fail.
⌺
n
n
%
n
%
n
%
n
n
%
n
n
%
16/26
269
241
89.6
42
17.4
142
58.9
3
22
15.5
25
145
17.2
17/27
168
152
90.5
25
16.4
89
58.6
4
7
7.9
11
93
11.8
18/28
5
5
100
1
20.0
2
40.0
–
–
–
–
2
–
36/46
274
249
90.9
24
9.6
148
59.4
4
25
16.9
29
152
19.0
37/47
201
177
88.1
25
14.1
97
54.8
3
9
9.3
12
100
12.0
38/48
28
28
100
6
21.4
18
64.3
–
–
–
–
18
0,0
945
852
90.2
123
14.4
496
58.2
14
63
12.7
77
510
15.1
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Tooth
⌺
Failure IV
I
II
III
Recall
Extraction
X-ray
post VA
IV a
Mi 1
IV b
Mi 2
I
V
VI
IV c
Mi 3
X-ray
+ Mi 1
Fail.
⌺
n
n
%
n
%
n
%
n
n
%
n
n
%
16/26
109
98
89.9
23
23.5
73
74.5
1
7
9.6
8
74
10.8
17/27
202
179
88.6
45
25.1
127
70.9
3
9
7.1
12
130
9.2
18/28
112
100
89.3
41
41.0
72
72.0
2
9
12.5
11
74
14.9
36/46
118
111
93.2
28
27.0
78
70.3
2
8
10.3
10
80
12.5
37/47
140
123
87.6
35
37.8
90
73.2
2
15
16.7
17
92
18.5
38/48
114
99
86.8
34
34.3
64
64.6
–
3
4.7
3
64
4.7
795
710
89.3
206
28.6
504
71.0
10
51
10.1
61
514
11.9
A failure was decisive for the removal of 23.3%
(n = 48) of the extracted VA teeth and 36.6% (n = 45)
of the extracted VE teeth. Most frequently extracted
due to failure were the vitally amputated upper second molars (34.8%; n = 8), and the vitally extirpated
lower second molars (54.2%; n = 13). The lower wisdom teeth (34 extractions (n = 3; 8.8%) in the pulpotomy group) and the upper second molars (42 extractions (n = 13; 31%) in the VE group) were extracted
least often. The VE and VA results are shown in Tables
III and IV.
Furthermore, the question of whether the RCF
level following VE had any significance with regard
to the failure rate was pursued. The RCF levels were
divided into three levels. The total failures of these
three groups were calculated as described under
material and method (Table V).
Table IV_Summarised VA results.
Without considering the indication range,
anamnestic symptoms, tooth position and RCF level,
the total failure rate was 11.9% for VAs and 15%
for VEs (statistically insignificant; p = 0.644). The VE
failure rate of the RCF level of -4, -3 corresponded
exactly to the VA failure rate of 11.9%. There was no
statistically significant difference (p = 0.226) in failure between RCF levels -4, -3 and -2, -1, 0. The RCF
level of -5 showed significantly more failures compared with the RCF levels of -4, -3 (p = 0.020) and -2,
-1 , 0 (p = 0.002).
Figs. 3a–d_53-year-old patient,
VA 38 (31 October 1995): prepared
cavity (a); N2 applied (b); after VA
and amalgam filling (c); X-ray control
after six years (d) .
Fig. 3a
Fig. 3b
Fig. 3c
Fig. 3d
roots
I 15
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_ 2011
[16] =>
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I research _ vital amputation
RCF level
X-ray + Mi1
n
-5
195
-4, -3
194
-2, -1, 0
124
Table V_VE failures of molars
according to RCF levels.
_Discussion
_Summary
A direct comparison between VAs and VEs, especially as regards incomplete root fillings, was only
possible within limits, as the number of VAs consisted
mainly of a negative selection, which otherwise would
have been entrusted to the pliers. The twice as high
extraction frequency of vitally amputated teeth
compared with that of vitally extirpated teeth (28.6%
versus 14.4%) may be attributed to the adverse baseline situation. Fractured or destroyed teeth were the
reason for extraction for 51.9% of all extractions in
the case of VAs. For VEs, this rate was 46.3%. However,
the extraction reason “endodontic failure” was attributed in 36.6% of the extractions to the VA teeth and
in 23.3% of the VE teeth.
A comparison of 710 N2 VAs and 852 N2 rootfilled molars after VE was done. The average followup period was 53.8 months for VAs and 49.4 for VEs.
The total failure rate (radiological and clinical) was
11.9% following VAs, which is equivalent to that of
VEs with slight underfilling (RCF level -4, -3). Adequately filled root canals led to fewer failures (8.9%)
than VAs. With a failure rate of approximately 19%,
the lower first VE- and second VA-molars were most
frequently affected.
Failures
Anamnestic pain causing an
increased frequency of failure in
n
%
VA cases, which was also observed
43
22,1
by Teixeira et al.following Ca(OH)2
23
11,9
treatment,7 was statistically in11
8,9
significant. Stern3 und Frankl19,20
also point out increased pain following VA. This was observable during our study as well.
Nevertheless, the total failure rate for vitally amputated teeth was lower (11.9%) than the average rate of
15.1% for vitally extirpated teeth.
The evaluation of pulpotomy cases only with accompanying X-rays revealed a failure rate of 10.1%,
which is comparable to the 9% Fisch encountered with
the Triopaste.17 Frankl reports only 2% of failures after
N2 VA, although he had done stringent case selection.19,20 In contrast, the radiological-pathological findings concerning eugenol pulpotomies in pain-free teeth
amounted to 58% after 12 months.4 Fifty per cent of all
Ca(OH)2 pulpotomies of aching teeth resulted in failure
after six to eight months.7 Massler et al. observed a total
failure of 65%, two to five years after Ca(OH)2 VAs.12
The correlation between failure and RCF level following VEs was investigated. Adequately filled teeth (-2,
-1 ad apicem) showed a failure rate of 8.9%, heavily underfilled teeth a rate of 22.1%. Hence, the conclusion
may be drawn that the success rate of VAs corresponds
to the one of properly performed root fillings following
VEs, and is far superior to a noticeably underfilled root
filling. Molven attributes a more favourable peri-apical
situation to pulpotomized than to root-filled roots.14
In their study, Asgary and Eghbal do not explain the
technical performance of the RCF.15 However, they establish that pulpotomies are statistically significantly
superior to RCTs of vital molars, although radiological
failure is neither defined nor numerically expressed.
Additionally, the follow-up time of six months is
considered very brief.
16 I roots
4_ 2011
During the follow-up period, 28.6% of all VA and
14.4% of VE teeth were extracted. Fractured or destroyed teeth were the reason for extraction in 51.9%
of all VA and in 46.3% of all VE cases. The extraction
reason “endodontic failure” occurred less frequently
after VA (23.3%) than VE (36.6%).
_For the practice
The patient should be advised of possible pain following the subsiding anaesthetic effect. Analgesics
are indicated after VA. An N2 VA is more successful
than an insufficient root filling after VE. Vital amputation is indicated in cases of almost inaccessible
canal systems, open apical foramina and for economic reasons.
Instead of an extraction or the impossibility of a VE
with adequate root filling, it is possible to consider—
besides a full pulpotomy, which was the subject of the
present study—a partial pulpotomy on:
_upper molars: VA of the buccal canals, filling of the
palatinal root;
_lower molars: VA of the mesial canals, filling of the
distal root; and
_deep crown margin caries, partial removal of the
pulp cavum._
Editorial note: A complete list of references is available from
the publisher.
_contact
roots
Dr Robert Teeuwen
Berliner Ring 100
52511 Geilenkirchen
Germany
robteeuwen@t-online.de
[17] =>
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[18] =>
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I practice management _ passive income
The passive income
practice
Author_Dr Phillip Palmer, Australia
_Exit planning has traditionally been a fairly
simple task for dentists. The choices a dentist faced
were either winding down the number of days
worked, thereby gradually easing into retirement,
or working until three to six months before wanting
to stop, and then advertising the practice for sale.
After negotiations with the buyer, dentists would
sell and walk away—much like a house sale. Sometimes there would be a good handover of patients
and staff, and sometimes this process would be less
than ideal.
18 I roots
4_ 2011
More recently, other options for exit planning
have become available for practice owners. Over the
last three to four years, for example, many dentists
in Australia having sold their practices stayed on to
work as employee dentists for the new owner. This
model in particular has increased in popularity recently with corporate entities often being the buyer.
Another model is deferred sale/employee with view,
whereby a new dentist (Dr Junior) works for a year
as an employee for Dr Senior. If all goes well, a contract is signed for the purchase of half (or even all)
[19] =>
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practice management _ passive income
the practice in some years hence. The employed
dentist continues to work as an associate, and
the transaction is settled after the agreed time.
This technique assures Dr Senior both a buyer and
extra income from Dr Junior during the years as
an employee. Through the incremental percentage
technique, after a similar trial period, the practice
contracts are exchanged and incrementally each
year a further percentage of the practice changes
hands from Dr Senior to Dr Junior.
In each case, after the practice is sold, the exowner commonly takes the money he made from
the sale, goes on a holiday and then invests whatever is left in real estate or the stock market to fund
his retirement. For a practice here in Australia grossing say AUS$800,000 per year, if sold on the open
market could bring up to AUS$500,000. If that
entire sum were used to purchase a residential investment property, one would be lucky to net more
than AUS$30,000 per year, and probably less, to
fund retirement.
Another way to exit plan and fund a dentist’s
retirement is to establish the passive income practice, also known as the “never sell concept”. Using
this method, the practice is set up in such a way as
to be self-managed, with little effort (1 day/month)
needed from the owner when the practice is mature.
The profit from the practice can be as high as 30 %
after payment of all normal expenses and clinicians’
wages.
deep knowledge and understanding of the systems
needed to run a practice.
Some degree (the more, the better) of management, leadership and business skills is also required
by the owner, including the ability to look at and
analyse the right numbers or to motivate key staff
members to manage the practice and outperform
through the judicious use of incentives, including
well-designed bonus systems. As the owner dentist
is no longer present full-time in the passive income
practice, there also needs to be regular training
in communication and the provision of service, i.e.
clinical training.
There definitely needs to be more than one clinician. Rarely is there sufficient profit over and above
the employee dentist’s wage (40 % after lab) to warrant running the practice as a business with such
a small staff.
There are plenty of horror stories out there,
especially after the global financial crisis, of retired
dentists needing to return to practice because the
practice sale did not fund their retirement the way
they expected it to. The never sell concept represents
a new way of looking at the asset that is your practice and how it can bring you returns long after your
clinical career comes to an end._
_about the author
If maintained as a going concern and run properly, there is no reason to expect a return from
the AUS$800,000 grossing practice of less than
AUS$200,000 p.a. (and still maintain an asset worth
at least AUS$500,000).
Obviously, for this option to work, the practice
and the staff need to be trained to be self-managed
and to provide a certain level of service and communication. Basically, they would need to have a
I
cad/cam
Former dentist Dr Phillip
Palmer is currently Director of
Prime Practice and Dentist Job
Search and regarded as
Australia’s leading expert in
the business of dentistry.
He can be contacted at
info@primepractice.com.au.
roots
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_ 2011
[20] =>
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I opinion _ K-files
Critical thinking:
The missing link in
endodontic education
Author_ Dr Barry Lee Musikant, USA
_After years of teachingendodontic programmes
around the country, I can say with strong conviction
that the process of critical thinking has not been applied to the mechanics of endodontics. Not for one
moment am I critical of a programme’s emphasis on
diagnosis, histology and pathology. The incorporation
of microscopes has vastly improved dentists’ abilities
to seek out fine structure that can be the difference
between success and failure.
Fig. 1
Fig. 1_Photograph of a K-file. Note
the high number of flutes that are
more horizontal in nature.
Fig. 2_Photograph of a relieved
reamer. Note the flat side and the
vertical flutes.
20 I roots
4_ 2011
Where critical thinking is missing is in the selection
of the design and utilisation of the instruments used
to shape the canals. For the most part, K-files are the
instruments recommended for the initial shaping of
canals. I have never detected any evidence that the
decision to use K-files resulted from an analysis of
what works best. It is simply a tool that has been
handed down from generation to generation either to
Fig. 2
perform the entire shaping procedure or to create a
glide path for the subsequent use of rotary NiTi files.
If K-files had been chosen as the most appropriate
instrument to use after critical analysis, we would expect these instruments at least initially to shape
canals more easily than other instruments. We would
expect that such problems as loss of length because
of the apical impaction of debris, distortion to the outside wall, elbowing and frank perforation would be
less inclined to occur because of superior design and method of usage.
Yet K-files are associated with all
the above problems, whereas their
counterpart, K-reamers, is far less
likely to produce such issues. In fact,
critical thinking was not applied to the choice of instruments. Tradition, inertia and simple prejudice take
the place of effective analysis.
Let’s examine how critical analysis would prevent
this widespread mistake that is perpetrated on our
student bodies over the years. Take a look at a photograph of a K-file (Fig. 1). Please note that the shank is
composed of 30 flutes along its 16mm of working
length. The greater the number of flutes, the more
horizontally oriented they are. Compare the 30 flutes
on a K-file to the 16 that are present on the shank of
a reamer (Fig. 2). Also, please note that with approximately half the flute number, each flute is significantly more vertically oriented along the length of the
reamer shank. Fewer flutes lead to less engagement
along length. Resistance in apical negotiation is directly related to the reduction in engagement.
A watch-winding motion is the recommended
way to use both the reamers and the K-files. Yet, when
a watch-winding motion is applied to the more hori-
[21] =>
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opinion _ K-files
Fig. 3
zontally oriented flutes of a K-file, the threads tend to
embed themselves into the canal walls without shaving any of the dentine away in the process. Increasing
the amount of engagement does not help in shaping
the canal. Compare the action of these flutes with the
more vertical orientation of the flutes on the reamer.
Using the same watch-winding stroke applied to the
K-files, the blades being more at right angles to the
plane of motion will immediately start shaving dentine from the walls of the canal, further reducing the
degree of engagement and the subsequent resistance
encountered as the reamers negotiate apically.
Clinically, the dentist encounters less resistance
when using reamers because there is less engagement along length, resulting from fewer flutes to
begin with and their greater ability to shave dentine
rather than embed into it. Embedment leads to increased resistance. Shaving dentine further reduces
the smaller amount of engagement that was already
present. The design and utilisation of the K-file works
against the very goals it wants to attain. Reamers
are designed and utilised in a way that is compatible
with their goals. Critical thinking would make these
basic points obvious. Controlled clinical testing of
both designs would immediately demonstrate the
superiority of reamers to K-files.
The comparison could easily stop at this point,
and reamers would be the unquestioned winner, but
there are other advantages that accrue to the user
as well. With less engagement along length, a cutting
blade more or less at right angles to the plane of
motion that removes dentine rather than embeds into
it, a more flexible instrument that is a consequence of
fewer twists along the length of the shank, the reamer
gives the dentist a superior tactile perception, giving
him the ability to differentiate between the tip of
the instrument hitting a solid wall or engaging within
a tight canal. Both situations will either stop or slow
down apical progress.
Rather, he must remove the reamer from
the canal, place a 45° bend at the tip
and, with a light peck-and-twist motion, attempt to manually negotiate
around the obstacle. On the other
hand, if tug-back is present from
the outset, the dentist knows to
continue apical negotiation using
either the recommended watchwinding motion or a twist-and-pull
motion until the apex is reached.
I
Fig. 3_Illustration of an asymmetrical
instrument’s ability to distinguish and
clean an oval-shaped canal.
A K-file that is already so heavily engaged along
length cannot make the distinction between a solid
wall and a tight canal. The resistance along length
obscures what the tip of the instrument is encountering. Using a K-file, all a dentist may know is that he is
short of length. Using an aggressive twist-and-pull
motion, the proper length can be regained even when
employing a K-file with a non-cutting tip. However,
too often the dentist will discover that the original
anatomy has been lost with the apical third transported to the outside wall of a curved canal. This is
the effect when a solid wall or impacted debris is
encountered, but not recognised as such because of
the excessive engagement of the K-file along length.
The absence of critical thinking is recapitulated
by maintaining the continued use of K-files. First,
we abdicate the use of reamers without making any
comparisons. Worse, while not learning the benefits
of reamers, we also lose our evolutionary potential
to improve upon a tool that in its present state is
superior to K-files.
Critical thinking demonstrates that reamers are
superior to K-files for several reasons, one of the main
reasons being reduced engagement along length.
By placing a flat along the entire working length of
the reamer, we now have a reamer that has even less
engagement along its working length. The result is an
Fig. 4_The Endo-Express
reciprocating handpiece
(Essential Dental Systems).
Fig. 4
However, if the tip of the instrument is hitting
a wall, there will be no tug-back when the reamer
is withdrawn, telling the dentist that he
must not attempt to proceed further.
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I 21
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_ 2011
[22] =>
RO0110_01_Titel
I opinion _ K-files
Figs. 5–7_Radiographs
showing clinical results achieved
with relieved reamers in a
reciprocating handpiece.
Fig. 5
instrument that is even more flexible
because it is thinner in cross-section,
includes two vertical columns of chisels that cut equally effectively in both
the clockwise and counter-clockwise
direction and is asymmetrical in crosssection, giving it the ability to differentiate between a round and oval canal.
No symmetric instrument can differentiate between a round and oval canal.
The ability to make this distinction tells the dentist
when to widen the canals to greater dimensions for
superior mechanical cleansing and better chemical
debridement via the irrigants (Fig. 3).
Fig. 7
Without critical thinking, no one knows that a
reamer is superior to a K-file and without that knowledge, no one knows that a reamer can be modified
to further improve its functionality. Perhaps, most
importantly, without the benefit of critical thinking,
those designing instruments to eliminate the shortcomings of K-files do not eliminate them. They merely
reduce them, still incorporating their use in the creation of the glide path1, and then proceed to introduce
rotary NiTi systems that, while overcoming the limitations of K-files, introduce significant new problems
that add cost, anxiety and unpredictability to canal
shaping.
_contact
roots
Dr Barry Lee Musikant
Essential Dental Systems, Inc.
89 Leuning Street
S. Hackensack , NJ 07606
USA
info@edsdental.com
22 I roots
4_ 2011
In the meantime, critical thinking would clearly
demonstrate that relieved reamers (Fig. 3) are not only
good for glide path creation but work far more safely
when used for the entire shaping procedure. Stainlesssteel relieved reamers are quite effective at recording
the curvatures of a canal.2 Unlike NiTi, they do not snap
back to the straight position, a property that increasingly distorts the apical end of curved canals as the tip
size and taper of the instruments increase.
The greater stiffness of stainless steel is compensated for by the relieved reamer design, never exceeding a .02 taper and routinely straightening the coronal curve prior to the use of larger-tipped instruments.
Used either in a tight watch-winding stroke or in a
Fig. 6
30° reciprocating handpiece (Fig. 4), the tip of the
instrument confined to such a short arc of motion
always stays centred in the canal. As long as patency
is maintained, these relieved reamers will not deviate
from the original pathway. Patency3 is maintained
by going 0.5mm beyond the constriction through a
25 relieved reamer, a technique that is easy to master
and is completely predictable in its results.
Unless one is exposed to the critical thinking
needed to open one’s mind to better working alternatives, the entire cascade of learning is stopped before
it starts.
Without critical thinking, one will never learn
that reamers are safer, more efficient and more effective than K-files. Without learning the superiority of
reamers, one will never learn that relieved reamers are
superior to non-relieved reamers. If one does not use
reamers, one will not be exposed to the advantages
of non-distorted shaping using a 30° reciprocating
handpiece. Without the exposure to a 30° reciprocating handpiece, one will never appreciate the absence
of torsional stress and cyclic fatigue4 that plagues
rotary NiTi, leading to unpredictable separation. And,
without the appreciation that instruments will simply
not break, one will not confidently shape canals to the
larger dimensions that are often required to ensure
proper debridement and irrigation. Examples of cases
done with relieved reamers in a reciprocating handpiece are shown in Figures 5–7.
We have been indoctrinating our students for
too long. It is about time that we educate them. Critical thinking is the way for students to make rational
decisions. They will become better dentists and serve
the needs of their patients better when these skills
are honed. There may be those out there who dispute
the conclusions that critical thinking will produce, but
I defy anyone who says this is not the proper way to
educate._
Editorial note: A complete list of references is available
from the publisher.
[23] =>
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[24] =>
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I opinion _ rubber dam
Rubber dam hazards?
Author_ Dr Kenneth S. Serota, Canada
been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence-based
medicine have criticised the adoption of interventions
evaluated by using only observational data. We think that
everyone might benefit if the most radical protagonists of
evidence-based medicine organised and participated in a
double blind, randomised, placebo-controlled, cross-over
trial of the parachute.
Fig. 1
_The September issue of Oral Health included
an article by Dr Ellis Neiburger entitled Rubber dam
hazards. The contextual inaccuracy, skewed perspective and postulatory bias of the author was disingenuous at best and horrifying at its worst. I’m not certain
how it managed to secret itself into our beloved centenarian journal, but it did. Before I comment on the
text, I’d like to share a scientific article with you published by Smith and Pell in the British Medical Journal in 2003 (entitled Parachute use to prevent death
and major trauma related to gravitational challenge:
systematic review of randomised controlled trials) to
give my concern about this article’s publication an
element of gravitas. The abstract reads:
Objectives: To determine whether parachutes are effective in preventing major trauma related to gravitational
challenge.
Design systematic: Review of randomised controlled
trials.
Data sources: Medline, Web of Science, Embase, and the
Cochrane Library databases; appropriate Internet sites
and citation lists.
Study selection: Studies showing the effects of using a
parachute during free fall.
Main outcome measure: Death or major trauma, defined
as an injury severity score > 15.
Results: We were unable to identify any randomised controlled trials of parachute intervention.
Conclusions: As with many interventions intended to
prevent ill health, the effectiveness of parachutes has not
24 I roots
4_ 2011
Not wishing to misjudge nor malign the author,
I searched the many publications attributed to Dr
Neiburger in the literature using Google Scholar. My
personal favourite was Similar mandibular osseous
lesions in Tyrannosaurus Rex and man,1 followed
closely by Voodoo Barbie and the dental office,2 not
to be outdone by Water line biofilm dangers—A tempest in a teapot.3 Of note, none of the references
pertaining to the hazards were dated beyond 1990.
As to the inaccuracies, rather than repeating the
text, I’ll answer the “factoids”: rubber dam is routinely
used in the vast majority of endodontic and restorative procedures by contemporary dentists; sterilisation of the rubber dam can be done readily; reuse is
the most scurrilous of the factoids proposed; colour
is not an issue, in fact it can be used to enhance photographic documentation; the physical and chemical
properties of the dam enable it to be used with most
if not all dental materials and its strength cannot be
in dispute, as the average endodontic procedure
does not require multiple replacement; damage from
clamps occurs because of improper placement; the
sheer enormity of clamp sizes and design allows for
literally any clinical situation with tissue injury essentially non-existent; there are a raft of alternatives to
clamp placement (Fig. 1); the issues pertaining to time
for placement, phobias, material residue in pockets
anon … even providing a rebuttal to the text gives it a
undeserved credibility.
Dentistry is perched on a slippery slope. In North
America alone, it represents a silo of approximately
$60 billion. Evidence-based science has been replaced
by eminence-based science and the concept of “nonfiduciary advocacy” has been lost in the ether. I wish I
possessed Randy Lang’s erudition and Will Rogers’
wit. His recent editorial on a specific orthodontic band
of dubious value beyond the strength of its marketing
showcased the fact that even amongst those whose
[25] =>
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opinion _ rubber dam
I
focus is narrowed by a specialty, a segment can be
catalysed through market forces to recognise
something as the holy grail, when another
faction sees the same product as having the
value of a Gwyneth Paltrow GOOP-substantiated cleanse.
In my own area of interest, a recent article by one of the better-known clinicians
questioned the value of the wealth of new
endodontic products coming to market,
especially the latest NiTi iteration that reintroduced reciprocation. The essence of the
article was, “if it ain’t broke, don’t fix it”, which
then included the take-away message that the
product long associated with the reputation of
the author had served the discipline well and it too
required only a paucity of instruments to achieve
100% predictable clinical success.
To bring this to a purposeful conclusion, I would
encourage you to google Bayes’ theorem. It is in
essence an equation and depending upon whether
you are a frequentist, a subjectivist or and objectivist,
the theorem suggests that if we assign some a priori
probabilities and then compute a posteriori probabilities, the degree of confidence in some hypotheses
can be conditioned by the new data that becomes
available. For example, the Venn diagram (Fig. 2)
relates to a population, the number expected to have
a type of cancer, the number that are indeed positive
for the cancer and the number that show a false
positive by virtue of a test for markers. Alter the variable, consider the efficacy of lasers by way of example, the degree of penetration into the dental profession, the advocacy of those that use them and the
perception of the value inherent based upon their
need to see viable applications and substantiated
results. It is a technology that will inevitably prove to
be an invaluable tool, albeit currently in its infancy.
Read all publications with extreme caution—think
HealOzone.
Dentistry is getting very complicated as technology and innovation alter its construct. The one essential aspect that must never be overlooked is the need
to sustain biological fundamentalism through assiduously conceived investigations and authorship that
follows the Cochrane Collaborative principles. We are
about to enter a decade wherein it is manifestly conceivable that teeth can be regenerated or replicated
and achieve morphological and functional integration into the gnathostomatic apparatus. While it may
not impact on the $4 billion a year whitening arena
of oral services, it will impact on many others. The
number of rubber dam hazard articles may well
breach the levees and floodgates and overwhelm the
profession, decimating the landscape and relocating
A
AB
B
Universe
Fig. 2
the populace. It is Oral Health’s job to stand on guard,
“oh Canada, to stand on guard for thee”._
References
1. Neiburger EJ. Similar mandibular osseous lesions in Tyrannosaurus rex and man. J Mass Dent Soc. 2005 Fall;54(3):14–7.
2. Neiburger EJ. Voodoo Barbie and the dental office. N Y State
Dent J. 2001 Jun-Jul;67(6):26–7.
3. Neiburger EJ. Water line biofilm dangers a tempest in a teapot.
J Mass Dent Soc. 2001 Winter;49(4):20–1.
_about the author
roots
Dr Kenneth S. Serota graduated from the University of
Toronto in 1973 and was awarded the George W. Switzer
Memorial Key for Excellence in Prosthodontics. He received
his Certificate in Endodontics and Master of Medical Sciences
degree from the Harvard-Forsyth Dental Center in Boston.
A recipient of the American Association of Endodontics
Memorial Research Award for his work in nuclear medicine
screening procedures related to dental pathology, his passion
is education, and most recently e-learning, and rich media. Dr Serota provided an
interactive endodontic programme for the Ontario Dental Association from 1983 to
1997 and was awarded the ODA Award of Merit for his efforts in the provision of
continuing education.
The author of more than 60 publications, Dr Serota is on the editorial board of
Endodontic Practice, Endo Tribune and Implant Tribune. He founded ROOTS, an
online educational forum for dentists from around the world who wish to learn cuttingedge endodontic therapy, and recently launched IMPLANTS (www.rximplants.com)
and www.tdsonline.org in order to provide dentists with a clear understanding of
the endodontic–implant algorithm in foundational dentistry.
roots
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_ 2011
[26] =>
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I news _ X-rays
Dental X-rays can
predict fractures
Fig. 1
Fig. 2
Fig. 1_Reference images presenting
the trabecular pattern as dense
trabeculation in a woman with small
intertrabecular spaces ...
Fig. 2_... mixed dense plus sparse
trabeculation in a woman with small
intertrabecular spaces cervically and
larger spaces more apically ...
Fig. 3_... and sparse trabeculation in
a woman with large intertrabecular
spaces.
_By using dental X-rays, the risk of fractures can
now be predicted long before a fracture actually occurs,
Swedish researchers at the University of Gothenburg’s
Sahlgrenska Academy have found.
In a previous study, researchers at the Academy and
the Public Dental Service of the Region Västra Götaland
had demonstrated that a sparse bone structure in the
trabecular bone in the mandible is linked to a greater
probability of having previously had fractures in other
parts of the body.
The Gothenburg researchers followed this research
with a new study that demonstrates that it is possible
to use dental X-rays to investigate the bone structure
in the lower jaw, which enables doctors to predict who
is at greater risk of fractures in the future.
“We have discovered that sparse bone structure in
the lower jaw in mid-life is directly linked to the risk of
fractures in other parts of the body later in life,” said
Prof Lauren Lissner, researcher at the Institute of Medicine at the Sahlgrenska Academy.
The study draws on data from The prospective
population study of women in Gothenburg, which was
begun in 1968. “Given that this study has now been
running for over 40 years, the material is globally
unique,” the Academy stated. The ongoing study includes 731 women, who have been examined on several occasions since 1968, when they were 38 to 60
years old. X-ray images of their jaw bone were analysed
in 1968 and 1980 and the results related to the incidence of subsequent fractures. “The youngest cohort is
now over 80 years old. Many of the cohorts, who were
26 I roots
4_ 2011
Fig. 3
born earlier, have died. We regularly check the cohorts’
status by monitoring the mortality and hospital registries,” Lissner told roots.
According to the Academy, for the first 12 years,
fractures were self-reported during follow-up examinations. It is only since the 1980s that it has been possible to use medical registers to identify fractures.
A total of 222 fractures were identified during the
whole observation period.
The study found that the bone structure of the jaw
was sparse in around 20 per cent of the participants
aged 38 to 54 when the first examination was carried
out, and that these participants were at a significantly
greater risk of fractures.
The researchers also concluded that the older the
person, the stronger the link between sparse bone
structure in the jaw and fractures in other parts of the
body. Although the study was carried out on women,
the researchers believe that the findings could be
generalised to men.
“Dental X-rays contain lots of information on bone
structure,” said Grethe Jonasson, researcher at the
Research Centre of the Public Dental Service in Västra
Götaland, who initiated the fractures study. “By
analysing these images, dentists can identify people
who are at greater risk of fractures long before the first
fracture occurs.”
The study A prospective study of mandibular trabecular bone to predict fracture incidence in women was
published in the October issue of the Bone journal._
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I feature _ interview
“The integrated systems provide
enormous support for the user
during root-canal preparation”
An interview with Dr Emanuele Ambu, Italy
Dr Emanuele Ambu
_Dr Emanuele Ambu is an internationally recognised endodontic expert. During the 15th Annual
Congress of the European Society of Endodontology
(ESE), which took place from 14 to 17 September in
Rome, Italy, the dedicated Italian specialist offered
interesting insights into his working methods. He
explained why it is particularly important to have
high-quality instruments in endodontics and why
he therefore likes to work in collaboration with the
Japanese company Morita.
_Marcel Meurer: Dr Ambu, what are you intensively involved in at the moment?
Dr Ambu: In practical research, I am currently
focusing on the application of digital volume tomography in endodontic treatment. I am also involved
in the so-called hybrid concept, which is a working
method that enables quicker, more reliable preparation of the root canal.
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4_ 2011
_How important is it in endodontics to be up to
date on the state of the art of this specialised field?
Extremely important! During the last 15 years,
there has been a whole series of paradigm shifts in
the area of root-canal treatment (RCT). Newly developed instruments and materials definitely support
the endodontists, thus ensuring a much more reliable
and easier treatment procedure. There are now rotary
nickel-titanium instruments (NiTi files) that enable
preparation of the root canal within a few minutes.
Moreover, instruments such as the apex locator
also help considerably to improve the quality of any
endodontic treatment, as the entire therapy can be
performed more quickly and with less pain for the
patient. In addition, there is technological progress
regarding the cleaning and sealing procedures of the
root canal, and microscopy and 3-D volume tomography (CBCT) have considerably facilitated endodontic treatment success. Surgical microscopes and 3-D
volume tomography are extremely essential in treatment planning and in the therapy itself to ensure
successful completion of complex endodontic cases.
At the end of the day, it is our duty as conscientious
dental practitioners always to treat patients according to state-of-the-art techniques.
_How important are specialist congresses such as
the ESE for you? What are the most important findings
that you took with you this year from Rome?
I think specialist society congresses are very important. Since I joined the ESE in 1999, I have not missed
one single congress. This year’s event in particular, was
one of the most interesting: over 200 lectures, fantastic poster presentations and also the fact that Rome is
a city that radiates a special magic, even for Italians like
me. I was personally involved during the congress in
presentations about pulp regeneration and the application of CBCT systems in endodontic treatment.
_There appears to be some kind of competition
between endodontics and implantology. Do you think
there is some rivalry between these two specialist
disciplines?
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feature _ interview
I think it is wrong to talk about rivalry between the
two areas of dentistry. Each case must be examined
very carefully. The main priority of each dentist should
be to try to conserve the tooth, by utilising other treatment areas. This includes the periodontal and restorative techniques of dentistry, which the treating dentist
should take into consideration and fully exploit. When
there is no possibility of conserving the tooth, there
is also no objection to providing a dental restoration
with a crown on an implant. An implant should therefore not be used solely because it is the cheaper option
for the patient or because it is easier for the dentist to
place an implant. Far too many teeth are extracted
nowadays because of inadequate endodontic skills
and knowledge. Nowadays, we know that there is
virtually no difference between the long-term success
rates of RCTs and implants. There is of course no golden
rule for when RCT should be carried out and when the
time is right for an implant. However, the American
Association of Endodontics issues very clear statements on the subject: the endodontic treatment of a
hopeless tooth is just as unethical as the extraction
and replacement of a restorable tooth with an implant.
_Where is the “art” in root-canal treatment?
In other words, what are the challenges and what
determines the degree of difficulty?
I
According to Dr Herbert Schilder, the aim of endodontic treatment is always the complete removal of
bacteria from the root-canal system. This allows apical
periodontitis to be controlled, and prevents its occurrence following treatment. In fact, this aim is relatively
easy to achieve: dentists must complete all treatment
steps carefully—beginning with correct isolation of the
treatment site using a rubber dam to the permanent
restoration of the tooth. Treatment of a single-rooted,
straight tooth is much easier than treatment of a molar
with four severely curved root canals. Nevertheless, we
now have instruments and techniques available that
enable reliable treatment of all teeth.
_You have had the opportunity to try out the Soaric
endodontic treatment unit from Morita. How does the
workstation support dentists during treatment?
I had the opportunity at the IDS in Cologne and
the congress in Rome to test Soaric and to work on a
phantom head. I really appreciate the integrated endodontic system of the treatment unit. Soaric is fitted
with an endo motor with integrated apex locator,
making it easier to use the rotary instruments. I think
that Soaric is fantastically well suited for endodontic
treatment. The attachment for direct connection of a
surgical microscope indicates that Soaric was entirely
developed for endodontic experts.
AD
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2QO\LQVWUXPHQWVIRUPRVWFDVHV
6LQJOHOHQJWKWHFKQLTXH
5
5
5
XSWR:/
XSWR:/
XSWR:/
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I feature _ interview
_In general, do you personally perform treatment alone (two-handed treatment) or rather with
an assistant (four-handed treatment)?
I always work using four-handed treatment with
an assistant. I am often also supported by a colleague
during surgical procedures. However, I am convinced
that Soaric also provides an excellent opportunity
to treat alone. The instruments are arranged pretty
well, so they enable the dentist to perform an intuitive treatment procedure.
_In your opinion, what makes Morita one of the
leading suppliers of units and instruments for rootcanal treatment?
The name Morita is familiar to every endodontic
specialist, not least because of the electronic apex
locators (Root ZX, J. Morita). The company is one of
the leading manufacturers of integrated endodontics. Integrated systems in particular, such as the
DentaPort or the old TriAuto ZX (the first endodontic handpiece with an integrated apex locator) or the
new TriAuto mini, provide the user with enormous
support during root-canal preparation.
_Which instrument is indispensible for an endodontist?
We require all instruments and equipment that
enable us to perform good treatment. In my opinion, a surgical microscope, apex locator and an appropriate endodontic handpiece are the minimal
requirements for providing good treatment. I personally believe that an electronic apex locator is
indispensible. The root canal can be prepared conventionally using files and sealed with gutta-percha
heated over a flame. What we really must establish
during root-canal preparation, however, is the exact
working length!
_Which is the most important instrument for
root-canal preparation? How many files do you
require as a rule?
We have developed a technique—the hybrid concept—which allows us to prepare a root canal using
only three instruments. For preparation, we require
the TriAuto mini, but not in automatic mode. We
reach the apex simply by using a 10 K-file, to create
a glide path. In this way, we reduce the likelihood
of the rotary instruments fracturing. The second
instrument is then used: the 35.08 EndoWave rotary
file is used to enlarge the access of the crown and
middle third to the root canal. The working length
is determined using the apex locator. We reach
the apex using the 20.06 EndoWave file and can
completely prepare the root canal using this file.
In accordance with the principle of estimating the
apical extension, we widen the canal with the rotary
instruments and use the attachment with the
largest diameter. We use the TriAuto mini in auto-
30 I roots
4_ 2011
matic mode in the case of canals with severe curvatures. With this technique, we reduce the risk of
damage to the tooth structure outside the canal.
We then reach the apex automatically using the
smallest rotary instrument in the world, the MGP 1
(a rotary NiTi file with a conicity of 0.02 mm and a
#10 tip diameter).
Then follows MGP 2 and MGP 3 (also with a
conicity of 0.02 mm and #15 and 20 diameters). The
DentaPort or the TriAuto mini in combination with
the Root ZX mini can be used in the automatic mode.
In this mode, rotation starts as soon as the file tip is
inserted into the canal opening. Once the apex has
been reached, the unit is simply removed by rotating the files in a counter-clockwise direction. Using
a glide path of 20.02, the 35.08 EndoWave file can
prepare the crown and middle third of the root
canal, even with severe curvatures. The apex is then
reached and prepared using the 20.04 EndoWave
file and finally preparation is completed using the
20.06 EndoWave file.
_What makes a good file?
The ideal instruments should be reliable. It is
particularly important that the files are fracture
resistant and can be used several times.
_What advice would you give to young colleagues
for their career path when they start in endodontics?
I would strongly advise young colleagues,
when starting their endodontic career, to observe
the endodontic treatment protocols and guidelines and use high-quality instruments. We use
certain instruments and units for a very long time
in our professional life, particularly because they
are of good quality. For example, I have been working with my first Root ZX since 1993, which is still
in good working order. I use it together with some
newer apex locators from Morita._
Editorial note: A video demonstrating
Morita’s hybrid concept is available on www.
dental-tribune.com/articles/content/id/
6828 or simply scan the QR code with you
smartphone.
_contact
J. Morita Europe GmbH
Justus-von-Liebig-Straße 27a
63128 Dietzenbach
Germany
www.morita.com/europe
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I industry news _ FKG
FKG Dentaire introduces
iRaCe and Scout-RaCe
_FKG Dentaire specialises in the development,
manufacture and distribution of dental products,
for the endodontic specialty in particular. This year,
the Swiss company introduced iRaCe and ScoutRaCe, two new and advanced rotary NiTi instrument
systems for safe and effective root-canal preparation.
_iRaCe―
Quick, effective and safe sequence
Thanks to their exclusive features, only three iRaCe
rotary NiTi files are needed to treat most cases
(straight, slightly curved and/or large). The iRaCe
sequence is easy to learn and to apply, resulting in
considerable time-savings.
_contact
roots
FKG Dentaire
Rue du Crêt-du-Locle 4
2304 La Chaux-de-Fonds
Switzerland
info@fkg.ch
www.fkg.ch
32 I roots
4_ 2011
The iRaCe rotary NiTi files offer the following
features:
_new shank enables easy identification of ISO sizes
(large ring) and taper (thin ring; yellow: 2%, red:
4%, blue: 6%).
Furthermore, two additional instruments— iRaCe
Plus—have been developed to allow for the treatment
of difficult cases, such as severely curved, narrowed
and calcified canals.
_Scout-RaCe―
Mechanical scouting sequence
Scout-RaCe enables a faster and better shaping of
the glide path than manual files. Scout-RaCe10.02 can
be used directly after a manual instrument ISO 08 up to
working length, followed by Scout-RaCe 15.02 and
Scout-RaCe 20.02. Thanks to its exceptional flexibility,
Scout-RaCe follows the canal anatomy perfectly.
Scout-RaCe offers the following features:
_exclusive rounded Safety Tip for perfect guidance;
_alternating cutting edges and thus no screwingin effect and no pulling in;
_sharp cutting edges, yielding time-savings through
efficient cutting;
_electrochemical polishing, resulting in better resistance to torsion and cyclic fatigue;
_SafetyMemoDisc to master fatigue and control the
number of uses;
_extreme flexibility thanks to the 0.02 taper;
_exclusive rounded Safety Tip;
_unique anti-screwing design;
_sharp cutting edges;
_electrochemical polishing for better resistance to
torsion and fatigue;
_SafetyMemoDisc for mastering metal fatigue and
controlling the number of uses._
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I meetings _ AMED
Dental symposium at home?
AMED goes virtual
Author_ Dr Terrell F. Pannkuk, USA
_The energy and expense of running
a physical meeting has become a significant problem for many organisational
leaders in 2011. With the worst economy
since the Great Depression, the Japan
tsunami affecting 40% of our membership, and the annual meeting scheduled
to be held in one of the most exclusive
areas in the world, the Academy of
Microscope Enhanced Dentistry (AMED)
found itself entering a perfect storm.
“The man of virtue makes the difficulty to be overcome his first business,
and success only a subsequent consideration” (Confucius) came to mind as
AMED President, Dr Bill Lannan, and I
took a step away from tradition this
past March after our very successful
Santa Barbara 2010 meeting. We regrouped and brainstormed a new idea:
a virtual dental conference with no
physical meeting space at all!
We developed a live three-day online programme
with multiple webinar channels and an interactive
website with chatting capability for attendees. The
meeting was organised into corporate forums, research and academic presentations, and featured
clinical presentations.
Most sessions were presented live with nearly 50
presenters in the three days. Teams of moderators, comoderators and guests were packed into my dental
office computer network, as mission control to ensure
the smooth running of the conference. We were in
touch live around the dental world from 10 to 12 November. Presenters spoke from Brussels to Florence to
Taiwan to Frankfurt to Sao Paolo to Tokyo to London
to Melbourne to Haifa to Vancouver to Athens to Riga
to Cape Town to Newport Beach, all simultaneously
with multiple channels. Real-time group Q & A followed each presentation in every time zone. The attendees from 26 countries said that they were having
much fun staying up all night interacting and listen-
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4_ 2011
ing to some of the most talented dentists in the
world lecturing from their homes on their computers
as if they were in one giant global room together.
There were even impromptu live presentations. It was
dental Woodstock, a ground-breaking event!
The meeting is now online for registrants to view
the presentations if they were unable to see them live.
Up to 28 self-instructional ADA CERP CE credits are
available by filling out surveys on the conference site.
The AMED site is now an active communication hub
where invitations are sent out for impromptu lectures
by some of the presenters. The unique aspect of the
AMED conference is that it continues to attract
participation well after the meeting. The buzz keeps
going on.
Attendees are able to see their colleagues’ online
presentations through the AMED website and are
then able to chat with them online. The virtual exhibit
hall, individual presentation pages, and overview
page are great places to meet. The attendees can also
write comments on the presenters’ page and obtain
feedback directly from the presenters. We plan to
continue these virtual meetings and will add more
presentations to our exclusive video-viewing library.
Please join the experience by logging onto
www.microscopedentistry.com. Members who register for the meeting will receive indefinite access as a
member benefit and non-members can register for
the event with 30-day access._
_contact
AMED Central Office
P.O. Box 15834
Fort Wayne, IN 46885-5834
USA
info@microscopedentistry.com
www.microscopedentistry.com
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I meetings _ DGEndo/DGET
Ten years of DGEndo
and the launch of DGET
Author_ Oscar von Stetten, Germany
_Thursday: Pre-congress and
general meeting
The first Annual Meeting of the DGET began with a
pre-congress event featuring six industry workshops.
Since root-canal preparation (RCP) is an important
and recurring issue in practice, a range of automated
RCP systems with various features was presented.
Prof Michael Baumann, for instance, presented a
system for implementing the crown-down method
following a specified instrument sequence.
_From 3 to 5 November, over 450 guests broke
visitor records during the tenth Annual Meeting of the
German Society of Endodontology (DGEndo) held at
the Kameha Grand hotel in Bonn, Germany. The meeting simultaneously marked the end of DGEndo and
the launch of the German Society of Endodontology
and Traumatology (DGET). With an excellent programme and an impressive line-up of international
speakers, the meeting was probably the most important German endodontics event of the year.
36 I roots
4_ 2011
Drs Christoph Zirkel and Josef Diemer discussed
RCP with reciprocating motion, a frequent topic of
debate over recent months. Here, the reduced risk of
instrument breakage and rapid preparation after the
glide path has been established is of particular interest to most colleagues. However, in addition to the
benefits, the weaknesses and limitations of these new
systems were also discussed. The often-advocated
one-file endo approach cannot always be implemented.
In his lecture, Dr Christian Gernhardt followed
along the same lines, stating that “it is ok to use more
than one file”. He highlighted the advantages and
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meetings _ DGEndo/DGET
disadvantages of various file systems and offered
advice on how to react to specific anatomical features
to ensure treatment success.
In his workshop entitled From hot to cold, Dr Dieter
Pahncke explained preparation methods with ultraflexible files and discussed various filling techniques.
I presented a workshop—Documentation with the
dental microscope—that was met with great interest.
Participants were able to examine and test many of
the solutions currently offered by the industry. Twelve
different documentation solutions were presented,
a number that is testimony to the depth and complexity of the field. Of enormous interest were the
fundamental physics—not necessarily simple but
nonetheless important—that clearly illustrated the
limits posed by optics. However, a whole range of
practical tips was offered on how to make documentation more useful.
Members attending the general meeting in the
evening were given a clear outline of the current
efforts and achievements of the board. During the
elections, board members were re-elected unani-
I
mously, demonstrating confidence in the existing
board and its strategies in promoting the society’s
interests. The day closed with a good meal in a relaxed
atmosphere.
_Friday: Main congress and birthday party
The main scientific programme was opened by
Dr Christian Gernhardt in an excellent manner, as
always. He was followed by Prof Marco Versiani, who
presented fascinating µCT images of the complex
root-canal anatomy and clearly and skilfully put
these images in the context of our everyday clinical
work. Thereafter, Dr Arnaldo Castellucci gave a concise yet entertaining summary of improvements in
non-surgical endodontics. He focused on the use of
ultrasonic instruments in endodontic treatment and
the establishment of a glide path for subsequent
rotary preparation.
After an excellent lunch, the programme continued with an insight into the fascinating field of adhesion to dentine following endodontic treatment. Prof
Junji Tagami from Tokyo demonstrated this complex
issue in a clear and interesting manner. The essence of
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4
_ 2011
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I meetings _ DGEndo/DGET
Prof Roland Weiger from Basel gave the audience
an extremely comprehensive update on dental traumatology. According to Prof Weiger, developments
in trauma treatment are far advanced and it is important to put this fundamental issue back into focus.
His extremely informative lecture was followed by an
announcement that a smartphone app—a detailed
and handy reference for correct and rapid therapy
planning—is to be developed in collaboration with the
DGET in 2012.
_3-D live operation: The grand finale
Photographs courtesy of Eric Müller,
OEMUS MEDIA.
his lecture was that chemically altered dentine does
not allow for complete adhesion. Therefore, fresh dentine has to be uncovered by mechanically removing
the altered layer, if good adhesion is to be achieved.
Prof Markus Haapasalo from Vancouver—without
a doubt one of the most experienced researchers and
clinicians in his field worldwide—spoke on the highly
complex issue of treatment planning and disinfection
of canal structures and gave a very good insight into
possible disinfection strategies.
The day ended with a big birthday celebration in
the Puregold Bar at the Kameha Grand. In his speech
on the occasion of DGEndo’s tenth anniversary,
Dr Hans-Willi Herrmann gave an interesting insight
into the history of the society—naturally, in his very
own inimitable style that had the audience laughing
on several occasions. Celebrations in the bar then
continued into the early hours.
The highlight of this year’s congress was the
microsurgical apicectomies carried out live on two
lower molars by Prof Syngcuk Kim. Particularly exciting for participants, the procedure was projected live
in 3-D thanks to technology from Zeiss. As always, it
was both fascinating and inspiring to watch such an
experienced surgeon. Prof Kim had already operated
live during the very first annual DGEndo meeting
in 2001. With his participation in the tenth annual
congress, we have come full circle.
This event clearly was a milestone. Looking back
at ten successful years of DGEndo and one year after
the foundation of the DGET, we are in an excellent
position to drive forward endodontic advances in
Germany.
“Ten years of DGEndo came to a close this weekend
and that is how it should be. The first annual convention of the DGET was a clear testimony to just how
dynamically our field is developing,” commented
Dr Christoph Zirkel. “Never before have we welcomed
so many participants, have so many students registered, have we launched so many new and exciting
projects in just one weekend. On behalf of the board,
I would like to thank all those who have given us their
support and had confidence in us. We will make every
effort to continue to earn the trust placed in us.”_
_Saturday: Main congress
The following day began with a lecture by Prof
Thomas Kvist from Gothenburg, which was well
attended despite the partying the previous evening.
He spoke on success rates in endodontics and their
significance for strategic treatment planning.
Dr Roy Nesari from San Francisco then gave a
most entertaining presentation on the marketing
concept at his endodontic practice. He explained his
particular focus on communication with referring
physicians, staff motivation and practice development. He certainly raised a number of interesting
aspects regarding marketing, while maintaining participants’ interest and offering useful ideas.
38 I roots
4_ 2011
_contact
DGET
Holbeinstraße 29
04229 Leipzig
Germany
sekretariat@dget.de
www.dget.de
roots
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I meetings _ events
International Events
2012
Pan Arab Endodontic Conference
11–14 January 2012
Dubai, UAE
www.paec2012.com
Swiss Society for Endodontology International
Conference
20 & 21 January 2012
Lausanne, Switzerland
www.endodontology.ch
DGET Spring Academy
2 & 3 March 2012
Heidelberg, Germany
www.dget.de
Russian Endodontic Congress
30 March–1 April 2012
Moscow, Russia
www.congress2012.endoforum.ru/e/index.html
SCANDEFA
26–28 April 2012
Copenhagen, Denmark
www.scandefa.dk
Trans-Tasman Endodontic Conference
21–23 June 2012
Queensland, Australia
www.tteconference.com
Skand Endo
23–25 August 2012
Oslo, Norway
nina.gerner@c2i.net
FDI Annual World Dental Congress
29 August–1 September 2012
Hong Kong, China
www.fdiworldental.org
ROOTS Summit
18–20 October 2012
Foz do Iguaçu, Brazil
DGET Annual Meeting
1–3 November 2012
Leipzig, Germany
www.dget.de
2013
International Dental Show
12–16 March 2013
Cologne, Germany
www.ids-cologne.de
IFEA World Endodontic Congress
23–26 May 2013
Tokyo, Japan
www2.convention.co.jp/ifea2013
ESE Biennial Congress
12–14 September 2013
Lisbon, Portugal
www.e-s-e.eu
40 I roots
4_ 2011
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about the publisher _ submission guidelines
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I
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roots
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_ 2011
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I about the publisher _ imprint
roots
international magazine of
endodontology
Publisher
Torsten R. Oemus
oemus@oemus-media.de
CEO
Ingolf Döbbecke
doebbecke@oemus-media.de
Published by
Oemus Media AG
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Jürgen Isbaner
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Lutz V. Hiller
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Managing Editor
Claudia Salwiczek
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Gernot Meyer
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Editorial Board
Fernando Goldberg, Argentina
Markus Haapasalo, Canada
Ken Serota, Canada
Clemens Bargholz, Germany
Michael Baumann, Germany
Benjamin Briseno, Germany
Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
Heike Steffen, Germany
Gary Cheung, Hong Kong
Unni Endal, Norway
Roman Borczyk, Poland
Bartosz Cerkaski, Poland
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
L. Stephan Buchanan, USA
Jo Dovgan, USA
Vladimir Gorokhovsky, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA
Jorge Vera, Mexico
Copyright Regulations
_roots international magazine of endodontology is published by Oemus Media AG and will appear in 2011 with one issue every quarter. The magazine
and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable
to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
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the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author.
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, legal venue is Leipzig, Germany.
42 I roots
4_ 2011
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