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MARCH 2007 www.endo-tribune.com VOL. 2, NO. 3

Preventing coronal leakageA sound coronal seal is key to en-dodontic success. Dr. GregoriKurtzman outlines his method forensuring a perfect seal, frombuildup to obturation.

page 6

Opening the doorDr. Kenneth Serota, founder of theRoots cybercommunity and theannual Roots Summit, invites im-plant specialists to join the con-versation.

page 18

Planning your exit You may be planning how your ca-reer will end. In the first of a two-part series, Dr. Thomas L. Snyderoutlines a strategy, timeline and ob-jectives for your career transition.

page 22

New offeringsHu-Friedy has launched a newendodontics company and its firstproduct, the DownPak obturationdevice. Preview this and other newlaunches on our products pages.

page 28

Trends Interview Practice Products

ENDO TRIBUNEThe World’s Endodontic Newspaper · U.S. Edition

PRSRT STDU.S. Postage

PAIDPermit # 306

Mechanicsburg, PA

Change is a significant evolution-ary tool provided it rests upon a solidand secure foundation. Innovations inmaterials and technologies occurringwithin the dental field are impactingpowerfully on its art and science;however, dentistry, like all healthcare, is both a business and a profes-sion. The pendulum swings that pred-icate trends and transitions withinthat nexus must be viewed from amacrocosmic perspective lest we fallprey to expediency in treatment rec-ommendation and execution. There isan almost Faustian reliance on broadoutcomes data, which in truth, maynot be sufficiently specific to directlyimpact clinical decision-making.1,2

Rudiments and fundamentals arethe abc’s of process. While the changefrom need dentistry to want dentistryis consistent with the societal trendschampioning botox, collagen, and sil-icone, it doesn’t necessarily reflect anenhanced awareness of the basic pre-cepts of dental health by our clientbase. Their focus has been shiftedaway from masticatory harmony andequilibrated function to whitening inall its myriad applications. Nowhereis the disruption in the logical and se-quential protocol to optimal dentalhealth more evident than the trend to

replace natural teeth with implants.At-risk patient cohorts3 may simply beencouraged to opt for virtual surgeryand immediate function as an alter-native to rehabilitative therapy.

Implant-driven treatment planningcan, if incorporated with vision, fostera melding of the specialties and offerpatients a less confusing and fraction-ated approach to their dental care.Orthodontists are training to placemini implants for the purpose of an-chorage. Endodontists can pre-dictably retreat procedural failures;4

however, if these teeth are deter-mined to be non-restorable, they canbe replaced with osseo-integrated fix-tures. Endo/ortho/prosthetic treat-ment plans include modalities togrow bone where there was none andobviate aggressive bone harvestingprocedures. Everything from enamelmatrix derivatives to bone morpho-genic proteins to stem cell research isdirected toward cellular and structur-al reconstitution. The issue of whodoes what is not of consequence;what matters most is that we educatepatients to understand their optionsand as a profession work to endlesslyelevate the standard of care. Walk into Dr. Steffan Scherer’s

Bismarck, North Dakota, office andyou’ll do a double-take, wondering ifthe hallway was some sort of weirdtime/space machine.

Where’s the bland, sterile environ-ment you’ve come to expect from adental office? What’s with the 1940s-eraTexaco gas pump, the Standard Oilsigns and the vintage banners from anold Plymouth dealership? What aboutthe seating area that looks like the wait-ing room of a 1950s auto repair shop?Does the neon sign above the receptiondesk really say “Service manager”?

Root canal who? Maybe you’re herefor an oil change.

Welcome to Custom Endodon-tics, a 3,600-sq.-ft. office Schererrenovated to showcase his otherpassions in life. A history buff andavid car collector, he has amasseda huge collection of vintage signs,old photographs, displays, col-lectibles and “automobilia.” Mostof his collection has been in stor-age for years, but in April 2006,Scherer and his staff moved into adowntown Bismarck landmark: aformer grocery warehouse built in1914. It provided 12-ft. ceilings andplenty of room to create a unique,memorable office space.

Dr. Steffan Scherer's endodontic office in Bismarck, ND, features a retro auto shop theme.The reception area and waiting room look like the counter and waiting area in a 1950sgarage. Dr. Scherer wears a shop mechanic's uniform instead of the typical lab coat.

A tale of two specialties: the endodontic/implantalgorithmby Kenneth S. Serota, DDS, MMSc

Endodontist combinespassions to create auto-themed officeby Pat M. Knapp, Dental Tribune

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page 20ET

News ENDO TRIBUNE U.S. Edition22

We invite and encourage submis-sions to Endo Tribune. If you wouldlike to contribute case studies, newsitems, new product information,trends articles, practice manage-ment tips, office happenings, orfeature story ideas, contact FredMichmershuizen, managing editor,at [email protected], or call 212.213.6252.

Sound offWould you like to respond to a

topic or issue you’ve read about inEndo Tribune? Send us an e-mailletter, pro or con, telling us whatyou think. Please keep letters to 500words or less. We will not publishunsigned letters. Letters may be ed-ited for clarity and available space.If you’d like to contribute an articleon the same topic, please write us aquick note telling us the subjectyou’d like to address and how longan article you would like to write.

New productsHave you introduced a new

product to the endodontic market?

Endo Tribune wants to share itwith our readers. Submit a pressrelease of no more than 300 wordsand an image or two (at least 300dpi and 1MB in size).

Case studiesDo you have a recent case you’d

like to share with colleagues? Doc-ument it succinctly in a 1,500- to

2,500-word article outlining the di-agnosis, treatment plan, and exe-cution of endodontic treatment.Include high-resolution images (atleast 300 dpi and 1MB in size) to il-lustrate the case, as well as yourbio and a high-res photo of you.

Practice management tipsHave you recently solved a

problem in your practice? Imple-mented a new program for patientcare or communication? Designedyour office space efficiently? Start-ed running staff meetings in anew way? Tell us about it in a sub-mission of 500 to 800 words.

Feature storiesKnow an endodontist or dentist

who would make an interesting fea-ture story? Do you or someone youknow have an interesting hobby, sidejob, or philosophy? We’d love to hearabout it. Contact Fred Michmer-shuizen, managing editor, at [email protected], orcall 212.213.6252. ET

Endo Tribune wants to hear from you!

YORK, Pa.– DENTSPLY Internation-al Inc. (NASDAQ: XRAY) announcedrecord sales and earnings for thethree months and year ended De-cember 31, 2006.

Net sales in the fourth quarter of2006 increased 5.4% to $471.3 mil-lion compared to $447.4 million re-ported in the fourth quarter of 2005.Net sales, excluding precious metalcontent, increased 5.3% in thefourth quarter of 2006. Sales of spe-cialty products, including implantsand orthodontic products along withall-ceramic Cercon products, expe-rienced double-digit sales growth.Sales decreased in the U.S. reflect-ing the short-term effects of the im-plementation of the U.S. StrategicPartnership Program.

Net income for the fourth quarterof 2006 was $65.0 million, or $0.42

per diluted share, compared to a netloss of $0.7 million in the fourthquarter of 2005. Net income in thefourth quarter of 2006 includes thenet of tax impact of both expensingstock options of $3.6 million ($0.02per diluted share) and of restructur-ing and other related items of $1.0million ($0.01 per diluted share).The fourth quarter also includes anet reduction to income tax expenseof $8.8 million ($0.06 per dilutedshare) from the resolution of certaintax matters.

Sales for all of 2006 increased5.6% to $1.81 billion compared to$1.72 billion in 2005. Sales exclud-ing precious metals increased 5.2%in 2006. Net income for 2006 was$223.7 million, or $1.41 per dilutedshare. The 2006 earnings includedthe following items: net of tax im-pact of expensing stock options of

$13.3 million ($0.08 diluted share);restructuring and other related ex-penses of $7.8 million ($5.0 millionafter-tax or $0.03 diluted share); andnet reduction of income tax expenseof $4.8 million ($0.03 per dilutedshare) related to the resolution ofcertain tax matters.

Bret Wise, chairman and CEO,said, “We are pleased that we havedelivered earnings performance atthe high end of our range of expec-tations for 2006. During the year, wehave made strategic investments inseveral key initiatives, including im-plementation of our Strategic Part-nership with our U.S. distributors,the expansion of our sales force inkey markets, and the January 1,2007 implementation of the mergerof our U.S. endodontic and implantbusinesses. We believe these initia-tives will generate substantial bene-

fits in 2007, and beyond. We remainconfident about the opportunities in2007, and we anticipate earnings inthe range of $1.56 to $1.61 per dilut-ed share.”

www.dentsply.com

ET

The American Society for Micro-biology (ASM) says that new geneticprofiling techniques may help iden-tify the types of bacteria that causesevere tooth decay in children.

In the January 2007 issue of theJournal of Clinical Microbiology,ASM notes that severe early child-hood caries (S-ECC), an extremelydestructive form of bacterial toothdecay that often attacks severalteeth at once, may be caused byStreptococcus mutans. However, re-searchers have not yet determinedwhether S-ECC is caused by a sin-gle strain of bacteria or a group of

bacterial species. Testing based oncultivation has been difficult be-cause nearly half of the bacteria insaliva and dental plaque cannot becultivated, ASM explains.

Researchers collected plaquesamples from 20 children, somewith S-ECC and some caries-free,and evaluated the difference in bac-terial diversity using denaturinggradient gel electrophoresis(DGGE), a cultivation-free methodthat isolates total microbial genomeDNA. The researchers found thatthe S-ECC group exhibited 94.5bacterial populations while thecaries-free children exhibited 113.4bacterial populations, suggestingthat caries-associated bacteria be-

come less diverse as specific groupsbegin to dominate plaque biofilm.

“These results suggest that themicrobial diversity and complexityof the microbial biota in dentalplaque are significantly less in S-ECC children than in caries-freechildren,” the researchers note.“Our study also demonstrated thatPCR-based 16S rRNA gene DGGE isa sufficiently valuable tool for differ-entiating the microbial compositionof the oral plaque in S-ECC childrenfrom that of caries-free children andmay be further developed as a pat-tern recognition tool with which toidentify specific group of bacteriapredominantly colonized in childrenof various caries status.” ET

DENTSPLY posts record sales for 2006

Genetic profiling tags cavity-causing bacteriaby John Hoffman, Dental Tribune

President/CEO Torsten R. [email protected]

COOEric [email protected]

Editor-in-ChiefProf. Dr. Arnaldo [email protected]

Managing EditorFred [email protected]

Managing Editor/NewsJohn [email protected]

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Dental Tribune America, LLC129 West 78th StreetNew York, NY 10024Tel.: 212.501.7530 Fax: 212.501.7533

Published by Dental Tribune America© 2007, Dental Tribune America, LLC.

All rights reserved.

Dental Tribune America makes every effortto report clinical information and manufac-turer’s product news accurately, but cannotassume responsibility for the validity ofproduct claims, or for typographical errors.The publishers also do not assume responsi-bility for product names or claims, or state-ments made by advertisers. Opinions ex-pressed by authors are their own and maynot reflect those of Dental Tribune America.

ENDO TRIBUNEThe World’s Endodontic Newspaper · U.S. Edition

Frederic Barnett, DMDRoman Borczyk, DDSL. Stephen Buchanan, DDS, FICD, FACDGary B. Carr, DDSJoseph S. Dovgan, DDS, MS, PCUnni Endal, DDSFernando Goldberg, DDS, PhDVladimir Gorokhovsky, PhDFabio G.M. Gorni, DDSJames L. Gutmann, DDS, PhD (honoriscausa), Cert Endo, FACD, FICD, FADIWilliam “Ben” Johnson, DDSKenneth Koch, DMDSergio Kuttler, DDSJohn T. McSpadden, DDSRichard E. Mounce, DDS, PCJohn Nusstein, DDS, MSOve A. Peters, PD Dr. med dent., MS,FICDDavid B. Rosenberg, DDSWilliam P. Saunders, Phd, BDS, FDS,RCS EdinKenneth S. Serota, DDS, MMScAsgeir Sigurdsson, DDSYoshitsugu Terauchi, DDS

Editorial Advisory BoardET

ENDO TRIBUNE U.S. Edition News 3

Dental instrument manufacturerHu-Friedy® has launched an en-dodontic products company namedEI (Endo Ingenuity) and its firstproduct, an obturation device calledDownPak.

“For years, doctors have been ask-ing us to get more involved in the fieldof endodontics,” says Ron Saslow,president and CEO of Hu-Friedy. “Wehave always responded that we would

do so only if we were able to developa breakthrough technology that deliv-ers benefits doctors can’t get from ex-isting endodontic products. DownPakis that breakthrough technology.”

According to EI General ManagerJames Spann, “DownPak is the firsthandheld device that utilizes bothheat and vibration to precisely soft-en, compact and disperse obturationfilling materials.” (For more detailedproduct information, see page 28.)

Hu-Friedy was founded by HugoFriedman in 1908 and has beenowned by the Saslow family since1959. “Hu-Friedy has a long tradition

of working closely with and listeningto its valued customers,” says Saslow.The launch of EI, he adds, “reflectsthe same commitment to close col-laboration with private practitioners,dental schools and leading educa-tors.” The new company’s stated goalis to “provide endodontic practition-ers with superior, innovative designsand advanced technologies that willmake them more successful in theirprofession.” ET

Hu-Friedy launches endo company

Dentists administering anesthesiaare again cautioned to ask patientsabout topical anesthesia they may betaking for skin conditions and recentdermatological procedures. The Foodand Drug Administration (FDA) hasissued a warning that using largeamounts of skin-numbing creams andlotions can cause irregular heartbeatsand seizures. Numbing creams andlotions, both prescription and over thecounter, often contain lidocaine,tetracaine, benzocaine or prilocaine.

FDA’s warning follows thedeaths of a 22-year-old womanand a 25-year-old woman whoused numbing creams after hav-ing hair removed with lasers. Thewomen wrapped their legs in plas-tic wrap to make the creams morepotent.

A dentist administering anesthe-sia may be unaware if a patient hasreceived topical anesthesia on a partof the body that is covered. ET

FDA warns on topical anesthesia

Dr. Eric M. Rivera has been ap-pointed chairman of the Universityof North Carolina-Chapel HillSchool of Dentistry’s Department ofEndodontics, effective Feb. 1.

Rivera, a faculty member at theschool since 2003, previously served asinterim chairman of the department.

He received his bachelor’s degreein chemistry, his DDS degree and hismaster’s degree and certificate inendodontics from UNC-Chapel Hill.After serving as graduate programdirector and chairman of the De-partment of Endodontics at the Uni-versity of Iowa College of Dentistry,Rivera joined the UNC-Chapel Hillfaculty as an associate professor.

Rivera’s career experience hasspanned academic, private practice,and corporate settings. His researchareas include the biochemical and

functional aspects of collagen cross-linking and structure of dentin re-lated to tooth fracture and the use ofcalcium hydroxide as a medicine inroot canal therapy.

In his new role, Rivera will leadefforts to increase the national andinternational prominence of the de-partment, identify ways to advancepatient-directed endodontic researchand strengthen the graduate pro-gram, among other responsibilities.

“Dr. Rivera’s career has been dis-tinguished by dedication to mentor-ing students and to scholarship,” saidDean John N. Williams. “He possess-es expertise in information technolo-gy that will be vital to our school aswe seek to meet the challenges andopportunities within academic den-tistry in the 21st century.”

www.dent.unc.edu

ET

Rivera is new UNC endo chair

The Goldman School of DentalMedicine at Boston University(BUSDM) is conducting a study, sup-ported by an $8,000 grant from theAmerican Dental Education Associa-tion (ADEA) Council of Sections Pro-ject Pool, to assess smoking cessationeducation in the school’s curricula.

“The overarching goal of thisproject is to provide a model forsmoking cessation training in dentalschools nationwide by drawingupon an already validated pro-gram,” says Brenda Heaton, an in-structor in the university’s depart-ment of health policy and healthservices research and the study’sprincipal investigator. BUSDM will“establish a precedent for the inte-gration of tobacco cessation educa-tion into the formal training of den-tal health professionals.”

Heaton said a 2005 Journal of theAmerican Dental Association surveyshowed half of the general dentistssurveyed viewed smoking cessation

activities as peripheral to dentistry.She believes ensuring BUDSM stu-dents receive formal smoking cessa-tion education will help them feelcomfortable advising their patientson the oral health risks of smokingand how to quit.

The school will administer an an-nual survey, adapted from BUSDM'sPrevention and Cessation Education(PACE) program, to DMD students toassess their general knowledge ofsmoking cessation treatment and levelof comfort talking to patients abouttheir options, among other areas. Staffwill research faculty and administra-tors' attitudes and behaviors related tosmoking cessation education. ET

BU assessessmokingcessationeducation

European scientists are prepar-ing to test a new drug delivery de-vice implanted inside dental pros-thetics. The Intellidrug tooth im-plant is seen as an alternative topills, especially for patients whocannot monitor their own drug in-take.

“The dental prosthesis consistsof a drug-filled reservoir, a valve,two sensors and several electron-ic components,” explains Dr. Oliv-er Scholz of the Fraunhofer Insti-tute for Biomedical EngineeringIBMT in St. Ingbert, where thesensors and electronics were de-veloped. The device is designed tofit inside two artifical molars.

“Saliva enters the reservoir viaa membrane, dissolves part of thesolid drug and flows through asmall duct into the mouth cavity,where it is absorbed by the mu-cous membranes in the patient’scheeks,” adds Scholz.

The duct is fitted with two sen-sors that monitor the amount ofmedicine being released into thebody. One is a flow sensor thatmeasures the volume of liquid en-tering the mouth via the duct,while the other measures the con-centration of the agent containedin the liquid. Based on the meas-urement results, the electroniccircuit either opens or closes avalve at the end of the duct to con-trol the dosage. If the agent hasbeen used up, the electronic sys-tem alerts the patient via a remotecontrol, which was also developedat the IBMT. This control permits

wireless operation of Intellidrug,and can be used by the patient ordoctor to set the dosage required.

The patient has to have theagent refilled every few weeks,says Scholz. This could be doneusing a deposit system wherebythe patient swaps the empty pros-thesis for a newly refilled one. Atthe same time, the battery couldbe replaced and the device couldbe serviced, says Scholz.

The prototype was on displayfor the first time at the MedTectrade fair in Stuttgart, Germany,beginning Feb. Intellidrug willundergo clinical testing thisyear—filled with a drug calledNaltrexon, which is taken by drugaddicts undergoing withdrawaltherapy.

www.intellidrug.org, www.gizmag.com, www.dawnfarm.org

ET

Tooth implants may benext drug delivery device

Research ENDO TRIBUNE U.S. Edition4

Objective: Compare the radiopac-ity of 3 endodontic points and 6 en-dodontic sealers as visualized on Dspeed film or a digital x-ray sensor.

Methods: The 5 sealers analyzedwere EZ-Fill (EZ), Pulpdent RootCanal Sealer (ZOE), InnoEndo (IE),Epiphany (EP), and ReokoSeal Auto(RSA). The 3 points analyzed wereDentsply Gutta-Percha (DGP),Schein Gutta-Percha (SGP), and Re-silon (RSL). Samples (10/gp) ap-proximately 1.0 mm thick werecured for 12 hours and then radi-ographed alongside a stepwedge ofaluminum alloy 1100 consisting of15 1mm thick steps. Each samplewas radiographed on both a Gen-dex eHD sensor and Kodak Ultra-speed film (film speed D). Both sys-tems used an x-ray generator at 70kVp and a target distance of 30 cm.The exposure time was 0.1 s for thedigital system and 0.5 s for film. Forevery radiograph, the average grey-scale value of the material was con-verted into absorbance notation andcompared with that of the referencestepwedge in order to determine

the equivalent radiopacity in termsof mm Al 1100 per mm material.Comparisons were made by inter-polating between the 2 adjacentsteps in every radiograph. The datawere subjected to 2-way repeatedmeasures ANOVA and SNK(P<0.05).

Results: The measured radiopaci-ty significantly depended (P<0.05)on the visualizing device for IE,ZOE, RSA, EP, SGP, and EZ. Mostmaterials appeared more ra-diopaque on the digital sensor; IEwas 36% more, ZOE was 14%more, and RSA was 10% more.The mean radiopacity of thematerials (in mm Al 1100 per mm material) was significantly different (P<0.001). The SNKranking for digital radiography was RSL(8.5±0.5) > EP(7.3±0.4) >EZ(6.4±1.3)=DGP(6.3±0.1)=SGP(6.1±0.2) > RSA(4.9±0.2)=ZOE(4.6±0.4)> IE(3.0±0.1).

Conclusion: The radiopacity of amaterial can depend on themethod of visualization.

Radiopacity of endodontic materials on film or a digital sensorRasimick B, Shah R, Deutsch A, Musikant BEssential Dental Systems, South Hackensack, NJ

J Dent Res 2007;86(Spec Iss B):2082. Available from: URL: http://iadr.confex.com/iadr/2007orleans/techprogram/abstract_92306.htm

There is concern that endodontical-ly treated patients are waiting toolong before placement of definitiverestorations and this wait is causingleakage of the interim restorations.It has been suggested that restora-tive materials that better seal teethshould be used.

Objective: To determine the amountof time patients are waiting follow-ing endodontic treatment beforeplacement of definitive restorations.

Method: Patient records with en-dodontic therapy performed duringthe past 10 years were pulled fromthe school database. The time inter-val was determined between com-pletion of endodontic therapy (andplacement of interim restorations)and the next procedure. Data wasseparated into pools A and B, basedon the next procedure: (A) a defini-tive restoration placed and (B) en-dodontic re-treatment. The datawas subjected to descriptive statis-tics and t-tests.

Results: Mean (103 days) and me-dian (47 days) for the data pool withno re-treatment (B) was much

higher than the recommended oneweek time interval before place-ment of a definitive restoration.Comparing the two data pools A andB showed the mean time intervalfor incidences of endodotic re-treat-ment (B) was 256 days which is148% higher than the time intervalfor instances where re-treatmentwas not necessary and a definitiverestoration was placed (A). T-testsshowed that there was a significantdifference between the mean timesof Pools A and B (p=0.005).

Conclusion: We found a mediantime period of 47 days before place-ment of a definitive restoration inpatients not requiring re-treatmentof endodontic therapy. This is almost6 weeks beyond the recommended 1week healing period. As patients ap-proach a wait period closer to themedian value of the re-treatmentgroup (122.5 days), their chance ofendodontic therapy failure greatlyincreases. Because patients are wait-ing longer than the recommendedone week period, more leak-proofrestorative materials should be used.

Supported in part by NIH grant DE07101.

Statistical assessment of interimrestorations following endodontic therapyKunz KR,1 Linebaugh ML,1 Wagner WC,1 Yaman P2

1University of Detroit Mercy, Detroit 2University of Michigan, Ann Arbor, MI


Endodontic sealers ideally shoulddemonstrate adhesive properties todentin in order to reach the objec-tives of the obturation of the canalspace and seal the canal space bothapically and coronally, thus de-creasing the chance of treatmentfailure. The Epiphany/Resilon ob-turation system is a new thermo-plastic synthetic polymer-basedroot canal filling material which isclaimed to form a monoblockwhich bonds to the dentinal wallswhen the Epiphany points are usedin conjunction with the Epiphanydual-cured resin sealer (Resilon)and the Epiphany primer.

Objectives: It is the purpose ofthis in vitro study to evaluate thepush-out bond strength to in-traradicular dentin of two poly-meric endodontic obturation sys-tems, Epiphany/Resilon andgutta-percha/AH 26.

Methods: In this study, humansingle-canal canines were endo-

dontically treated and obturatedwith two different endodontic ob-turation systems (Epiphany/Re-silon system and gutta-percha/AH26). Thirty roots (divided into twogroups) were horizontally slicedfor a push-out strength test, whichwas performed from apical tocoronal in a universal testing ma-chine. Differences in push-outbond strength between the twodifferent material systems wereobtained using repeated meas-ures analysis of variance onranks.

Results: The mean push-outbond strength was 0.51 (± 0.30)MPa for Group Epiphany (EP)and 1.70 (± 0.71) for Group Gutta-percha (GP).

Conclusion: GP had significantlyhigher push-out bond strengththan EP (p<0.0001). The results ofthis study challenge some of theclaims made for this new obturat-ing system.

Push-out bond strength of anendodontic obturation system (Resilon)Sly MM, IUSD, Zionsville, Ind.; Moore BK, Indiana University School ofDentistry, Indianapolis; Platt JA, IUSD, Indianapolis


Objectives: Mineral trioxide ag-gregate (MTA) has been advocatedfor root perforations repairing andas root-end filling material. Theachievement of a good seal be-tween the tooth and the filling ma-terial is essential in order to pre-vent recontamination and to en-sure long-term clinical success.This study compared the sealingability of two new chemically-modified mineral cements to MTAusing a fluid transport system. Fur-thermore, the dentine/cementmarginal adaptation was evaluat-ed using a SEM-Replica technique.

Methods: The experimental ce-ments (CS1% and CS2%) werecharacterized by the presence of aphyllosilicate as plasticizer and ofCaCl2 as accelerant. Thirty sin-gle-rooted extracted teeth wereendodontically prepared. Copiousirrigation with NaOCl 5% andEDTA 17% was used throughoutduring the instrumentation. Fi-nally they were obturated withgutta-percha without sealer. Ahorizontal apicectomy and a root-end preparation (3 mm) were car-ried out. The gutta-percha was re-moved after root-end filling with

the experimental cements andMTA. The root samples were pre-pared for the permeability testsand fixed to plexiglas supports(2x2x0.5 cm). Fluid flow meas-urement was conducted under ahydraulic pressure of 6.9 KPa for 5min. after 4, 24, 48 hours, after 7,15 days and after 1, 3 months fromthe endodontic treatment. Thefluid flow data were statisticallycompared using a two-wayANOVA. A SEM-Replica techniqueusing a polyvinyl/siloxane im-pression material was used toevaluate the dentine/cementmarginal adaptation.

Results: All tested cementsshowed a fluid flow reductionover time. The experimental ce-ments presented a fluid flow ratesimilar to MTA, but lower at the 4hours-evaluation. SEM-Replicaobservations indicated an excel-lent marginal adaptation to denti-nal walls of all tested cements.

Conclusion: The experimentalcements showed suitable proper-ties to be considered as alterna-tive to available root-end fillingmaterials.

Sealing ability of innovative silicatic cements for endodonticsPitzolu G,1 Gandolfi MG,1 Sauro S,2 Zanna S,1 De Carlo B,1 Piana G,1

Prati C,1 Mongiorgi R1

1University of Bologna, Italy 2King's College London, United Kingdom


ENDO TRIBUNE U.S. Edition Research 5

Background: Witwatersrand Den-tal School forms the epicentre ofendodontic treatment in Gauteng,South Africa. There is very little re-search conducted with regard topatients presenting for endodontictreatment, thus far.

Objective: To assess the timetaken to endodontically treat pa-tients; presenting with a multi-tude of clinical and demographicfactors.

Method: A prospective, ran-domised trial of 100 patients pre-sented with endodontically in-volved teeth. Age of patient, sex,description of pain, pain dura-tion, root length, and spontaneityof pain were recorded. Endodon-tic treatment was then per-formed.

Results: In 2006, 100 patients pre-sented for endodontic treatment.Data was captured in ExcelSpreadsheet where demographicand clinical variables (sex, spon-taneous pain, type of pain) weredummy coded into 0 or 1. Thedata was cleaned then importedinto SAS version 9.1. Multiple lin-ear regression was used to predicttreatment time in patients who

presented themselves with demo-graphic and clinically involvedendodontic teeth. A bi-variate re-lationship was established be-tween the response and the ex-planatory variable by means ofscatterplots and Pearson correla-tion coefficient. The residuals aswell as normal probability plotswere established in order to in-spect the variation of the residualvalues with each of the continu-ous explanatory variables. Statis-tical significance was consideredat 90% confidence interval (0.10).An increase in age caused a de-crease in treatment time by 0.44units. Similarly, females con-tributed 7.58 units less towardstreatment time than males did.However, patients who reportedspontaneous pain and the de-scription of sharp pain, on aver-age, increased treatment time by14.37 and 10.26 units respectively.

Conclusion: We managed to es-tablish that the main predictorsfor treatment time were descrip-tion of sharp pain and sponta-neous pain. These predictors areimportant to determine a cost-ef-fective and time-efficient treat-ment procedure with minimaldiscomfort to the patient.

Factors influencing the treatment timeof endodontic proceduresTootla S, Wits Dental School, Houghton, South Africa

J Dent Res 2007;86(Spec Iss B):0479. Available from: URL:http://iadr.confex.com/iadr/2007orleans/techprogram/abstract_91839.htm

Endodontic treatment and im-plant-supported restoration areboth viable treatment options torestore the functionality and es-thetics of the dentition. Bothtreatment modalities have highsuccess rate and predictability.Clinical decision making isoften influenced by many fac-tors in addition to success ratesuch as cost, time, function, andesthetics. Patient perceptionand preference play an impor-tant role in the ultimate clinicaldecision making.

Objective: The purpose of thisstudy was to compare endodon-tic treatment (Endo) and single

implant restoration (Implant)regarding time to function, cost,and patient satisfaction.

Materials and methods: 254 pa-tient satisfaction surveys weresent to patients who receivedsingle implant restoration orendodontic treatment in theposterior mandible at BaylorCollege of Dentistry. Surveyquestions included patient satis-faction towards the cost, dura-tion of the treatment, appear-ance and the ability to eat afterthe treatment. 53 responsesfrom Endo patients and 36responses from Implant patientswere received. Treatmentrecords of responded patientswere reviewed to record the du-ration of the treatment, number

of visits, treatment protocol,post-op intervention, and cost.Patient survey results were eval-uated using Pearson chi squareanalysis to determine differencein the response to each questionbetween the groups. Overall sat-isfaction was analyzed by Stu-dent's t-test using a derivedsummative score.

Results: Time to function wassignificantly longer in Implantpatients compared to Endo. Im-plant also required more post-op interventions. Endo patientswere significantly more likelyto report satisfaction with treat-

ment cost (p<0.05) and lesslikely to report dissatisfactionregarding treatment duration,as compared to Implant patients(p<0.05). However, there is nostatistical difference in overallsatisfaction between the twogroups.

Conclusion: Implant treatmentrequires more time and inter-vention to achieve functioncompared to Endo treatment.This delay causes significantdissatisfaction among patients.However, Endo and Implanttreatments have similar overallpatient satisfaction.

Comparative outcome analysis of endodontic treatment and single implant restorationCarter J, Jones D, Solomon E, He JBaylor College of Dentistry, Dallas


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Mesenchymal stem cell-mediat-ed tissue regeneration is a prom-ising approach for regenerativemedicine for a wide range of ap-plications. Here we report a newpopulation of stem cells isolated

from the root apical papilla ofhuman teeth (SCAP, stem cellsfrom apical papilla). Using aminipig model, we transplantedboth human SCAP and periodon-tal ligament stem cells (PDLSCs)

to generate a root/periodontalcomplex capable of supporting aporcelain crown, resulting innormal tooth function. Thiswork integrates a stem cell-me-diated tissue regeneration strat-

egy, engineered materials forstructure, and current dentalcrown technologies. This hy-bridized tissue engineering ap-proach led to recovery of toothstrength and appearance.

Mesenchymal stem cell-mediated functional tooth regeneration in swine

Sonoyama W, Liu Y, Fang D, Yamaza T, Seo BM, Zhang C, Liu H, Gronthos S, Wang CY, Shi S, Wang SCenter for Craniofacial Molecular Biology, University of Southern California School of Dentistry, Los Angeles

PLoS ONE 2006. 1:e79.

Trends ENDO TRIBUNE U.S. Edition6

Introduction

Endodontic failure has been asso-ciated with coronal leakage withinthe canal system following obtura-tion. The literature suggests thatcoronal leakage is far more likely adeterminant of clinical success orfailure than apical leakage.1 Recentadvances in resin obturation materi-als have been shown to provide supe-rior sealing of the canal system, butwithout addressing the coronal as-pect of the tooth, failure endodonti-cally may occur. Studies confirm thata sound coronal seal is of paramountimportance to the overall success ofroot canal treatment.2,3 Regardless ofthe obturation method the best ruleis: a properly cleaned, shaped, andobturated tooth should be perma-nently restored as soon as possible.4

No matter what our intentionsare following obturation of the canalsystem, patients may delay restora-tion of the tooth that has been treat-ed. Financial concerns and timeconstraints often influence whenthe final restoration is completed.Additionally, between visits an ad-hesive material will prevent leakageand contamination of the canal.

Coronal leakageCoronal leakage has been indi-

cated in the literature as the majordeterminant of endodontic successor failure. No matter what we placein the canal, if the coronal portion ofthe tooth is not sealed with materi-als that bond to tooth structure andare resistant to dissolution by oralfluids, then over time endodonticfailure may be inevitable.

It is not unusual to have a patientpresent with decay at the margin ofthe crown of a tooth that had prior en-dodontic therapy. Because the toothwas treated endodontically, sensitivi-ty that may indicate a problem underthe crown will not alert the patient toseek dental care. Coronal leakage foreven a minimal amount of time mayquickly lead to apical migration ofbacteria. When the patient does

present coronal leakage, it may havebeen ongoing for an extended periodof time complicating treatment orrendering the tooth non-restorableand necessitating extraction.

The literature indicates signifi-cant coronal dye and bacterial leak-age following exposure of sealedroot canals to artificial and naturalsaliva leading to complete bacterialleakage that may occur within twodays.5 Supported in an in vitro study,researchers found that dye leakagecan occur in as little as three days.6

It has been suggested that gutta-per-cha does not offer an effective barri-er to crown-down leakage when ex-posed to the oral environment.7 Ad-ditional studies using gutta-perchaand various sealers indicate thatgutta-percha will allow bacterialleakage. But use of an adhesive seal-er can significantly slow or stopcoronal-apical bacterial migration.8

The predominant bacteria foundin root-filled teeth with coronalleakage and persistent apical peri-odontitis is the gram-positive facul-tative anaerobe Staphylococcus.This is followed by the groups Strep-tococcus and Enterococcus; all nor-mal salivary flora.9 Coronal leakageprovides a constant source of mi-croorganisms and nutrients that ini-tiate and maintain periradicular in-flammation and may well be thelargest cause of failure in endodon-tic therapy.10

Endodontic obturation materialsdo not prevent coronal microleakagefor an indefinite period of time.11 In asample of 937 root filled teeth thathad not received restorative treat-ment during the previous year, thedata showed that the technical stan-dard of both coronal restoration androot filling were essential to periapi-cal health.12 It is not uncommon forcoronal leakage to occur followingroot canal treatment as a result ofthe presence of deficient compositeresin fillings and secondary cariesunder restorations.13

Yet the endodontic materials uti-lized over the past fifty years haveshown that they do not preventcoronal leakage when challenged.

In yet another investigation, forty-five root canals were cleaned,shaped and then obturated withgutta-percha and root canal sealerusing a lateral condensation tech-nique. The coronal portions of theroot filling materials were placed incontact with Staphylococcus epider-midis and Proteus vulgaris. Thenumber of days required for thesebacteria to penetrate the entire rootcanals was determined. Over 50% ofthe root canals were completelycontaminated after a 19-day expo-sure to S. epidermidis. Fifty percentof the root canals were also totallycontaminated when the coronal sur-faces of their fillings were exposedto P. vulgaris for 42 days.14

When comparing AH-26 andother commonly used sealers after45 days of exposure to the oral cavi-ty, none of the sealers was capableof preventing leakage and coronaldye penetration.15 So we can see thatthe quality of both the coronalrestoration and obturation materialare essential to periapical health asnone of the present-day root canalsealers may hermetically seal “theroot canal wall—gutta-percha fillinginterface.” In this respect, the im-portance of perfectly sealing coronalrestorations (both temporary andpermanent) needs to be empha-sized.16

Pre-endodontic therapybuidups (canal projection)

Coronal leakage is a major con-tributor to endodontic failure.17 Abonded core placed prior to disinfec-tion and obturation of the canal sys-tem of the tooth can greatly diminishthe leakage potential both duringand after endodontic therapy.

Isolation of the pulp chamber canbe a challenging task when minimalcoronal structure remains and en-dodontic therapy is required as partof the oral rehabilitation (Fig. 1).Coronal reinforcement has tradi-tionally been addressed followingthe endodontic phase. But a coronalbonded buildup can simplify the en-dodontic phase and strengthen thetooth, decreasing the possibility of

further damage to the tooth due tothe dam clamp or mastication be-fore a full coverage restoration canbe placed. The Canal Projector coreallows isolation of the individualcanals by surrounding them with aresin buildup (Fig. 2). Sealing thepulpal floor and area surroundingthe canal orifices also will decreasecoronal leakage potential duringand following endodontic treatment.

Following identification of thecanal orifices and caries removal, aCanal Projector cone (CJM Engi-neering, Santa Barbara, CA, www.cj-mengineering.com) is placed on ahand file and inserted into eachcanal. A dentin adhesive is placedon all exposed surfaces and lightcured. This is followed by injectionof a dual-cure build-up materialaround the projector cones. Whenset of the buildup material has beencompleted, the hand files and pro-jectors can be removed, leavingstraight-line access into each indi-vidual canal. Visualization of the ori-fice is elevated to the occlusal planeinstead of deep within the tooth, anda bonded seal coronally aroundeach orifice is achieved. Should therestoring dentist wish to place postsin to the tooth, post space prepara-tion is simplified and misdirection ofthe post preparation is minimized.

Coronal restoration (access sealing)

Microorganisms can penetratethrough different temporary restora-tive materials and supposedly wellobturated root canals. The use of ad-hesive sealers may play an impor-tant role by minimizing coronalleakage. In addition, the importanceof an immediate definitive coronalseal should be emphasized after ob-turation of the canal system.18–20

Seventy extracted single-rootedmandibular premolars were studiedto determine the length of time need-ed for bacteria present in naturalhuman saliva to penetrate throughthree commonly used temporaryrestorative materials and through theentire root canal system obturatedwith the lateral condensation tech-nique. The average time for brothcontamination of access cavitiesclosed with gutta-percha (7.85 days),IRM (12.95 days) and Cavit-G (9.80days) indicated that even in the shortperiods of time normally permittedbetween visits, complete leakage mayresult. IRM, long a common tempo-rary material, was shown to leak to asignificantly higher degree than glassionomers.21 Due to its adhesive na-ture, glass-ionomer cement may pre-vent bacterial penetration to the peri-apex of root-filled teeth over a 1-month period as compared to IRM orCavit temporary restorations.22

Improving endodontic successthrough coronal leakage preventionby Gregori Kurtzman, DDS

Fig. 1: Severe coronal breakdown of alower molar requiring endodontictherapy.

Fig. 2: Coronal pre-endodontic buildupachieved with Canal Projectors provid-ing individual straight-line access intoeach canal.

Fig. 3: Temporary restoration using theglass ionomer Fugi Triage® Pink (GCAmerica, Alsip, IL) to seal endodonticaccess. (Courtesy of Dr. Mark Grebosky) � page 8ET


Another important considerationwith regard to the temporary restora-tion’s ability to prevent coronal leak-age is how the material behavesunder mechanical load and thermo-cycling. Non-adhesive temporariesshow an increased percentage ofmarginal breakdown and increasedmicroleakage after thermocyclingand loading. There was no significantimprovement with increased thick-ness of the temporary material.23–25

When crowns were sealed withIRM, recontamination was detectedwithin 13.5 days in the canals med-icated with chlorhexidine, after 17.2days in the group medicated withCaOH2 and after 11.9 days in thegroup medicated with bothchlorhexidine and CaOH2. Thegroup with no medication, butsealed with IRM, showed recontam-ination after 8.7 days. There werestatistically significant differencesbetween the teeth with or withoutcoronal seal. The coronal seal de-layed but did not prevent leakage ofmicroorganisms.26 Other studiesconfirm that IRM started to leakafter ten days, whereas Cavit andDyract leaked after two weeks.27

The use of a resin based tempo-rary restorative material or glassionomer over partially removedresin composite restorations couldbe beneficial in achieving better re-sistance to marginal leakage (Fig.3). Maintaining partially removedpermanent restorations does notseem to cause a problem withachieving marginal seal.28 Glassionomer provided a statistically bet-ter coronal seal than bonded com-posite or a bonded amalgam pre-venting bacterial apical migration.29

This may be due to the glassionomer’s ability to adhere to thescerlotic dentin found on the pulpalfloor better than adhesive resins.The key seems to be to lock out thecoronal bacteria and the apical areawill heal (Figs. 4, 5).

Mineral trioxide aggregate (MTA)has, since its introduction a few yearsago, been advocated as a sealing ma-terial especially when perforation hasoccurred. But an investigation foundmild inflammation was observed in17% of the roots with and 39% of theroots without an orifice plug; so with-out development of severe inflamma-tion, the sealing efficacy of MTA ori-fice plugs could not be determined.30

Should amalgam be the materialof choice for the dentist, a bonded

amalgam produced signif-icantly less leakage thanthe non-bonded amal-gams. To prevent the rein-fection of the endodonti-cally treated molar, it maybe preferable to restorethe tooth immediatelyafter obturation by em-ploying a bonded amal-gam coronal-radiculartechnique.31 Core buildupor access closure with ad-hesive materials hasshown good long-termleakage resistance. The“sandwich” technique (GIbase with overlaying com-posite) and the compositeresin restorations allowedsignificantly less coronalleakage than glassionomer cement restora-tions. This may be be-cause the composite resin preventssalivary dissolution of the glassionomer over the long term.32

Results indicate that the sealingability of adhesive and flowable ma-terials can decrease coronal leakagepotential.33 Because of the risk ofcoronal microleakage, endodonti-cally treated teeth should be re-stored as quickly as possible.34 It ismore prudent to use a permanentrestorative material for provisionalrestorations to prevent inadequatecanal sealing and the resulting riskof fluid penetration.35

To minimize the potential of per-foration when reentering the toothto place either a post or to retreatendodontically, placement of a con-trasting colored resin over each ori-fice may be beneficial. This is fol-lowed by covering the entire pulpalfloor with a tooth-colored flowableresin (Figs. 6–8). These are avail-able in a multitude of easily identifi-able colored flowable composites.Available in pink (PermaFlo® Pink)or purple (PermaFlo® Purple) fromUltradent (South Jordan, UT), darkred (Flow-it dark gingival) fromPentron Clinical Technologies(Wallingford, CT) or dark blue fromDenMat (Santa Maria, CA).

Coronal microleakage has re-ceived considerable attention as afactor related to failure of endodontictreatment and much emphasis isplaced on the quality of the finalrestoration. Intracanal posts are fre-quently used for the retention ofcoronal restorations. Many authorshave examined coronal microleak-age with respect to gutta-percha rootfillings and coronal restorations, butfew have investigated the coronalseal afforded by various post systems.

The seal provided by a cementedpost depends on the seal of the ce-ment used. It appears that the den-tine-bonding cements (adhesiveresins and glass ionomers) have lessmicroleakage than the traditional,non-dentine-bonding cements (ie,zinc phosphates and polycarboxo-lates).36 Resin-supported polyethyl-ene fiber and glass fiber postsshowed the lowest coronal leakagewhen compared with stainless steeland zirconia posts. This may be dueto better adhesion of the lutingagent to these resin-impregnatedposts than metal or ceramic posts,which do not allow adhesive pene-tration into the surface of the post.

There were no significant differ-ences between resin-supportedpolyethylene fiber and glass fiberposts at any time period. The initialleakage measurements in zirconiapost and stainless steel posts weresimilar, but became significantlydifferent at 3 and 6 months. Resin-supported polyethylene fiber postsand glass fiber posts tested exhibit-ed less microleakage compared tozirconia post systems.37

Cleansing the canal (smear layers)

Coronal sealing ability is not theonly factor to influence the seal of thecanal and prevent apical leakage.How well the sealer adheres to thecanal walls is also important. Smearlayer can play a factor that may pre-vent sealer penetration into thedentinal tubules. The frequency ofbacterial penetration through teethobturated with intact smear layer(70%) was significantly greater thanthat of teeth from which the smearlayer had been removed (30%).

Removal of the smearlayer enhanced sealabili-ty as evidenced by in-creased resistance tobacterial penetration.38

The incidence of apicalleakage was reduced inthe absence of the smearand the adaptation ofgutta-percha was im-proved no matter whatobturation method wasused later.39–41 However,regardless of the obtura-tion technique (thermo-plastized, lateral or verti-cal condensation or sin-gle cone) when a non-ad-hesive sealer was used,leakage increased after30 days.42

What is used to obtu-rate the canals is impor-

tant, however, the manner in whichthe canal was prepared prior to ob-turation also determines how wellthe canal is sealed when therapy iscompleted. Rotary instrumentationwith NiTi files has shown less mi-croleakage then hand-instrumentprepared canals, irrespective ofwhat was used to obturate thecanal.43 The machining of the canalwalls with NiTi rotary instrumentsprovides smoother canal walls andshapes that are easier to obturatethan can be achieved with stainlesssteel files. The better the adaptationof the obturation material to the in-strumented dentinal walls, the lessleakage is to be expected along theentire root length. The better thecanal walls are prepared, the moresmear layer and organic debris isremoved, which is beneficial to rootcanal sealing.

Smear layer removal is bestachieved by irrigating the canalswith NaOCL (sodium hypochlorite)followed by 17% EDTA solution.44

Whereas the NaOCL dissolves theorganic component of the smearlayer exposing the dentinal tubuleslining the canal walls, EDTA, achelating agent, dissolves the inor-ganic portion of the dentin openingthe dentinal tubules. Alternating be-tween the two irrigants as the instru-mentation is being performed willpermit removal of more organic de-bris further into the tubules, increas-ing resistance to bacterial penetra-tion once the canal is obturated.45,46

Obturation The purpose of the obturation

phase of endodontic therapy is two-fold: to prevent microorganisms fromre-entering the root canal systemand to isolate any microorganismsthat may remain within the toothfrom nutrients in tissue fluids. Nomatter how well we seal the canal, ifthe coronal portion of the tooth is notthoroughly sealed then bacterialleakage may only be a matter of time.

Accessory canals may be presentin the pulp chamber leading to thefurcation area. This may be an addi-tional source of leakage that oftengoes unaddressed either following

Fig. 4: Placement of an imme-diate coronal restoration withFugi IX™ (GC America, Alsip,IL) glass ionomer followingendodontic therapy with evi-dent periapical lesion. (Cour-tesy of Dr. Martin Trope)

� page 6ET

� page 10ET

Fig. 5: Coronal seal has beenmaintained allowing apicalhealing of periapical lesionone year following treatment.(Courtesy of Dr. Martin Trope)

Fig. 6: The pulp chamber has beenetched and an adhesive applied to allsurfaces.

Fig. 7: To assist in locating the orifices later,a contrasting color light cure resin is ap-plied over each orifice and cured.

Fig. 8: The entire pulpal floor is coveredby a flowable composite and cured.


obturation of the canals or duringthe restorative phase. Placement ofa layer of resin-modified glassionomer cement or adhesive resinto seal this area immediately follow-ing obturation can prevent leakageprior to final restoration of thetooth.47 But it must always be re-membered that success will only beachieved if the root canal systemhas been as thoroughly debrided ofinfected material as possible. Irriga-tion is key for removal of this smearlayer lining the canal walls.

The obturation material is a dou-ble-edged sword. Which sealer isused is as important as which corematerial is placed within the canal.Gutta-percha has limitations in re-sistance to coronal leakage thathave been overcome with the newerresin alternatives. Although sealerscan form close adhesion to the rootcanal wall, none are able to bond tothe gutta-percha core material.Upon setting, shrinkage of the seal-er allows the sealer to pull awayfrom the gutta-percha core, leavinga micro gap through which bacteriamay pass.48 Several alternatives areavailable for core material selection.

Resilon™, a resin gutta-perchaalternative that is bondable withmethacrylic sealers such asEpiphany™ (Pentron Clinical Tech-nologies, Wallingford, CT) and Re-alSeal™ (SybronEndo, Orange, CA)was introduced three years ago afterextensive studies. The core materialResilon is available in .02, .04 or .06taper ISO sized cones from PentronClinical Technologies (Wallingford,CT) or SybronEndo (Orange CA),and as sized apical plugs (Light-speed Technologies, San Antonio,TX).49,50 Resilon showed significant-ly less leakage than gutta-percha. Instudies performed at the Universityof North Carolina, the gutta-perchagroup demonstrated leakage in 80%of specimens and was not depen-dant on obturation technique orwhich sealer was used.51

Because of these limitations seenwith gutta-percha, the seal of a coro-nal restoration may be as importantas the gutta-percha fill in preventingreinfection of the root canal. Studieshave shown that leakage of bacteriawith Resilon is significantly reducedcompared with gutta-percha. Thesignificance of this is, should thecoronal break down, the adhesiveobturation material may slow downor prevent apical migration of bacte-ria allowing healing to occur (Figs.9, 10). An additional benefit whenfilling the canals with the new resin-based obturation material was thatan increase was observed in the invitro resistance to fracture of en-dodontically treated single-canal ex-tracted teeth when compared withstandard gutta-percha techniques.Resilon demonstrated a twenty-fivepercent increase in root strengththan gutta-percha samples.52

Fiber obturators, an alternativecore material, may be used when apost will be placed to strengthen the

root and retain the coronal core.These allow obturation of the canaland placement of the post at thesame step, assuring coronal seal.53,54

Microbial leakage occurred morequickly in lateral and vertical con-densation techniques compared withobturation with fiber obturation sys-tems.55 Currently, two fiber obturatorsystems are commercially available:the FibreFill™ system (Pentron Clin-ical Technologies, Wallingford, CT),which was introduced in 2001; andthe recently available InnoEndo™system (Heraeus Kulzer, Armonk,NY). Both systems use resin sealersallowing formation of a monoblockacross the root to both strengthenand seal the canal system.

Sealer selection is very importantto prevent microleakage and permita bond to the core material. Zincoxide and eugenol (ZOE) sealershave been a mainstay in endodontictherapy for over one hundred years.When exposed to coronal leakage,ZOE sealers demonstrated completeleakage by the second day. Resultsindicated that none of the ZOE for-mulations tested could predictablyproduce a fluid-tight seal even up tothe fourth day.56

AH-26, an epoxy sealer originallyintroduced forty years ago, was alsounable to bond to gutta-percha lead-ing to coronal leakage issues. Leak-age with AH-26 was not dependant onobturation technique, showing grossleakage increasing within the firstfour months following obturationwhen coronally challenged. Coronalleakage was significantly greater dur-ing the first 4 months.57 Completebacterial leakage with AH-26 may beseen in as few as 8.5 weeks should thecoronal restoration permit leakage.58

Additionally, in vitro studies foundgutta-percha and AH-26 or AH Pluspermitted leakage of both bacteriaand fungi. Leakage in experimentalteeth occurred between 14 and 87days, with 47% of the samples show-ing leakage. AH-26 sealer permittedbacterial leakage in 45% and fungi

leakage in 60% samples. The sam-ples with AH Plus demonstrated bac-terial leakage in 50% and in 55% ofthe fungi samples. There was no sta-tistically significant difference in pen-etration of bacteria and fungi be-tween the two versions of the sealer.59

Comparative studies looking atperiapical inflammation betweenteeth treated with gutta-percha withAH-26 sealer and Resilon withmethacrylic sealer found statisticallyless inflammatory response with theResilon treated teeth. Mild inflamma-tion was observed in 82% of rootsfilled with gutta-percha and AH-26sealer compared with 19% of Resilontreated teeth. The monoblock provid-ed by the Resilon system was associ-ated with less apical periodontitis,which may be because of its superiorresistance to coronal microleakage.60

As AH-26 is unable to bond to gutta-percha, polymerization shrinkage ofthe epoxy resin can result in a microgap leading to the leakage reportedin the literature (Fig. 11). Alterna-tively, the bond reported between themethacrylic sealer (Epiphany or Re-alSeal) and Resilon is sufficient toprevent micro gap formation as thesealer polymerizes (Fig. 12).

Electrophoresis leakage studiesrecently completed at the Universityof Maryland comparing gutta-per-cha with AH-26 sealer and Resilonwith Epiphany sealer found signifi-cant differences in leakage resist-ance. The gutta-percha/AH-26group demonstrated an average re-sistance of 404.6 micro amps with100% of the samples leaking, com-pared to an average resistance of27.7 micro amps with 60% showingsome leakage. The lower the valueof resistance in micro amps, themore resistant the specimen was toleakage.61 These results supportother studies indicating that whenchallenged, gutta-percha and AH-26do not offer resistance to coronalleakage. Should a practitioner wishto continue using these materials, apermanent restoration needs to beplaced at the appointment when en-dodontic therapy is completed.

ConclusionOf 41 articles published between

1969 and 1999 (the majority fromthe 1990s), the literature suggeststhat the prognosis of root canaltreated teeth can be improved bysealing the canal and minimizingthe leakage of oral fluids and bacte-ria into the periradicular areas assoon as possible after the comple-tion of root canal therapy.62

Endodontic success is a multifac-torial issue. Like a jigsaw puzzle,the full picture can only be seenwhen all the pieces are fit together.How the canals are instrumented isas important as what is used to ob-turate the canal system. This is alsoinfluenced by what is placed coro-nally and when the coronal aspect issealed. NiTi rotary instruments andan irrigation protocol that includesNaOCL and EDTA will maximize thesealing ability of glass ionomer orthe newer methacrylic resin sealers.The last piece of the puzzle, sealingcoronally, should be performed withadhesive, permanent restorativematerials immediately at the con-clusion of the first endodontic ap-pointment to prevent apical migra-tion of bacteria and assure sealabil-ity of the canals.

A complete listing of references isavailable from the publisher. [email protected].

ET

Fig. 9: Periapical lesions present associ-ated with lower premolar and molar ob-turated with Resilon system at comple-tion of endodontic treatment. (Courtesyof Dr. Joseph Maggio)

Fig. 10: Seven months post completion ofendodontic treatment, showing loss ofcoronal restorations, yet apical lesionsseen previously have resolved signifi-cantly. (Courtesy of Dr. Joseph Maggio)

Fig. 11: SEM demonstrating microgapformation with AH-26 epoxy sealer dueto polymerization shrinkage. (ES –epoxy sealer, D – dentin)

Fig. 12: SEM demonstrating intimate con-tact with methacrylic sealer and Resilonand dentinal tubula penetration of the seal-er. (RS – methacrylic sealer, D – dentin)

� page 8ET

Gregori Kurtzman, DDS, is in privategeneral practice in Silver Spring, Mary-land. He has lectured both nationally andinternationally on the topics of restora-tive dentistry, endodontics and dental im-

plant surgery and prosthetics, and hashad numerous journal articles publishedin peer-reviewed publications. Dr.Kurtzman is on the editorial board ofnumerous publications. He is a consult-ant and clinical evaluator to multipledental manufacturers. He has earnedfellowships in the Academy of GeneralDentistry, the International Congress of Oral Implantologists, the PierreFauchard Academy, American College ofDentists, Masterships in The Academy ofGeneral Dentistry and the Implant Pros-thetic Section of the International Con-gress of Oral Implantologists. Additional-ly, he is a former Assistant ProgramDirector for a university-based implantmaxi-course. He can be reached [email protected].

About the authorET


Irrigation has an importantrole during endodontic treat-ment. To achieve the best chem-ical preparation possible, wepropose an optimal sequencefor the use of various irrigatingagents.

During the last several years,endodontics has progressed to thepoint that treatment is less trau-matic for the patient and lessstressful for the dentist. However,if the use of nickel titanium rotaryinstruments has allowed us togain time during endodontictreatment, it has also tempted usto neglect one of the main objec-tives of endodontics: the "clean-ing" that Dr. Herbert Schilder em-phasized when he insisted on"cleaning and shaping" the rootcanal. It may be more appropriateto say, "shaping for cleaning."

The main goal of the root canaltreatment is to completely elimi-nate the different components ofthe pulpal tissue, calcification,and bacteria, and to place a her-metic seal to prevent infection orreinfection and to promote heal-ing of the surrounding tissues ifneeded.

There are many techniquesavailable to accomplish the rootcanal preparation. There are alsomany techniques for filling theroot canal system (i.e., verticalcompaction of warm gutta-per-cha, System B, lateral condensa-tion, etc.).

We must ask ourselves thequestion: "Why do we irrigate andwhat irrigation protocol will pro-vide the cleanest canal?" In thiscontext, remember that shaping is

the result of endodontic instru-ments, while cleaning resultsfrom irrigation. Therefore, wehave two types of preparation:chemical and mechanical. Thisarticle addresses chemical prepa-ration.

The close correlation betweenthese two types of preparation hasbeen proven. In fact, with greatertapered preparations, the quantityand the concentration of the irri-gating solution will be greater andwill therefore better eliminate thesmear layer.1 Files can clean onlyparts of the root canal system.They create a reservoir that canhold the different irrigating solu-tions, which will access and cleanportions of the root canal systemthat the instruments cannotreach.

In endodontics, the most com-monly used irrigating solution issodium hypochlorite (NaOCl). Ithas many desirable qualities andproperties. It performs bacterici-dal cytotoxicity, dissolution of or-ganic material, and minor lubrifi-cation.2 But sodium hypochloriteby itself is not sufficient for totalcleaning of the endodontic sys-tem.3 It has no effect on the smearlayer and its high surface tensiondoes not allow for cleaning anddisinfection of the root canal sys-tem's totality. For this reason, andaccording to individual clinicalsituations, we must use other irri-gants in combination with sodiumhypochlorite.

This article does not addressretreatments and dissolving obtu-ration material. Our discussionshere are limited to vital andnecrotic teeth, as well as those

teeth with internal resorptions.The various irrigants that will beused according to the clinical sit-uations are:

• EDTA (Ethylene diaminetetra-acetic acid) (17%) (Smear Clear,SybronEndo, Orange, Calif.)

• Chlorhexidine 0.2%

• Sodium hypochlorite 5.25%

• Citric acid 50%

• Distilled water

In general, the most commonstep after accomplishing the accesscavity is the introduction of an en-dodontic file in the root canal. Butthis step should not be consideredautomatic, for many reasons.These include:

• The spread of bacterial toxins inall of the endodontic system and inthe periapical area will affect asuccessful prognosis for the en-dodontic treatment due to thepost-operative "flare-up" that mayoccur.

• The breakdown and accumulationof pulp tissue with its collagenicmay create an organic plug withinthe root canal.

Remember that the access cavity,having four walls, will create a"reservoir" for the irrigation solu-tions to be frequently and continu-ously refreshed.

Vital teeth In clinical cases such as the one

shown in Figs. 1a and b, we are

challenged with treating the com-plexities of the different compo-nents of the pulp, and eventuallythe presence of bacteria. For thesecases we suggest the following irri-gation sequence.

Step 1: Apply sodium hypochloriteand/or urea peroxide

The purpose of this mixture is to:

• Create a collagenic anti-aggre-gation effect due to the prote-olytic and lipidic affinity of ureaperoxide.4

• Destroy the biggest amount ofpulp tissue inside the access cav-ity and provide a better view ofthe canal orifices by controllingbleeding and preventing any col-lagenic plugs from forming.

At this stage the EDTA is onlyimportant for its antibacterial ef-fect in combination with other an-tibacterial agents.4

Step 2: Irrigate with 2ml of sodiumhypochlorite 5.25 percent (60°C)

The warm NaOCl is more effi-cient in destroying the collagenand this will reduce the timeneeded for the elimination of theorganic portion of the tissue. Thisirrigation will create an efferves-cent effect between the sodiumhypochlorite and urea peroxide.This "elevator effect" will evacu-ate the organic debris outside theaccess cavity, disorganize thecoronal pulp tissue, and help tobetter detect the canal orifices.5,6

Step 3: Apply sodium hypochloriteagain and activate using a K file (08-10).

This will disorganize the pulpaltissue in both the cervical andmiddle thirds of the endodonticsystem. This step has to be pre-ceded by an abundant irrigationwith distilled water in order toeliminate the first mixture pres-ent in the access cavity.

Step 4:Once the preparation of the canal has begun, apply Smear Clear (SybronEndo,Orange, Calif.) (17 percentEDTA cetrimide, andsurfactants)

The EDTA is an organic acidthat eliminates the mineral part ofpulp tissue;7,8 the surface tensioninhibiter will allow better contactwith the dentin for higher effi-ciency.

1-2-3 steps in endodontic irrigationBy Philippe Sleiman, DDS, DUA, MSc, PhD, FICD

Figs. 1a-b: Several anteriorteeth treated in asingle session usingK3 rotary files.Fig. 1a Fig. 1b

ENDO TRIBUNE U.S. Edition Trends 13

We advise alternating the use ofEDTA from the beginning of thepreparation in order to eliminatethe mineral layer before it thick-

ens and condenses inside thecanal systems, closing the en-trances of lateral and accessorycanals and dentinal tubules.

Each time a rotary file is work-ing inside the canal, irrigating so-lution must be present. Ultrasonicactivation of the irrigating solu-

tion, using a small-diameter file,is advised for a more efficientchemical preparation.

The early use of EDTA facili-tates the flow of the different irri-gants in the lateral canals, permit-ting a chemical preparation of theendodontic system.9 EDTA alsoplays an important role in the re-duction of inflammatory reactionby inhibiting the affinity ofmacrophages to the vaso-activepeptides of the pulpal tissue.10 TheEDTA should not be inside thecanal for longer than 4 or 5 min-utes.

Chlorehexidine can be used fora total elimination of the bacteriainside the canal. Distilled water isused between each irrigating so-lution to prevent an acid/base re-action between sodium hypochlo-rite and EDTA and for a more effi-cient action of the chemicals onthe tissues. Copious irrigation isnecessary to neutralize all thechemical agents by the end of thepreparation and before the fittingof the gutta percha cones so thatthe master cone does not pushany of the chemicals outside thecanal, potentially causing an in-flammation of the surroundingtissues.11

AD

Fig. 2: A central incisortreated in two sessions.The pulp was necroticand some swellingwas noticed.

page 14ET


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Necrotic teeth The main difference between

vital teeth and necrotic ones is theabsence, not in total, of the pulpalparenchyme and the abundanceof bacteria present in the latter.Figs. 2 and 3 illustrate necroticcases.

Irrigation should be initiatedwith either sodium hypochlorite(5.25%, 60ºC) for its bacterial ef-fect or with chlorohexidine(0.2%) (10 minutes)12 for the elim-ination of various bacterial typespresent in the root canals anddentinal tubuli.13 Distilled watershould be used to neutralize theeffect of these irrigants. Then thesame irrigation sequence de-scribed previously for vital teethshould be repeated.

By eliminating the smear layerand opening the dentinal tubuli,the EDTA will permit an easy flowof NaOCl or chlorhexidine for abetter disinfection of the en-dodontic system. In both clinicalsituations (vital and necroticteeth) it is necessary4,14,15 to endour sequence by using distilledwater to eliminate the chemicalagents or to neutralize their ef-

fects. This will inhibit their flowtoward the periodontal tissues,the alteration of the filling materi-al, and the formation of a precipi-tating layer due to the crystalliza-tion of sodium hypochlorite afterdrying the canal walls.

Presence of resorptionsWhen we suspect an internal

resorption, the irrigation se-quence is the same as was de-scribed for vital teeth. But this se-quence should be followed by theuse of citric acid 50 percent (10minutes) to eliminate the granu-lation tissue and to obtain smoothdentinal walls. This will amelio-rate the adaptation of the filling

material. The citric acid is elimi-nated by NaOCl and distilledwater. The same sequence isadopted for external apical re-sorptions but with an activation ofthe patency.

DiscussionMany types of irrigants can be

used in endodontic treatment,such as H2O2

16, anesthetic solu-tions, physiological serum, andde-ionized water. Our proposedsequence of irrigation can becomemore complex to address differentclinical situations (Fig. 4).

The alternate use of urea per-oxide, sodium hypochlorite,

chlorhexidine, citric acid, distilledwater, and EDTA is essential forthe cleaning of the endodonticsystem.3,16,17

The time we gain by using ro-tary NiTi instruments should beoffset by abundant irrigation for abetter cleaning of the endodonticsystem. This will contribute to theincreased success rate of en-dodontic treatment.

Chemical preparation is a dou-ble-edged sword: it will help usachieve adequate cleaning of themain canal and its systems, but itmust be followed by a 3-dimen-sional obturation to fill all thespaces that have been cleansedand prepared.

page 13ET

Fig. 3 Fig. 4

Fig. 3: An upper caninetreated in onesession, after acrown fracture ofthe compositefilling.

Fig. 4: A retreatment of two lower

premolars.


Perfect absorption of the fluid isessential in the main canal and all ofits systems. If this is not accom-plished, adherence between thesealer and the dentin will be com-promised. In addition, the presenceof the fluid inside the systems cancreate negative hydraulic pressure,preventing the obturation materialfrom entering the complexity of the

root canal systems and accomplish-ing a 3-dimensional obturation.

With the introduction of newmaterials for root canal obtura-tion and progress toward adhesiveendodontics, the root canal irriga-tion/chemical preparation is com-parable (with some small modifi-cations) to dentine and enamelconditioning prior to the use ofadhesive restorative materials.

ConclusionIrrigation is often dismissed

during endodontic treatment, butmust not be overlooked. It is one ofthe major keys of success for en-dodontic treatment. Irrigation—usually reduced to a needle on the

tray—has to be systematically eval-uated in order to become an en-dodontic entity having a precisechronology and codification.

(Editor’s note: This article originally ap-peared in Oral Health and Dental PracticeManagement, and appears here in revisedform by permission of the author.)ET

References1. Peters O, Barbakow F. Effects of irri-

gation on debris and smear layer oncanal walls prepared by two rotarytechniques: a scanning electron mi-croscopic study. J Endod 2000;26:6-10.

2. Barnard D, Davies J, Figdor D. Sus-ceptibility of Actinomyces Israelii toantibiotics, sodium hypochloriteand calcium hydroxide. Int End J1996;29:320-6.

3. Ayhan H, Sultan N, Cirak M. Antimi-crobial effects of various endodonticirrigants on selected microorgan-isms. Int End J 1999;32:99-102.

4. Buck R, Eleazer P, Staat. In vitro dis-infection of dentinal tubules by var-ious endodontics irrigants. J Endod1999;25:786-8.

5. Shiozawa A. Characterization of re-active oxygen species generatedfrom the mixture of NaOCI andH202 used as root canal irrigants. JEndod 2000;26:11-15.

6. Yoshida T, Shibat Shinohara T. Clin-ical evaluation of the efficacy ofEDTA solution as an endodontic ir-rigant. J Endod 1995;21:592-3.

7. Hottel T, El-Refai N, Jones J. Com-parison of the effects of threechelating agents on the root canalsof extracted human teeth. J Endod1999;25:716-17.

8. Berutti T, Marini R, Angeretti A.Penetration ability of different irrig-ants into dentinal tubules. J Endod1997;23:725-7.

9. Heling I, Irani E, Karni S. In vitroantimicrobial effect of RC-Prepwithin dentinal tubules. J Endod1999;25:782-5.

10. Segura J, Calvo J. The disodium saltof EDTA inhibits the binding of va-soactive-intestinal peptide to macro-phage membrane: endodontic impli-cations. J Endod 1996;22:337-40.

11. Brown D, Newton C. In vitro study ofapical extrusion of sodium hypochlo-rite during endodontic canal prepa-ration. J Endod 1995;21:587-90.

12. Heling I, Chandler NP. Antimicro-bial effect of irrigant combinationswithin dentinal tubules. Int End J1998;31:8-14.

13. D'arcangelo Q, Varvara G. An eval-uation of the action of root canalirrigants on facultative aerobic-anaerobic, obligate anaerobic, andmicroaerophilic bacteria. J Endod1999;25:351-3.

14. Hata G, Uemura M, Weine F. Re-moval of smear layer in the rootcanal using oxidative potentialwater. J Endod 1996;22:643-5.

15. Perez F, Calas P, Rochd T. Effect ofdentin treatment on in vitro roottubule bacterial invasion. J Endod1996;82:446-51.

16. Takeda FH, Harsashima T, KimuraY. A comparative study of the re-moval of smear layer by three en-dodontic irrigants and two types oflaser. Int End J 1999;32:32-3.

17. Calas P, Rochd T, Druilhet P. Invitro adhesion of two strains ofPrevotella Negrescens to thedentin of the root canal: the partplayed by different irrigation solu-tions. J Endod 1998;24:112-15.

Philippe Sleiman, DDS, DUA, MSc,PhD, FICD, is an endodontist and in-structor at the Lebanese UniversityDental School. He lectures and con-ducts hands-on endodontics coursesworldwide and has contributed to sev-eral endodontic publications. His lineof endodontic instruments is distrib-uted by Hu-Friedy.

Dr. Sleiman can be reached at:

[email protected].

About the authorET

AD


There are a myriad of problems inchoosing between implant and en-dodontic therapies, as they differprofoundly. Different modes of out-come measurements frustrate directcomparison. The factors to be con-sidered include patient-related is-sues (systemic and oral health, aswell as comfort and treatment per-ceptions), tooth and periodontium-related factors (pulpal and periodon-tal conditions, color characteristicsof the teeth, quantity and quality ofbone, and soft-tissue anatomy), andtreatment-related factors (the poten-tial for procedural complications, re-quired adjunctive procedures, andtreatment outcomes). Long-term,large, clearly defined studies, withsimple and clear outcome meas-ures—for example, survival in com-bination with defined treatment pro-tocols—are needed to measure theclinical performance of endodonticand implant therapies.5,6 Jan Lindhehas stated that implants should beused to replace missing teeth, notteeth. The tragedy of using mathe-matical manipulation to provide ac-curate information for informed con-sent is that the cohort(s) used andthe multivariate analysis derivedmay be altered to prejudice results.

The goal of preserving the natu-ral dentition has long provided thefoundation for clinical decision-making in dentistry. Current trendsin implant dentistry have weakenedthis paradigm as many practitionershave moved quickly to adopt im-plant dentistry as a new standard ofcare; however, the rapidity of thisshift is a cause for concern amongothers. Many short-term studieshave reported favorable data sup-porting the growth of single-unit im-plant dentistry, but the lack of stan-dardized outcome evaluations andbroadly conceived dimensions ofperformance makes it difficult tocompare these reports. Thus, evenwith the exciting new treatment op-tions implant dentistry offers pa-

tients and practitioners, all due con-sideration should first be given totreatments aimed at preserving andrestoring compromised teeth beforepursuing extraction and replace-ment (Figs. 1a-f and 2a-b).

Based on selected follow-up stud-ies, the chance of teeth without api-cal periodontitis to remain free ofdisease after initial endodontictreatment or those with apical peri-odontitis to completely heal afterinitial treatment or retreatment andthe chance of teeth with apical peri-odontitis to completely heal afterapical surgery is a lower percentage

than demonstrated for implants;however, the chance for these teethto be functional over time is 86 per-cent to 92 percent, which placesthem in the same strata as implants.The number of outcome predictorsbecomes literally arcane beyond theaforementioned obvious variables—intra-operative complications, num-ber of roots, treatment technique,periodontal procedures required,ferrule size, etc.—and yet, all arepredictable mainstream proce-dures.7-9 Expediency does not obvi-ate their impact on success and thusthe creation of a logical treatmentplanning algorithm becomes all themore relevant.

In a recent article on paradigmshifts reflecting dentistry’s future,10 areputable educator reported pollingaudiences of dentists at continuingeducation programs as theoreticalscientific evidence (“Hands up” ifyou’ve had root canal therapy andresidual pain, sensitivity, or aware-ness of the presence of somethinguntoward remaining associatedwith the endodontically treatedtooth.) The same question posed tothe same cohort in regard to thosewho had implant placement elicitedno complaints. The presumptionwas that dentists seek out other den-tists as care providers, thus the ex-pectation that the results should re-flect the highest standard of care.He summarized that the trend to re-

move endodontically suspect teethand replace them with implants willcontinue.

The creation of a trend must havesubstantiation in objective fact, notsubjective interpolation. One canonly hope that the excesses of thependulum swing to biomimetic re-placement will reverse and dentistrywill reframe yet again. The profes-sion needs to revisit all aspects oftreatment planning to create a morefunctionally integrated perspective.The specialties, and those areaswith aspirations to be specialties,have operated independent of oneanother or at best with minimallinkage. The result has been a failedinterdisciplinary approach, with theconcept of comprehensive care rele-gated to fulfilling the art of dentistry,but not the biologic science.Nowhere is this more appalling thanin the dismissal of endodontic suc-cess potential.11

Endodontics and implant den-tistry are in continual experimentalstates of flux in regard to successpredictors and treatment outcomeprotocols. Any procedure that canbe validated by evidence-based sci-ence should be factored into com-prehensive care. A rush to judgmentand anecdotal, empirical bias mustnever replace case selection, treat-ment planning and ultimately re-spect for the healing capacity of a bi-

A tale of two specialties:the endodontic/implant algorithm

page 1ET

Figs. 1a, 1b, and 1c: The patient’s chief complaint was pressure on contact and thermal sensitivity in the mandibular leftquadrant. The mandibular first molar had a history of inadequate root canal therapy and the second molar was acutely pul-pitic as a result of a leaking amalgam restoration.

Fig. 1a Fig. 1b Fig. 1c

Fig. 1d: Retreatment of the first molarand initial root canal therapy on thesecond molar were performed and cal-cium hydroxide left in the canals ofboth teeth for 2 weeks.

Figs. 1e, 1f: The teeth were obturated with gutta-percha and resin sealer and thefloor of the chamber bonded with flowable composite resin (Permaflo, Ultradent,South Jordan, Utah). If the biologic mandate for endodontic success is followedduring the initial procedure or if reengineering of a failing procedure addressesthe microflora as the etiologic vector, predictable clinical success is possible in themajority of cases. With crown lengthening, creation of a proper circumferentialferrule for both teeth, a successful resolution should be achieved.

Fig. 1d Fig. 1e Fig. 1f

Fig. 2a Fig. 2b

Figs. 2a and 2b: The mandibular right second bicuspid demonstrated an asymmetri-cal periradicular lesion. The canal was obturated with gutta-percha and resin sealerand a post channel left to the marker (arrow), which was filled with calcium hydrox-ide as an interim means of preventing recontamination. The patient was advised thatideally, the FPD planned would not be the most desirable option. Orthodontic up-righting and realignment to create a space for implant placement or orthodontic clo-sure of the space was preferable to the treatment plan in force. The dentist of recorddid not feel that orthodontics was a necessity to resolve this case ideally. Ideally, thiscase should have been completed with consideration for axial loading and hygienicmaintenance. The choice not to treat in the most interdisciplinary appropriate man-ner will in all likelihood lead to failure of one or both of the abutments.

Interview ENDO TRIBUNE U.S. Edition18

In 1998, Dr. Kenneth Serotafounded the Roots cybercommunityand the rxroots.com website to pro-vide educational and networkingopportunities to endodontic special-ists and general dentists practicingendodontics. In January 2007, therxroots.com site was revamped andits features replicated in a new web-site for the implant dentistry com-munity, rximplants.com. Dr. Serotarecently took the time to speak withEndo Tribune about the new andrenovated websites and what hecalls the “nexus” of the endodonticand implant specialties.

ET: Why did you want to integratethe Roots website with an Implantssite? What does this say about thesynergies between the two disciplines?

Serota: I chose to integrate Rootsand Implants simply because en-dodontics is the essential foundationof all reconstructive dentistry. Im-plants is the biomimetic exemplar ofreconstructive dentistry. There is avery realistic algorithm that is essen-tial in choosing one instead of theother. Essentially, they both work.Where they both seem to fail is in therealm of the restorative component.As such, there is increasingly a unifi-cation phenomenon in terms of howimplants and endodontics must beseen. Implants replace missingteeth, not teeth; however, in bothdisciplines, the foundation, the oc-clusion, and the functional consider-ation of the rehabilitation leads tothe ultimate success. If we as a pro-fession recognize that endodontictreatment in whatever context willpreserve the integrity of the denti-tion, we can then see implants in thetrue light of replacement of irretriev-ably damaged components, not as anexpedient alternative.

ET: Why do you think endodontistsand implant specialists need to betalking to one another?

Serota: I think all specialists needto be talking to one another. Com-prehensive care has always been

the necessity, just sadly not the real-ity in far too much treatment. Thetrees are often treated, not the for-est. I feel that implants have becomea force of nature that at this point isdriving by default, but will in timedrive by design, the integration of allthe “specialties” of dental care. Re-gardless of how you practice orwhere you practice, the essence ofquality is integration of all the partsin harmonious function. Nowhere isthat more integral than in the foun-dation components.

ET: Did the implants website existalready, or is it totally new? How areyou attracting implant specialists tothe site?

Serota: The new Implant site is atthe moment a mirror of the Roots site.In both cases, we’ve added a Market-place using Flash coding and expand-ed the Digital Library for postingcases. In this way, we can link a nexusof industry and professional educationwithout stepping on toes. We intend tofactor in 3D patient and professionaleducation in what are ostensibly par-allel communities. The sites as theyare continually being developed willincorporate functionality relativelyunseen on most dental sites. That willtake funding and time, but it will hap-pen. For now, the sites are repositoriesor archives for all things endodontic-or implant-related, and provide the

link to the Roots and Im-plant discussion forums.They are two differentmembership databases,but have the ability tocross post.

ET: What are the primaryimprovements to the siteover the old Roots site?

Serota: The mem-bership signup is farmore intuitive and au-tomated, and the un-subscribe feature isdesigned to be easy sothat folks can literallycome and go.

Marketplace is a real attempt tostop the commercialism of so manysites. Rather than bombardingmembers with constant ads, theMarketplace provides a 24/7/365exposition hall for vendors to show-case new products, offer the cyber-community consideration on pur-chase, or develop focus groupsthrough the cybercommunity. Thedesign is analogous to walkingdown the aisles at a convention. Ihope that vendors will see that set-ting up a “booth” that is active24/7/365 is a very positive way ofshowcasing what they provide andin turn bringing people to sites tohear how their products are used.Monies from the purchase of“booths” go toward scholarships forfolks who otherwise could not at-tend the annual Roots Summit (seethe Roots Summit link on the rx-roots.com site for more informa-tion).

The Digital Library enables any-one to post cases and retrieve arti-cles or animations or PowerPointpresentations—whatever anyonewishes to share. We also plan to es-tablish an automated Case ReportTemplate to facilitate creation ofjournal-quality submissions to helppotential authors develop a sense ofhow to get their work published inthe print media.

ET: What about Coaches Corner? Howdoes it work and what is its intent?

Serota: Coaches Corner is basical-ly an email link to [email protected] [email protected]. You don’thave to belong to the cybercommuni-ty and receive all the mail. If youhave a question or concern about atreatment or diagnosis, you can postthe inquiry to the “coach,” remainanonymous to the group, but havethe question answered by as many as2,000 members.

Coaches Corner is for those whowish to seek diagnostic, treatmentplanning, or any other advice fromthe membership, without being onthe forum. The questions are posedand the answers returned…it’s basi-cally “Ask the Expert,” with a twist.

ET: What other features are youplanning?

Serota: I have a series of alphapages or flat pages ready to be coded,but the monies just aren’t there yet. Inthe future, we intend to create RSSfeeds, post 3D animations in PDF for-mat, and create a “virtual faculty” withreal-time, hands-on courses, so thatwe can integrate webcasts, etc., withlaboratory-based sessions. I feel wecan also help people use the ever-pro-liferating hand-held devices to learn tocommunicate with one another. Theend game is “Move records, not pa-tients.” The day of the multidiscipli-nary virtual consultation is near, as thetechnology is here. The goal will be touse Roots and Implants and whateverelse arrives to drive that engine.

ET: What’s in the future for the Rootsonline community?

Serota: We may well one day in-clude sites for ortho, lasers, occlu-sion, cosmetics, etc. That’s why ourparent site is called rxdentistry.com.For now, it’s Roots and Implants. Theothers will come if we can get folksto realize that integration and unifi-cation is the goal, not commerce,banners, and idle chatter.

If opinion leaders and academics ineach of the fields participate in thistype of forum, the potential of journals,cross-postings, and other channels willin time create true comprehensivecare treatment planning—or as I feel itwill be called in time— unificationtreatment planning: an integrated,harmonious synergy of all disciplinesin staged and defined sequencing. ET

Roots online community opens door to implant specialtyAn interview with Kenneth Serota, DDS, MMSc, founder of www.rxroots.com and www.rximplants.com

The rxroots.com and rximplants.com sites share acommon portal designed to illustrate the synergiesbetween the two specialties.

Both sites provide an entry to discussion forums, a Digital Archive of cases and presentations, a Marketplace providing accessto industry manufacturers and suppliers, and Coaches Corner, an “ask the expert” feature.

Kenneth S. Serota, DDS, MMScEndodontic Solutions4310 Sherwoodtowne Blvd., Ste. 300Mississauga, OntarioL4Z 4C4 Canadakendo@endosolns.comwww.endosolns.comwww.rxroots.comwww.rximplants.com

ContactET


ologic organism. When the naturaltooth can no longer be treated with-in predictable parameters, then thebiomimetic option should be pre-sented, taking into account all vari-ables that impact upon its successrate (Figs. 3a-f). The choice is notbetween implants and endodontics,but between what is restorable andsalvageable periodontally vs. im-plant replacement as an algorithmof functional success. The true deci-sion is not between endodontics andimplants, but greater accuracy in di-agnosis of fractures of endodontical-ly treated teeth, the success ofcrown lengthening procedures, andthe success of periodontal therapyin regard to marginal periodontitis.

A treatment risk assessment algo-rithm is one of many tools that willoptimize predictable clinical suc-cess. In order for the practitioner tosuccessfully integrate any newtreatment approach, it must repre-sent inclusion of the new; however,not at the expense of exclusion ofthe traditional. As such, endodonticsand implantology must acknowl-edge and ultimately embrace thestrengths each brings to the equa-tion that creates dental health.

All credibility, all good conscience,all evidence of truth come only fromthe senses. Friedrich Nietzsche

A complete listing of references isavailable from the publisher. [email protected].

ET

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AD

Fig. 3a: A radiographicsurvey identified a rar-efied apical area associ-ated with a traumatizedmaxillary lateral incisor.

Fig. 3b: The canal wasidentified and instru-mented, then sealed withcalcium hydroxide.

Fig. 3c: Two weeks later,the canal space was ob-turated. Fig. 3d: Eighteen months

later, the apical lesionhad increased in size andit was decided to removethe tooth and replace itwith an implant fixture.

Fig. 3e: The tooth wasremoved atraumaticallyand the socket site grafted.

Fig. 3f: Four months later a fixture and healingabutment were placed. The algorithm sequencefollowed was logical andsequential; the patient un-derstood her options andchose to retain her naturaltooth if at all possible.

Dr. Kenneth S. Serota is in private endo-dontic practice in Mississauga, Ontario.He is the founder of the Roots (www.rx-roots.com) and Implants (www.rxim-plants.com) cybercommunities. He canbe reached at [email protected].

About the authorET

Feature ENDO TRIBUNE U.S. Edition20

It all started with a tractor

Scherer grew up in the Min-neapolis/St. Paul area, and as ateenager on his father’s hobbyfarm, he did much of the repairwork on the farm’s vehicles. Soon,he knew a lot about old trucks andtractors, and grew to admire

them. In 1984, 20 years old andpurchasing his first car, he chosea 1955 Dodge Coronet.

Scherer earned his dental de-gree in 1991 from the Universityof Minnesota, where he graduatedwith Distinct Honors and wasawarded the Dinh Quan Award forExcellence in Endodontics. Hecompleted his endodontic trainingat the University of North Caroli-na, Chapel Hill. Even in dentalschool he was a “motor head,”

constantly fixing and driving oldcars. “During my residency inNorth Carolina, I had a 1965Cadillac and a 1968 Chrysler NewYorker and drove them to schoolevery day. I was happy becausethere was no salt on the roads inNorth Carolina and I could drivethem year-round.”

He still owns his first car, and23 years later has a car collectionthat would interest even Jay Leno.(As a matter of fact, Leno, whoowns about 100 cars himself, soonplans to visit Bismarck to seeScherer and another local collec-tors’ cars.) Scherer won’t say how

many cars he owns now, but afriend puts it this way: “He ownstwo wreckers, so how many carsdo you think he has?”

Scherer’s collection includesmany specimens of his favorite au-tomobile era: the 1950s. “I like carswith big fins and big motors, most-ly Chryslers, Dodges, Plymouthsand DeSoto’s,” he says. The jewelof his collection is a beige and gold1957 DeSoto Adventurer convert-ible, which he purchased 10 yearsago and spent six years restoring.He doesn’t drive it: “Only 300 weremade, and there are only nine leftin the world.” But he does drive his

Endodontist combines passionsto create auto-themed office

Scherer’s practice name and logo reflect his love for classic American automobiles.

page 1ET Scherer won’t say how many cars he ownsnow, but a friend puts it this way: “He owns

two wreckers, so how many cars do youthink he has?”

The Custom Endodontics staff includes (left to right) Dr. Steffan Scherer, Heather,Alyssa, Beth, Shana, BryAnna, and Tina.

Even the hallways are decorated with part of Scherer’smassive automobiliacollection, including an old Coca Colamachine, neon signsand a vintage Firestonetire sign. Tin ceilings, industrial ductworkand exposed-brickwalls add to the retro look.

sandraehnert

Notiz

the images are not big enough to blow them up, really! I think it works this way.

other cars, choosing a dif-ferent one each week of theyear, weather permitting.

Bringing it to work

Intertwined with his loveof cars is Scherer’s affectionfor automobile-related col-lectibles, or “automobilia,”as well as historic items. “Itell my wife and friends it’snot a hobby, it’s a lifestyle,”he laughs. “Every thing I dois swimming in history.”Family vacations with hiswife Lisa and their threechildren, Erik (15), Peter(13) and Esther (9) areoften planned around a carswap meet or historical des-tination.

The idea to deck the office withpart of his automobilia collectionwas his staff’s. Scherer workedwith The Levin Group, a dentalpractice management consultan-cy, a few years ago to build prac-tice productivity, and Levin con-sultants also encouraged thethemed approach. When the prac-tice moved to a new location in2006, it allowed Scherer evenmore space—and a custom-de-signed environment—to displayhis collection.

Patient reactions have beenoverwhelmingly good, says Scher-er. “Most people walk in and lookkind of confused, like they thinkthey’ve come to the wrong place,”he says. “They usually think it’seither a bar or a restaurant.”

The first thing they see whenthey arrive is a “service counter”reception area that recalls a 1940sor 50s auto repair shop. Neonsigns, an old gas pump, period-look chairs and black-and-whitephotos of Bismarck and the sur-rounding area reinforce thetheme, and Scherer and his staffwear “shop shirts” instead of thetypical lab coat and scrubs. Othermemorabilia is everywhere: inbathrooms, in the operatories andsterilization room and even in thehallway.

While the office may look old-fashioned, the practice is anythingbut. In addition to his surgical mi-croscope, Scherer has a complete-ly paperless office and has inte-grated wireless notepads for pa-tient charts and records, digital x-rays and multiple flat-screenmonitors in each of his three ac-tive operatories. The retro envi-ronment is just a fun bonus.Scherer, who has the only

endodontic practicein a sparsely populat-ed region, draws pa-tients from threestates and 110 refer-ring dental offices.Often, patients drivea substantial distanceto arrive at his office,and he wants to makeit worth their while.

“Our goal was toreally have a psycho-logical impact on thepatient who may notbe thrilled to be com-ing to an endodon-tist’s office,” Schererexplains. “We wantthem to forget about

the fact they’re going to have aroot canal and just be fascinatedwith the office. The point of thetheme is to take their minds offthe procedure they’re going to behaving. They tell us it works.”

Photos by Dan Masseth, Magic Photo Art, Bismarck

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ENDO TRIBUNE U.S. Edition Feature 21

Learn How to Get Them (AND NEVER HAVE TO ASK THAT QUESTION AGAIN)

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Scherer renovated 3,600 sq. ft. of a 1914 grocery warehouse indowntown Bismarck. Twelve-foot ceilings posed a challenge whenhe wanted to hang his Global Surgical microscope from the ceiling.

“We want them toforget about the factthey’re going to havea root canal and just

be fascinated withthe office.“

Steffan J. Scherer, DDS, MSCustom Endodontics521 E. Main Ave.Bismarck, ND 58501Phone: 701.255.2523customendodontics@webcomus.comwww.customendodontics.com

ContactET

Practice ENDO TRIBUNE U.S. Edition22

In the early days of 2007, you maybe reflecting on how your careerwill end. In any life transition, prop-er planning can be the differencebetween success and disappoint-ment. If you are thinking of a prac-tice transition in the next five years,today is a good time to get started.Designing a strategy, timeline andobjectives will create the roadmapfor your journey into retirement. Inthis two-part article, we’ll review 10key points you should consider tomaximize a successful practicetransition.

A realistic outlook is needed toproperly strategize for retirement.In this issue we’ll address five keyquestions to get the transition plan-ning process started:

1. Can I afford to retire?When wanting to retire collides

with being able to retire, the out-come can be devastating. Enlist theservices of a financial planner toquantify the answer through a re-tirement income need analysis,which will project what you willneed to live comfortably, for howlong, based upon your current as-sets. If a shortfall is uncovered, plannow so you can make adjustmentsto your lifestyle or income before it’stoo late.

2. Will anyone buy my practice?The condition of your physical

plant will either help or hinder yourability to sell. If your practice has aworn out look, and if your equip-ment is old, finding a young dentistwilling to buy could prove difficult.If you are going to practice fiveyears or more, consider updatingequipment, or updating your officethrough smart interior decorating.You will receive tax breaks for Sec-tion 179 expense or depreciation, aswell as recouping some of the valuewhen your practice is sold. Remem-ber that in an urban or suburbanarea, competition will be fierce forbuyers. Enhancing your physicalplant will help you compete in thelong run. For practices located insmall towns or rural areas, moretime is needed for recruitment ofpotential candidates since the num-ber of potential purchasers is farless than in metropolitan or subur-ban areas.

3. Am I up to date with technology?If you are one of the 10 percent of

dentists who do not have a dentalsoftware program and you plan topractice at least two years, make the

investment to automate. Most pur-chasers are skeptical of a practice’spotential if computer records cannotbe accessed or generated. Generallyspeaking, investing in clinical tech-nology is only worth it if you can de-rive benefit from it immediately.

4. How efficient and profitableis my practice?

Building up your practice beforeretirement is not counter-produc-tive. In fact, increasing your net in-come for the years leading up to thesale of the practice may increase thevalue of your practice quite hand-somely as well as possibly providemore funds for your retirementplan. Most practices benefit fromprofessional consulting and makingthat investment should provide goodreturns.

5. What are my real estate issues; is my building worthmore than my practice?Since most solo practitioners own

their office space, special considera-tion must be made for the majorityof buyers who will not want to pur-chase the real estate with the prac-

tice. Most buyers will want to payrent initially and then make a pur-chase after a few years of practiceownership. If a deferred real estatesale is part of your future, be surethat your Agreement of Sale for yourpractice includes a future purchaseoption, which allows a buyer thefirst right of refusal to purchase thebuilding. Not being able to sell yourpractice and your office space maydetrimentally affect your financialplan. Work with a financial adviserto allow for this possibility.

In cases where your real estate’svalue is greater than the value ofyour practice, selling both assets to-gether may create problems withfunding for potential buyers. If abuyer cannot obtain funding for thedown payment for the real estatetransaction, you may need to be-come a landlord, until a purchasecan be made. If so, be sure to chargerent that is comparable to other pro-fessional practices in your area. Setlease terms to a minimum of fiveyears with a five-year renewal. Thisprovides lenders with assurancethat the tenant will remain.

Part 2: Five key points you need to consider as you get closer to apractice sale.

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Planning your exit strategy: key questions to addressby Thomas L. Snyder, DMD, MBA

Part 1 of 2

Thomas L. Snyder, DMD, MBA, is alecturer, author, and managingpartner of The Snyder Group, LLC, atransition and financial manage-ment consulting services firm locat-ed in Marlton, N.J. Snyder hashelped plan and value dental prac-tices, and designed associate andpartner relationships. He can bereached at 800.988.5674 or by e-mailat [email protected].

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