Endo Mail

Review of Ruddle on Retreatment
Amy Beth Dukoff, D.M.D.
Management of Blocks, Ledges, Transportation, and

Perforations
A Review of Ruddle on Retreatment
Amy Dukoff
Amy Dukoff
r. Cliff Ruddle is the founder and director of

Advanced Endodontics. He gives lectures, presents
hands-on workshops, and has a micro endodontic training
center. This tape will show these techniques and provide
more information.
This videotape reviews previously taught endodontic
techniques with alternative methods of treatment. In this
tape, the techniques are demontrated with plastic models,
extracted teeth, operating on patients and 3-D animation.
Each segment is organized, explanatory, and well thoughtout. Dr. Ruddle outlines his approach to a cases treatment
plan and his rationale for it. For example, crown-down is
explained visually, and and Dr. Ruddle explains why it is
important to open the coronal third before the apical third.
He explains how opening the coronal one-third facilitates the
apical instrumentation.
MTA is described with its use and application.
Furthermore, Dr. Ruddle incorporates CollaCote in his
treatment plans. He says that he makes a breakdown into a
breakthrough. Of course, tooth selection along with great
access is a must.
The video is worth watching. He reveiws techniques and
basic concepts well. I highly recommend this tape. Dr.
Ruddle has a very positive attitude in support of his process.
His encouraging style of teaching the material enhances the
tape.
Ruddle videotapes
11/02/1999
ENDO TIP
You can reach Dr. Ruddle at:

Advanced Endodontics
227 Las Alturas Road
Santa Barbara, CA 93103
Phone: (800) 753-3636
Fax: (805) 965-8253
www.endoinfo.com
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad01ruddle.html[2/21/2011 10:24:50 ]
Review of Ruddle on Retreatment
FEEDBACK?
We welcome your responses and questions.
Please feel free to visit the Endo Forum and add your
comments about any of the articles in Endo-Mail.
Copyright 2000 by Musikant, Deutsch, Kase, Dukoff, Bui, & Hoffman. All rights reserved.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad01ruddle.html[2/21/2011 10:24:50 ]
Vicoprofen Product Review
Vicoprofen: Effective Pain Relief?

A Product Review
Amy Dukoff
Amy Dukoff
icoprofen combines two widely used analgesics. It

produces a wonderful combination for the management
of dental pain. The additive effect provides the doctor
with an alternative for the patient seeking pain relief.
The Vicoprofen tablet is 7.5 mg of Hydrocodone Bitrate
with 200 mg of Ibuprofen. Hydrocodone Bitrate is a semisynthetic, central acting opoid. Ibuprofren is a non-steroidal
anti-inflammatory, peripheral acting drug. It is supplied in a
fixed combination orally for short term usage (usually less
than 10 days). Any contraindications and warnings for
Ibuprofren are the same for Hydrocodone and Ibuprofen
respectively.
Knoll Pharmaceutical Company provides research
describing the analgesic. They claim that there is a rapid
onset of 11.0 to 16.2 minutes with its maximum effect in one
hour. They also claim that most adverse reactions were mild
and moderate with gastrointestinal reactions common. The
manufacturer recommends 1 tablet every four to six hours
with a maximum dosage of 5 tablets for a 24-hour period.
Their study found that one Vicoprofen (7.5 mg) was equal in
relieving pain to two tablets of acetaminophen with codeine
(300 mg/30 mg x 2).
The suggested prescription is Vicoprofen #40 Tabs. I
usually dispense #12#16, with instructions to take one
tablet every 4-6 hours as needed for pain.
I give this product a Four Star rating. I like hydrocodone
for some of my patients because they tolerate it better than
codeine.
Some patients dont like the side effects of codeine but
arent allergic to it and would like pain relief similar to
codeines narcotic effects.
Ibuprofen has also been shown to be effective in treating
inflammation. In the past, I have had the patients alternate
between Tylenol with codeine and Advil. Vicoprofen in this
combination seems to be effective and worth trying.
11/02/1999
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad02vicoprofen.html[2/21/2011 10:24:50 ]
Vicoprofen Product Review
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad02vicoprofen.html[2/21/2011 10:24:50 ]
Review of Pro Root Instructional Video
Pro Root Instructional Video

A Product Review
Amy Dukoff
Amy Dukoff
RO ROOT is an instructional video by Densply and

Tulsa Dental. Its subject is MTA (Mineral Trioxide
Aggregate), which is a new material with a variety of
uses. MTA can be used as a repair material for the root
structure. One application is for procedural errors.
MTA adheres well to the root wall. Also, it seals in cases
of internal resorbtion and furcal communications. In
addition, the video shows cases of success during
apexification, pulp-capping pulpotomies, and as a root end
seal.
The video discusses MTAs properties. The video states
that MTA allows for normal healing, new cementum growth,
adequate setting time, and the least leakage. They give
supporting research.
The video is informative and direct. I recommend viewing
the video, and I also recommend the clinical use of MTA.
MTA has been an adjuct in my practice. I have found that
MTA does seal and repair well, but my method of dispensing
the material for each use differs from the method shown in
the video. I am more frugal, using only a small amount of
the powder with a correspondingly small amount of distilled
water. I use the packet for more than one procedure, and it
works well.
On the whole, the video is a good educational tool.
November-December 2000
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad03proroot.html[2/21/2011 10:24:50 ]
Review of Celebrex and COX-2
Celebrex and COX-2

A Product Review
Amy Dukoff
Amy Dukoff
ELEBREX IS A COX-2, nonsteroidal, antiinflammatory drug. Celebrex is made by Searle/Pfizer

and is the brand name for celecoxib. The
recommended dose is 200 mg daily or 100 mg twice a day.
COX-2 is an isoform of cyclooxygenase (COX).
Cyclooxygenases are used in the cyclooxygenase pathway of
the inflammatory process. Cyclooxygenases occur in two
Celebrex
isoforms: COX-1 and COX-2. They are used in the
metabolism of arachidonic acid to produce prostaglandins.
COX-1 affects upper gastrointestinal tract mucosal protection
and platelet aggregation. COX -1 is seen in many tissues, yet
COX-2 presence may go unnoticed. They both are important
in mediating inflammation and pain.
Celebrex inhibits COX-2 and not COX-1. Therefore, the
upper gastrointestinal mucosal protection remains, and
studies have shown that COX-2 non-inflammatory drugs
have a lower incidence of gastrointestinal ulceration than
conventional non-steroidal anti-inflammatories.
Celebrex does have some limitations. It cannot be taken
with Bactrim or Septra. Also, if your patient is on Librium,
you should be cautious with its use, Furthermore, for some
patients the expense can be a factor, since Celebrex costs
$2.50 per pill. As with all non-steroidal anti-inflammatories,
one must take heed of the contra-indications for this family
of drugs.
March-April 2001
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad04celebrex.html[2/21/2011 10:24:51 ]
The Importance of Diagnosis

Amy Dukoff
Amy Dukoff
IAGNOSIS IS ESSENTIAL before initiating root

canal therapy. A separate appointment is often needed
to diagnosis accurately. If the patients need is odontogenic,
the patent will be grateful that the right tooth is treated so that
his symptoms are dissipated. If it is not odontogenic, the
proper referral or treatment is needed.
The patients symptoms and the patients description of
what he or she thinks has happened to the tooth are
important, of course. However, after a patient explains why
he feels it is a specific tooth, the patient may pinpoint another
tooth. A complete diagnosis is needed for an understanding
of the patients chief complaint; that diagnosis includes
objective findings of clinical and radiographic examination
and clinical tests. Clinical findings are not limited to pulp
vitality tests, intra-oral or extra-oral exam. One must also
evaluate for TMD ( tempromandibular disorder).
Furthermore, evaluating for bruxism, clenching, and
abnormal habits can lead to additional clues to conditions that
might affect the patients symptoms. Finally, radiographic
examination and evaluation are required. All the pieces are
put together in order to make an accurate diagnosis.
Radiographic evaluation is very dependent on your
subjective evaluation and observation. Certain findings are
indisputable, such as the number of teeth, restorations
present, and gross findingsa radiolucency or grossly short
obturation of the root canal space, for example. Some
observations may be considered subjective. For example, the
obturation in a premolar maybe thin to one practitioner yet
acceptable to another. Also, canal in the mesial buccal root
of a first molar that seems well obturated to one practitioner
may reveal a missed MB2 to another practitioner. In many
cases, calcified bodies in the pulp chamber can be a sign of
pulpal changes and necrosis to some practitioners. Other
practitioners may view these changes as normal since there
maybe no periapical pathology found. Radiographs are a
wonderful aid. However, their interpretations are subjective
to the practitioners eyes.
The consultation visit is extremely important. A good
mutual understanding of the treatment and proper diagnosis is
important in attaining a successful outcome.
A good mutual
understanding
of the
treatment and
proper
diagnosis is
important in
attaining a
successful
outcome.
May-June 2001
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad05diagnosis.html[2/21/2011 10:24:51 ]
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad05diagnosis.html[2/21/2011 10:24:51 ]
Beware of the Groove

Amy Dukoff
Amy Dukoff
HE TOOTHS ROOT SHAPE is sometimes

overlooked. A root may have many cross-sectional
shapes, and the shape can change at different places on the
root. Many times, a radiograph does not indicate any
aberration in the root form. However, as instrumentation
takes place from within, the practitioner must have a mental
note of the outside root form.
The radicular form changes shape. In maxillary lateral
incisors, the radicular cross-sectional pulp chamber varies
from ovoid to conical. In maxillary premolars, there are
many irregularities in the root form. These irregularities may
be the result of fused roots with separated canals, fused roots
with webbing, fused roots with a common apical foramen, or
three-rooted tooth. The tapers and the apical portion can be
very narrow and curved. When instrumentation takes place,
one must monitor how wide to prepare the canal. Otherwise,
you can strip and perforate unintentionally.
Maxillary molars and mandibular molars may have
invaginations in their root walls. They can have different
root wall thickness. In the case of some mandibular molars,
the distal wall may be thin and may have an additional
problem of an external invagination. One must take heed of
any external invagination while instrumentation takes place.
The problems that may be encountered if overinstrumentation takes place where a groove or external
invagination is present include stripping and lateral wall
perforation. Furthermore, the walls can become more prone
to fracture during some obturation techniques and some
restorative procedures. Over-instrumentation will take away
too much tooth structure. Care must be taken in
instrumentation with respect to both internal and external
structure.
It is important to evaluate the external anatomy before
beginning instrumentation. Radiographs are a wonderful aid
in viewing the root structure in two dimensions. However,
the external anatomy with its external invaginations requires
constant attention.
Evaluate the
external
anatomy before
instrumenting.
July-August 2001
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad06beware.html[2/21/2011 10:24:52 ]
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad06beware.html[2/21/2011 10:24:52 ]
How Trauma Affects the Nerve

Amy Dukoff
Amy Dukoff
EETH REACT to trauma in various ways. Their

Keen
response can cause immediate changes or delayed
observation and
changes that can take weeks or years to become apparent.
close
The traumatic experience may cause gradual changes in the
root-canal system that do not become apparent until years
examination
later.
are imperative.
A good dental history is important to identify the type of
trauma. Trauma can be due to abnormal occlusal contacts. It
may have been caused by a recent blow to the tooth in
question. Further investigation may reveal an injury that
occurred many years earlier. When you are taking the
history, it is important to determine how, when, and where
the injury occurred. The corresponding symptoms at the time
of injury are also important, along with the progression of
symptoms. The patient will usually provide the important
facts if prompted carefully and thoroughly.
The clinical examination has many parts, proceeding
through neurologic, external, intraoral soft tissue, hard tissue,
and radiographic phases of examination. Vital tests are also
needed. After all the information has been gathered, a
diagnosis can be made.
Trauma will cause a pulpitis. Determining whether the
pulpitis is reversible or irreversible may take more than one
appointment. Sometimes in a recent trauma with percussion
tenderness alone and in normal occlusion, the symptoms may
resolve and no treatment will be needed.
At other times, if the pain is intermittent over a year, then
irreversible pulpitis may be suspected. And at still other
times, you may see a change in the shade of the clinical
crown over the span of years. Furthermore, on radiographic
interpretation, calcification or internal resorbtion may be
seen.
Keen observation of the tooth in question is imperative.
Close examination is a must for diagnosis and subquent
treatment.
September-October 2001
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad07trauma.html[2/21/2011 10:24:52 ]
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad07trauma.html[2/21/2011 10:24:52 ]
Internal Resorption
Internal Resorption
Amy Dukoff
Amy Dukoff
OOTH RESORPTION may go unnoticed for many

years. Often, the patient is unaware of it because of the
lack of symptoms. Usually, the practitioner will discover the
resorption in an unusual radiographic finding upon a routine
examination when periapical radiographs are taken.
Treatment of internal resorption begins with proper
identification. Diagnosis differentiates internal resorption
from external resorption. It is important in treatment to know
if the resorption is purely internal, initiating within the pulp
chamber and not communicating with the periodontal
ligament. If the resorptive area is communicating, then it is
an internal-external resorptive case, and the prognosis is
questionable.
Internal resorption can be the result of many factors:
Management
and treatment
are essential.
partial removal of the pulp

caries
trauma
pulp capping with calcium hydroxide
a cracked tooth
The patients history will give the practioner clues to when
the tooth was last worked on and whether trauma was
involved. The resorptive process can progress at different
speeds and with different periods of activity.
Internal resorption can be managed with conventional nonsurgical root-canal therapy. Prognosis is good; however, the
patient must be recalled, since the resorptive defect can
recur. If there is a perforation of the root to the periodontal
ligament, then repair must be undertaken to create a barrier.
Calcium hydroxide has osseous reparative properties that
make it a good choice to create a barrier.
Internal resorption is a problem all practitioners come
across in practice. Successful treatment requires proper
diagnosis and a good history. Management and treatment are
essential.
FEEDBACK?
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad08internalresorption.html[2/21/2011 10:24:53 ]
Internal Resorption
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad08internalresorption.html[2/21/2011 10:24:53 ]
Isolation
Isolation
Amy Dukoff
Amy Dukoff
ROPER endodontic access is crucial to the success of

the final treatment. The access openings can help the
practitioner overcome many technical difficulties that he
or she may encounter during treatment. Before access is
gained, isolation is essential. This crucial step is often
overlooked or not given its proper attention.
Isolation is attained with the placement of a rubber dam.
Ideally, the dam is placed only on the treatment tooth.
However, in cases where there is gross subgingival decay and
placement is precarious, it is better to use the two adjacent
teeth as anchors. This method of anchoring the dam will
facilitate the practitioners removing the gross decay,
controlling gingival bleeding, and performing the procedure.
The rubber dam, of course, is designed to help prevent the
entrance of germs into the pulp cavity, assuring the safety of
the patient.
The Endodontic access opening can be affected by the
rubber dam placement. It is important to evaluate the
inclination of the tooth and projected root structure before
placing the rubber dam. Getting a visual orientation of the
tooth in its position in the arch is critical before initiating the
access opening. Often, the practitioner will lose sight of vital
information and clues to the location of the canal once the
rubber dam is placed. This is especially true with calcified or
inclined teeth. It is sometimes necessary to make small
reference marks on the tooth for orientation to facilitate the
access-opening procedure.
At times, other proceduressuch as crown lengthening,
periodontal evaluation or treatment, or removal of a wisdom
toothmay be needed before the access opening. If the
decay is subgingival, crown lengthening may be needed.
Many times periodontal treatmentsuch as osseous
recontouring, gingival recontouring, root resection, or
hemisectionis needed as part of therapy. Wisdom tooth
extraction may be needed if there is a pericoronitis, swelling
that limits mandibular opening, or swelling with an inclined
tooth. These are just a few situations in which other
treatments are needed before beginning the isolation
procedure.
The importance of isolation in an endodontic procedure is
often overlooked. Yet it is an important factor in the
outcome of the treatment. Isolation is required before
This crucial
step is often
overlooked or
not given its
proper
attention.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad09isolation.html[2/21/2011 10:24:54 ]
Isolation
initiating the treatment.

January-February 2002
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad09isolation.html[2/21/2011 10:24:54 ]
Breakage of Instruments
Amy Dukoff
Amy Dukoff
reakage of instruments is a common problem for all

practitioners. Breakage can occur for a multitude of
reasons. The operator can be as careful as possible and
still an instrument may separate. The challenge then
becomes how to turn this into a positive and successful
situation. Handling the occurrence with confidence gives the
patient the comfort of knowing that all will be well.
Fractures can occur with K-files, Hedstroms, reamers,
NiTi, and rotary instruments. Generally, instruments should
be discarded if one of the following occurs:
There are unwound flutes on the instrument.
The instrument has seen excessive use.
The operator had to place excessive bending or
precurving.
You see corrosion on the instrument.
Instruments may separate for any of several reasons. They
can break due to the operators overworking the file. One
cannot force an instrument to the desired length. Instruments
may also break due to advancing from a smaller to a larger
instrument, skipping steps in the progressive sequence. Some
instruments, especially the NiTi and rotary instruments,
separate more easily than stainless steel. One can check NiTi
instruments by bending them in ones hand before use.
Rotary instruments may break without warning during use.
Once an instrument is separated, the operator must inform
the patient of the occurrence. Speaking to and informing the
patient is usually the most difficult task. We want to
transform the reaction of the patient from fear to comfort.
Figure 1
Many times, a matter-of-fact approach is best, simply stating
that an instrument separated because of the metals
weakness. Speaking with confidence, demonstrating that you
are in control of the situation, instills a feeling of comfort in
the patient.
One clinical example is the following. I was referred a
patient with a separated file in the MB1 canal. The other
canals were calcified. (See Figure 1.) The patient was
asymptomatic and aware of the occurrence. The patient was
referred to me to complete the case. Upon accessing the case,
I found an MB2 that bypassed the instrument and had a
common apex. Also, I found the DB canal. (See Figure 2.)
The patient remained asymptomatic throughout the treatment.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad10breakage.html[2/21/2011 10:24:54 ]
In the final post-operative radiograph , the separated

instrument could not be noted. The result was a success.
(See Figure 3.)
Figure 2
FIGURE 1: A separated
file in the MB1 canal.
Figure 3
FIGURE 2: An MB2 was found that

bypassed the broken instrument
and had a common apex.
FIGURE 3: In the postoperative radiograph, the

instrument is not visible.
Breakage or separation of instruments are problems that all

practitioners experience. No matter how hard one tries to
avoid this occurrence, it usually will occur at some point.
Sometimes the instrument is simply used as part of the
obturation system. At other times the instrument is bypassed,
or, during further instrumentation, the separated file is
removed using one of a variety of techniques. Managing the
situation will provide the patient with added confidence and
trust in you.
May-June 2002
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad10breakage.html[2/21/2011 10:24:54 ]
Orthodontics and the Root

Amy Dukoff
Amy Dukoff
RACES ARE A FACT OF LIFE for many adolescents.

Malocclusion is esthetically and functionally
undesirable. Most parents are concerned about how
their children will look in their teen and adult years.
However, when orthodontics is being considered, the longterm effect on the root is sometimes a forgotten consideration
.
Roots respond to orthodontic movement. The forces from
the orthodontic movement cause disturbances in the
circulation of the pulp. Circulatory disturbances can result in
the degeneration of the odontoblast. Pulp changes are
associated with orthodontic forces applied beyond the
tolerance limit of the tooth.
The results of orthodontic movement can be seen on a
radiograph. Resorption may occur, and the root ends may
become shortened and blunted. Even though these changes
are present, pulp vitality may not be affected.
Orthodontics is important when needed for correct
alignment. However, teeth with complete apices may have
more severe degeneration of the odontoblasts the
incompletely formed root apexes. In most cases, damage to
the pulp is reversible and does not result in a need for
endodontic therapy.
Changes are proportional to the amount of force that is
applied. The greater the force, the greater the disturbance in
the pulp chamber. The odontoblasts respond in many ways.
Some odontoblasts will degenerate. Others may increase the
deposition of reparative dentin. It is important to monitor the
duration and degree of pain the patient experiences after each
orthodontic procedure.
Orthodontics produces wonderful results. Understanding
how orthodontic procedures affect the pulp will improve the
treatments final result and ensure that the pulp remains
healthy.
Endo Tip
If a Peeso breaks
in the canal, just
touch the shaft
with any rotating
high speed bur.
The spinning bur
will either loosen
the Peeso up or
actually spin it out
of the canal.
FEEDBACK?
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad11orthodontics.html[2/21/2011 10:24:55 ]
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad11orthodontics.html[2/21/2011 10:24:55 ]
Missed Appointments
Missed Appointments
Amy Dukoff
Amy Dukoff
ISSED APPOINTMENTS can play havoc with a

doctors schedule. Besides the down time, the loss of
income can be a strain on the practice. One-visit endodontics
is the key to reducing the number of missed appointments.
Many patients are anxious about the endodontic procedure
because of their previous experience or because of what a
friend has said about the procedure. Pain motivates the
patient to come for treatment. After the pain has been
relieved, many patients miss the follow-up appointment.
Completing the procedure in one visit eliminates the need for
the patient to return to complete the treatment. Furthermore,
completing the procedure in a single visit eliminates the
patients risk of an incomplete treatment with possible reinfection or breakage of the coronal structure. One-visit
endodontics creates a positive environment for the patient
especially the apprehensive one.
Certainly, keeping the patients interest in the treatment is
key. Undoubtedly, many patients have very busy, complex
lives that match the bustling pace of city life. Just getting a
patient to commit to a time or treatment plan can be quite an
arduous task. Completing the endodontics in one visit can
enhance the general dentists treatment plan, for the
restorative can begin so much sooner. One-visit endodontics
is wonderful for the patientwho is delighted that the
procedure is overat the same time that it reduces the
likelihood that the patient will miss the next appointment.
There will always be some patients who do not keep their
appointments. Learning to make good use of the empty
time that results is a constant struggle. Discipline is needed to
utilize the time properly. Managing your time in the office is
key to making a missed appointments time into a productive
period. There is always work to do in the office. Having a
to-do list for ones self keeps wasted time to a minimum.
Missed-appointment time is a good time to review accounts,
inventory, and patients histories. Its time for catching up
on reading and correspondence. These unexpected holes in
ones schedule can become valuable to the practitioner.
Missed appointments are always an unwelcome surprise.
Making the down time into positive, productive time is
challenging. It becomes rewarding when the time is well
spent.
file:///D|/...DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad12missedappointments.html[2/21/2011 10:24:56 ]
Missed Appointments
FEEDBACK?
file:///D|/...DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad12missedappointments.html[2/21/2011 10:24:56 ]
Did You Know Where Rx Came From?

Amy Dukoff
Amy Dukoff
Figure 1
OR YEARS I SAW the symbol Rx and used it without
knowing what it meant or symbolized. Finally, I
stumbled upon the meaning of it and took note. The symbol
Rx is derived from the major lines in the symbol of the Eye
of Horus. Horus was an Egyptian god, the god of Nekhen, a
village in Egypt, and god of the sky, of light, and of
goodness. He was the son of Isis, the nature goddess, and
Osiris, the god of the underworld. Osiris was murdered by
Figure 2
his evil brother Seth, the god of darkness and evil. Horus
sought to avenge his fathers death by challenging his uncle
Seth to a fight. Seth cut out Horuss eye, but Thoth, a god
associated with wisdom and compassion, magically restored
the eye. Horus did defeat Seth, finally. Horuss eye, also
called the wadjet eye, became a symbol for health. The
Egyptians considered it a symbol of good and restored health.
The symbol was passed along through the ages. As
William Osler wrote in 1910, In a cursive form it is found in
mediaeval translations of the works of Ptolemy the
astrologer, as the sign of the planet Jupiter. As such it was
placed upon horoscopes and upon formula containing drugs
Figure 3
made for administration to the body, so that the harmful
properties of these drugs might be removed under the
influence of the lucky planet.
There is another theory of Rxs origin. In that version, Rx
is an abbreviation for the Latin word recipere, which means
take or take thus. Long ago, this would not have been a
direction to a patient but to a pharmacist, preceding the
physicians recipe for preparing a medication.
That may be, but the shape of the symbol is a strong
argument in favor of the Eye of Horus as its origin.
TOP TO BOTTOM: The
If you look closely at the major lines of the eye of Horus,
Eye of Horus, the symbol
you can see the elements of the symbol Rx.
February-March 2003
for Jupiter, and the Rx

symbol share similar
elements.
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad13rx.html[2/21/2011 10:24:56 ]
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad13rx.html[2/21/2011 10:24:56 ]
HIPAA Is Here
HIPAA Is Here
Amy Dukoff
Amy Dukoff
HE ACRONYM HIPAA stands for Health Insurance

Portability and Accountability Act. Congress passed
this act in 1996 to improve the effectiveness of the health
care system. The goals of HIPAA are to protect our patients
privacy, maintain patient information and billing in
accordance with the national standards, and keep our
patients charts secure. The privacy of a patients medical
history and billing are to be protected. In the words of the U.
S. Department of Health and Human Services, The new
privacy regulations ensure a national floor of privacy
protections for patients by limiting the ways that health plans,
pharmacies, hospitals and other covered entities can use
patients personal medical information. The regulations
protect medical records and other individually identifiable
health information, whether it is on paper, in computers or
communicated orally. The fines for failure to comply are
stiff, from $25,000 to $250,000 with criminal penalties.
HIPAAs policies may take time to digest, but adapting to
their new set of standards does not really require much of a
change in what one is currently doing. All it takes is a new
awareness of what HIPAA is protecting and what we as
health care providers must do to comply.
I have adapted the following list of key provisions of these
new standards from the Department of Health and Human
Services guidelines:
Access to Medical Records

Patients generally should be able to see and obtain copies of
their medical records and request corrections if they identify
errors and mistakes. Doctors generally should provide access
to these records within 30 days and may charge patients for
the cost of copying and sending the records.
Notice of Privacy Practices

Doctors must provide a notice to their patients how they may
use personal medical information and their rights under the
new privacy regulation. Doctors are expected to provide the
notice on the patients first visit following the April 14, 2003,
compliance date and upon request. You generally should ask
patients to sign, initial, or otherwise acknowledge that they
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad14hipaa.html[2/21/2011 10:24:57 ]
HIPAA Is Here
received this notice.
Limits on Use of Personal Medical Information

The privacy rule sets limits on how doctors may use
individually identifiable health information. The rule does not
restrict the ability of doctors, nurses, and other providers to
share information needed to treat their patients. In other
situations, though, personal health information generally may
not be used for purposes not related to health care, and you
may use or share only the minimum amount of protected
information needed for a particular purpose.
Confidential Communications
Under the privacy rule, patients can request that their doctors
take reasonable steps to ensure that their communications
with the patient are confidential. For example, a patient could
ask a doctor to call his or her office rather than home, and
the doctors office should comply with that request if it can
be reasonably accommodated.
HIPAA affects the dentist and the entire practice team. Part
of the dentists responsibility is to educate the dental team
and employees. The front desk area becomes an area of
concern when a patients privacy is considered. For example,
the support staff must keep a low tone of voice so that other
patients cannot overhear conversation with or about a specific
patient. Also, computer screens should be placed and angled
so that patients cannot view them easily. HIPAA requires that
you take steps to protect the information you write and send
electronically about a patient. Faxes and emails should have
privacy warnings on them.
To gain more information on HIPAA, you can contact the
ADA. You may be able to attend an informative seminar on
compliance, as I did. The U. S. Department of Health and
Human Services has a helpful website where you will find
guidelines and technical assistance with compliance at
http://www.hhs.gov/ocr/hipaa/. Healthcare Compliance
Solutions, Inc. (HCSI) located in Sandy, Utah, can help you
accomplish compliance. Their fax is (801) 943-6658 and
telephone (801) 947-0183. Their website is at
http://www.hcsiinc.com/. They helped our office take the
necessary steps to be compliant.
All of us work hard at providing the best care for our
patients. HIPAA is another way to ensure that each patients
privacy is more closely monitored and to increase out
awareness in this area.
May-June 2003
Cavit washes out. Use ZOP or
HIPAA Is Here
glass ionomer as temporary

material.
FEEDBACK?
HIPAA Is Here

Young Bui, D.D.S.
The Apex Locator: Essential, but Not Infallible

Amy Dukoff
Amy Dukoff
HE END of the root canal is what we are looking

for. Finding the end is the desired result one must
achieve before instrumentation. When one begins a case, the
tooth must be evaluated to see how to find the apical limit
needed for instrumentation. Knowing the correct apical limit
allows one to determine the correct working length. The
practitioner who does not know the correct working length
may inadvertently
create an apical perforation
over-instrument
over-extend obturation material
under-prepare the root canal space with inadequate
obturation
Biomechanical preparation with obturation that is not based
on an accurate determination of the apical limit could lead to
postoperative pain and complications. Determining the
correct working length is essential.
An apex locator is a useful tool for finding the apical
foramen. The apical foramen is usually not at the anatomical
apex. The apical foramen and the anatomical apex usually
differ by approximately 0.5 mm to 1.0 mm. In older people,
the deviation can be greater. The apical foramen is not
visible on radiograph. The apex locator locates the apical
foramen with a great deal of accuracy. The readout on the
apex locator locates the apex or apical foramen and the
apical constriction. (The apical foramen is also called the
major diameter while the apical constriction is called the
minor diameter.) Between the two locations, the readout is
colored green. The practitioner needs to decide which value
is to be the working length. The apex locator reliably gives
the correct values. The radiographic vertex is often used as
the working length; however it does not always correspond to
the actual apical foramen.
In the case of maxillary molars, the palatal root is often a
good example of the fact that the radiographic vertex does not
always coincide with the apical foramen. Drs. Melanie KimPark, Linda Baughan, and Gary Hartwell clearly illustrate this
in Working Length Determination in Palatal Roots of
Maxillary Molars, an article in the Journal of Endodontics.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad15apexlocator.html[2/21/2011 10:24:57 ]
HIPAA Is Here
They show that in palatal canal curves greater than 25 degrees

there is a statistical difference between the actual and
radiographic lengths. Since the palatal root does curve
buccally in a majority of the cases, the radiographic working
length may be short. This is just one example in which the
radiographic working length is not the same as the actual
working length
Knowing the exact apical terminus is vital in achieving a
good result. Biomechanical preparation is improved and
postoperative discomfort is decreased when the correct
working length is known and used.
Young Bui
N APEX LOCATOR is a very useful device in rootcanal therapy. It can save you time and prevent giving
your patients unnecessary doses of radiation. The apex
locator will give you a reading when the reamer reaches the
apical constriction, thus preventing you from overinstrumenting. It has a 95 percent accuracy.
Sometimes, the apex locator gives you a wild reading just
as soon as the reamer enters the canal. This often occurs in
wet canals or in a tooth with a large metal filling or crown
because the readings rely on relative differences in electrical
conductivity. The apex locator will give you the most
accurate reading when the canal is dry and the reamer fits
snugly in the canal. If the apex locator has a built-in reset
button, you can quickly and easily recalibrate the reading.
The Endex by Osada is one such device widely used by the
doctors in our office.
With all this in mind, I had a false reading by my apex
locator this morning when I was treating an upper left second
premolar. The reading for the buccal canal was 18 mm. The
canal was dry, and the reamer used for the measurement fit
snugly in the canal. I got the same reading with the
SafeSiders 25/.08 NiTi file after instrumentation was
completed. Upon fitting the gutta-percha point, I noticed that
the point was about 2 mm short and there was a large puff of
cement extruding to the side of the canal as seen in Figure 1.
There appears to be a horizontal fracture or a large lateral
canal at the level of the puff. I decided to take a workinglength x-ray, Figure 2, to see where the canal ended. The
working length was 20 mm. I cleaned and shaped the buccal
canal again and dried it with paper points. There was no
blood stain on the point tip, indicating that the working length
was not out of the apex. Figure 3 shows the final x-ray with
the proper working length, lateral puff, and the puff of
cement extruding from the apex.
The apex locator is a very dependable device. It makes
root canal treatment a lot simpler and saves you a lot of time
that would be spent in taking unnecessary x-rays. Although
the reading is usually quite accurate, there are times when the
anatomy of the tooth will cause the locator to provide a false
reading, as in the case above. That is why I always prefer to
take a mastercone x-ray before closing the tooth. This
preview of the finished product will give you the opportunity
Figure 1
FIGURE 1: The guttapercha point is about 2

mm short and there is a
large puff of cement
extruding to the side of the
canal.
Figure 2
FIGURE 2: Working-length
x-ray.
Figure 3
FIGURE 3: The canal filled

to the apex.
HIPAA Is Here
to make any adjustment before you let the patient leave.

FEEDBACK?
To Retreat or Not to Retreat?

Amy Dukoff
Amy Dukoff
In discussing
ETREATMENT today is the standard of care . . . in the
retreatment with
right cases. What used to be an easy decision to retreat
patients its
today is more complex. Each case must be evaluated
important to
radiographically and symptomatically in order to decide
emphasize that a
whether retreatment is appropriate. In every case, the patient
tooths requiring
has to be well informed of his or her options. The risks that
are involved must be explained as well as the prognosis and retreatment is not
a treatment
costs.
failure.
The retreatment decision is made on a case-by-case basis.
If symptoms and disease are present, retreatment is usually
indicated. Even without symptoms, retreatment may be
indicated to prevent a future emergency. A common clinical
finding that favors retreatment would be the presence of an
incompletely obturated root canal system. Sometimes, a
history of sporadic symptoms pointing to the tooth in
question will indicate the need for retreatment. In rare cases,
even the most perfectly executed non-surgical root canal
therapy may need to be redone if the patient continually
complains, it just never felt right. Sometimes, its hard to
understand why the tooth hurts, but if the tooth does hurt, its
important to listen to the patient and decide whether
retreatment is indicative from a clinical or patient
management perspective.
The success rate for retreatment is lower than the rate for
initial treatment. Moreover, there can be obstacles that
compromise retreatment. These obstacles may be
calcifications, complex morphology, ledges, blocks, separated
instruments, and the thinness of the root dentin. In addition,
the periodontal condition of the surrounding bone can affect
the prognosis.
The patient must be advised of alternative treatment
options with their respective costs and success rates. Given
the success rates for implants, they are often the preferred
alternative to retreatment.
In any discussion of retreatment with patients, its
important to emphasize that a tooths requiring retreatment is
not a treatment failure. If symptoms and disease are present,
then treatment of the apical periodontitis is necessary. It may
be the case that the root canal procedure went well but
disease pathology is present. It may also be the case that
radiographs show a treatment that was less than textbook
perfect, requiring retreatment even though the patient
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad16retreatment.html[2/21/2011 10:24:58 ]
considers the procedure successful and is not experiencing

symptoms. Therefore, the need for retreatment is usually not
caused by the failure of a root canal procedure and should not
be presented to the patient from that perspective.
Cavit washes out. Use ZOP or

glass ionomer as temporary
material.
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad16retreatment.html[2/21/2011 10:24:58 ]
Endodontics and the Immature Tooth

Amy Dukoff
Amy Dukoff
HEN ENDODONTIC therapy is required on an

Maturogenesis
immature tooth with an open apex, ensuring
is the treatment
maturogenesis is the treatment of choice. Until the
of choice.
tooth is fully mature, the apex is open and the root canal
walls are thin. Closure of the apex is needed in the root
development of immature teeth, but continued root
development and dentin formation are also needed. We want
to allow not just apexogenesisthe closure of the apexbut
maturogenesisthe continued maturation of the tooth, the
normal process of root and apex formation with eventual
closure of the apex, and continued dentin formation along the
root walls to increase their thickness and length. Canal walls
need thickness and an appropriate internal shape if the mature
tooth is to be strong. The thin canal walls and open apex
make root-canal therapy on an immature tooth extremely
difficult. Keeping the pulp alive and allowing the tooth to
mature is preferred because the mature tooth is a much better
candidate for successful root-canal therapy.
If the pulp is necrotic, apexification may be required. In
this procedure, necrotic tissue is removed, and apex closure is
induced. The desired effect of apexification is a calcified
barrier across the open apex to allow for obturation with
gutta-percha. However, apexification does not allow for the
development of the root-canal walls. To achieve
apexification, the canal must be free of infection. Calcium
hydroxide is used to promote apical closure by stimulating
the formation of a calcified barrier. The successful formation
of the hard-tissue barrier is usually determined by tactile
sensation.
Mineral trioxide aggregate (MTA) can also be used to
create an artificial apical barrier. MTA is placed into the
canal to create an apical plug of 3?4 mm. Once the MTA is
set, the canal can be obturated with gutta-percha.
Encouraging maturogenesis is the desired treatment. If
maturogenesis cannot be achieved, then apexification by
calcium hydroxide or artificial closure using MTA must be
utilized. The ultimate success can be determined only on
recall with the absence of pain and pathology.
February-March 2004
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad17immature.html[2/21/2011 10:24:58 ]
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad17immature.html[2/21/2011 10:24:58 ]
Cracked Teeth
Cracked Teeth
Amy Dukoff
Amy Dukoff
RACKED TEETH are usually difficult to diagnose, but

they are commonly seen in practice. Naturally, we see
them in older patients, since their teeth have been in
use for a long time, subjected to years of the stresses and
strains of mastication. However, in practice, I have seen
them in patients of all ages, since a crack may be caused by a
single incident as well as cumulative stresses. Often, the
patient who has a cracked tooth reports eating hard foods,
such as hard candies, ice, popcorn, hard breads, nuts, or dried
peas.
Continued mastication of hard objects very often causes
fatigue of the tooth structure, which could lead to cracks.
Also, occlusal aberrations can weaken the tooth structure and
eventually create a crack, as can such habits as clenching and
grinding. Many times a crack sound is heard immediately,
but the crack may actually have been present but undetected
for a while.
When a crack occurs in a tooth with a restoration, or in a
tooth near one that has a restoration, the patient may jump to
the conclusion that the pain he or she feels is the fault of the
dentist. Diagnosis can be a frustrating experience for the
practitioner, who may be unable to see anything wrong
with the patients tooth restoration. The patient and the
dentist have to come to a mutual understanding about the
condition of the tooth and the nature of the crack. When a
cracked tooth requires treatment, the nature, location, and
severity of the crack may suggest a variety of treatment
options with a variety of prognoses.
The anatomy of certain teeth makes them more susceptible
to cracks. The cuspal height and shape may increase the
force on the tooths structure, leading to cracks. Keeping a
tooth healthy is important in preventing cracks; therefore,
care should be taken as to all aspects of the tooth.
In diagnosing a crack, transillumination, microscopic
evaluation, x-rays, staining techniques, and a bite stick are
important. Transillumination helps the dentist to visualize the
crack by the difference of the transmitted light through the
tooth since the crack blocks light, causing a dark appearance.
Microscopic evaluation helps to clinically detect the extent of
the crack when it is near or in the root. Radiographs can
show the bone breakdown around the tooth, which can help
determine the size of the crack. Various stains, such as
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad18crackedteeth.html[2/21/2011 10:24:59 ]
Cracked Teeth
methylene blue, may also help visualize the crack. Lastly, a

bite stick could help reproduce the patients symptoms and
thereby help in locating the crack. These are just a few aids
used to identify cracks.
Cracked teeth can be a diagnostic challenge. However,
resolution of the patients problem is satisfying. Proper
techniques in diagnosing and analyzing the clinical condition
are likely to lead to a good result.
Summer 2004
FEEDBACK?
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad18crackedteeth.html[2/21/2011 10:24:59 ]
Sometimes It Just Is
Amy Dukoff
Amy Dukoff
OMETIMES a patient presents with a chief complaint

that surprises the practitioner. The complaint may not
correspond to the practitioners assessment of the
patients condition. At times, the patients perception may be
mistaken; at other times, however, complications such as
hard-tissue changes or calcification may be affecting the
practitioners diagnosis. In such cases, listening carefully to
the patient and following the clues in the patients complaint
are essential to making the correct diagnosis.
Hard-tissue changes can make diagnosis difficult.
Calcifications can make the diagnosis confusing. Extensive
formation of hard tissue on the dentinal walls can occur along
with the obliteration of the pulp chamber. This condition may
be caused by trauma, caries, periodontal disease, or other
irritants. Furthermore, pulp stones and diffuse calcifications
can occur. Pulp stones usually occur in the pulp chamber,
while diffuse calcifications occur in the radicular pulp.
Calcification makes the location of the pulp chamber difficult
to read, which may mislead the practitioner as to the
proximity of the caries to the pulpal chamber.
Listening to the patient will give the practitioner important
clues to lead the practitioner to the right tooth or area in
question. When a patient presents with pain on a tooth with
hard tissue changes, the practitioner should be alerted to the
likelihood that changes occurred due to pulpal reactions.
Many times caries may be present, but since the pulp
chamber is obliterated, the depth of the caries in relationship
to the pulp chamber can be misleading. Also, if a crack is
present, the pulp chamber may become obliterated.
Therefore, even if a shallow restoration is present or does not
exist, pulpal obliteration can be caused by a crack. Lastly,
trauma may also cause excessive stress, which in turn may
initiate pulpal calcification. Evidence of calcification gives
clues to the practitioner that the pulp has responded to an
irritation.
Therefore, if the patient is complaining in the region, a full
evaluation of the teeth in question is vital. A tooth free of
restoration may have a surprising result in response to pulp
testing. As always, listening to the patient is key in accurate
diagnosis.
Fall 2004
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad19sometimes.html[2/21/2011 10:24:59 ]
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad19sometimes.html[2/21/2011 10:24:59 ]
Success for the Patient

Amy Dukoff
Amy Dukoff
IAGNOSIS is of paramount importance, and it is

dependent on the patients chief complaint. Because
diagnosis begins with the patient, the essential requirement
for an accurate diagnosisand for establishing patient trust
is the listening skill of the practitioner and the
practitioners staff. Listening to the patients total needs,
understanding them, and responding to them are vital to
achieving a proper treatment plan. The best plan satisfies the
patients needs.
Receptionists usually make the first step in diagnosis. They
are the ones who initially greet patients and ask them to fill
out the forms that provide needed information, including
medical history, personal information, and financial
information. Through these forms, the patient gives the
medical team the first impression of the patients condition.
When the patient is seated in the chair, the practitioner
reviews the information that the patient provided. At this
time, the patient also makes the practitioner aware of the
condition, as the patient perceives it. The patient will also
detail the history of the pain and the level of distress that
accompanies the condition. Understanding the patients pain
will help the practitioner diagnose the origin of the problem.
The first few minutes will help establish confidence and trust
between the patient and the practitioner.
The patients financial and time constraints play a role in
what the treatment plan will ultimately be. Patients may be
limited to their insurance benefits or to their personal budget.
Its always wise to inform the patient of all the treatment
options with their corresponding costs and long-term
benefits. In addition to financial constraints, time may be a
large factor, especially in our mobile society, since patients
may be traveling frequently or planning to move. Depending
on the patients level of pain and its severity, the treatment
plan may be altered to fit the patients financial and time
constraints. These two factors play a large part in deciding on
a treatment plan for the tooth in question.
Finalizing a treatment plan is the ultimate goal. Sometimes
it takes a team of specialists working side by side with the
practitioner to solve the patients individual needs. Having
the patient leave satisfied with the treatment plan is a great
achievement.
Having the
patient leave
satisfied with
the treatment
plan is a great
achievement.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad20success.html[2/21/2011 10:25:00 ]
Winter 2004
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad20success.html[2/21/2011 10:25:00 ]
Redoing an Office
Redoing an Office
Amy Dukoff
Amy Dukoff
HE DECISION to redo, renovate, redecorate, and

update an office is usually a huge one. It is not just the
financial commitment that makes the decision momentous,
but also the amount of time and effort that is required to
compete the task. Furthermore, the inconvenience to the
doctor is enormous.
However, to the patient, the changes are usually welcome.
Patients are usually glad to see that their doctor takes pride in
his or her work, profession, and surroundings. Many patients
judge the doctor by the appearance of the office. An office
that makes a good impression is extremely important for the
first-time patient. In a specialty practice, such as ours, many
of the patients are first-time patients, so the appearance of
our office is especially important to them. We want them to
be comfortable with the surroundings. Most patients are
happy to see their doctor upgrading and recognize that the
doctor cares about their feelings and the way that they
perceive the office. Since technology is always changing, it
is good for the patients to know that their doctor is staying in
the forefront and keeping pace with what is new. Patients
will tend to be forgiving during the transition phase.
Timing is important. It is often good to decide to redo an
office at the beginning of a new lease, as we did. The hardest
part of the process is making decisions that everyone in the
office likes. One must always remember that the big
picture of completing a project is more important than the
temporary inconvenience during the construction. With
careful planning, the results will be worth the inconvenience.
January-March 2005
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad21redoing.html[2/21/2011 10:25:00 ]
The Mandibular Second Molar Morphology
Amy Dukoff, D.M.D.

Amy Dukoff
Amy Dukoff
HE ABNORMALITIES of the mandibular second

Achieving a
molar are often not fully taken into account when root
successful
canal therapy is being considered. Usually, non-surgical root
result in root
canal therapy is thought of as a routine endodontic
procedure. On first glance at a radiograph of a mandibular
canal therapy
second molar, the toooth often appears normal in
on second
morphology. However, when the procedure begins, very
molars presents
often the practitioner then realizes the extent of the
a challenge to
difficulties that he or she may have to overcome.
The mandibular second molar is typically compared to the
all clinicians.
first mandibular molar. The differences are instructive. First,
they are smaller coronally than the first mandibular molar.
Second, they are more symmetrical than the first molar.
Furthermore, the second molars roots have a tendency to be
close together while being in a gradual curve. The first and
second molars have similar access, which is in the mesial
aspect of the crown extending just slightly distal. Of course,
this access may have to be modified due to caries and
coronal structure. Both molars must resist the forces of
mastication.
The second mandibular molars have some distinct
characteristics. They are extremely susceptible to vertical
fracture. Therefore, mesial-distal fractures if present have a
very poor prognosis. Furthermore, the C-shaped root system
is an anatomical variation of second molars. They can be
seen with a fin or web connecting the root systems. The Cshaped canal may not be easily detectable on radiographic
interpretation. In their article C-Shaped Canal System in
Mandibular Second Molars: Part II-Radiographic Features,
in the December 2004 Journal of Endodontics, Drs. Bing Fan,
Gary Cheung, Mingwen Fan, James Gutmann, and Wei Fan,
suggest that with close scrutiny one may possibly predict the
presence of the C-shaped canal. The groove linking the
canals may be so thin that one cannot see it by inspecting the
radiograph. Its important to be critical in looking at all
second molar radiographs.
Achieving a successful result in root canal threapy on
second molars presents a challenge to all clinicians. Its
imperative to be critical before beginning and understand the
case before proceeding.
April-June 2005
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad22mandibular.html[2/21/2011 10:25:01 ]
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad22mandibular.html[2/21/2011 10:25:01 ]
To Retreat or Not When a Post Is Present
Amy Dukoff, D.M.D.

Amy Dukoff
Amy Dukoff
ECIDING whether to retreat an endodontically treated

tooth can be difficult. The best course of treatment is
not always clear from radiographs or from the patients
symptoms. Making a careful diagnosis and discussing the
treatment options with the patient usually produces the best
results.
The tooth may have a radiographic area that is
asymptomatic. If disassembly would include post removal
and possibly a new crown, many factors must be considered.
First, one has to determine whether the post can be removed
without causing a lot of structural damage to the tooth and
weakening it. Then, the practitioner must determine whether
the new post and core with a new crown will be functional.
The new restoration must satisfy the patients needs. The
type of existing post can help determine your decision. For
example, a resin/fiber post could be more difficult to remove
than a parallel post cemented with zinc phosphate. Also, the
posts proximity to the furcation or its length could contribute
to the decision. In addition, the thickness of the post relative
to the thickness of the dentin plays a role in the decision.
Besides these concerns, the anatomical concerns must always
be reviewed. These may include the proximity to the
mandibular canal or the mental foramen.
If the tooth is symptomatic, then a course of action must
be determined and executed. Sometimes the patient will
benefit from a course of antibiotics begun a few days before
treatment to lessen the potential flare-up and make the
procedure more comfortable for the patient. Because the
patient will be more comfortable, removing any post system
will be easier. Furthermore, the antibiotics may allow the
effect of anesthesia to be more pronounced. Of course, the
antibiotics may decrease the symptoms for a short term,
making it more difficult to gain the input of other specialists
if it is needed.
Ultimately, the patient should decide with you on the best
course of treatment. The decision to retreat an
endodontically treated tooth is dependent on many factors
and is very personalized. Discussing the risks and benefits
with the patient is the best course to follow. Advise the
patient and work with the patient to establish the final
retreatment plan.
The decision is
dependent on
many factors.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad23retreat.html[2/21/2011 10:25:01 ]
July-September 2005
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad23retreat.html[2/21/2011 10:25:01 ]
Education
Amy Dukoff, D.M.D.
Education
Amy Dukoff
Amy Dukoff
DUCATION is key at all stages of practice. A practice

always in motion is vibrant and attracts the attention of
its staff and its patients. The key to being and staying a
success is always trying to better oneself. As endodontists,
we know that the more the referring doctor understands the
art of endodontics the more the patient benefits.
The general dentist plays the key role in diagnosis of the
tooth, but planning treatment in a case is difficult in itself.
Its hard to look at a radiograph and know whether the root
canal therapy failed due to a missed canal, underfilled canal,
or a crack. Whether to retreat a case or just have the tooth
extracted is usually a difficult decision. Diagnosing the cause
of pain can be troublesome to the practitioner.
As specialists, we believe that it is important to share new
trends in endodontics with general practitioners, for they face
a variety of different cases and treatment options. It is
important for the specialist to work as a team with the
general practitioner, sharing information. Staying current
with the latest trends will allow the general practitioner to
better evaluate teeth that have previously had root canal
therapy, as well as diagnosing whether root canal therapy is
indicated.
Endodontics has changed in many ways. Keeping up with
new techniques changes the way we evaluate previous root
canal therapy. When one encounters an old silverpoint fill
without a rarefaction or symptom, does that always mean that
one should retreat? When a thin, filled case looks good yet
still has thermal and percussion symptoms, does one retreat
even if it looks good at first glance?
Our evaluation of previous root canal therapy has also
changed due to the way we now shape the canals. Today, we
advocate enlarging the canal system to a .08 taper with nickel
titanium versus the traditional step-back technique. Also, we
encourage enlarging the apex with a # 35 SafeSiders
reamer. The larger apex size along with the greater taper
allows for a cleaner and well shaped canal that tends to
correlate to the architecture of the canal structure. Looking at
a finished tapered canal is quite different from looking at a
conventional 0.02 taper.
Keeping up
with new
techniques
changes the
way we
evaluate
previous root
canal therapy.
September - October 2005

FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad24education.html[2/21/2011 10:25:01 ]
Education

file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad24education.html[2/21/2011 10:25:01 ]
To Treat or Not to Treat
Amy Dukoff, D.M.D.

Amy Dukoff
Amy Dukoff
OME NEW PATIENTS come to your office after

Making the
having sought you out because they feel that youre the
right decision
one who can solve their problems. They have been all
creates a better
over and no one has been able to find what is causing their
pain. But they are sure that you can. The patient may
bond between
localize the pain to one side, and then its up to you. You are
you and the
in a difficult position. Its tempting to tell the patient that
patient.
what another practitioner did was not as good as what you
could do. Dont give in to that temptation. In addition, dont
be too quick to treat a tooth. Take the time for a thorough
evaluation and diagnosis, and take the time to establish trust
and confidence between patient and practitioner.
I had a patient present herself to my office with pain in the
upper right quadrant. She had had three new posterior
composites placed a few months earlier. She did not know
the source of her pain. On her first emergency visit, it
seemed that tooth #4 could easily be isolated as the source,
due to her intense symptoms of thermal pain and the depth of
her filling as revealed radiographically. However, the next
day she returned with the pain continuing and hardly
abating. Her two other molars, #2 and #3, seemed as if they
might also need root canal therapy. However, with her
wisdom teeth present and pressing on teeth #2 and #3, a
consultation with an oral surgeon regarding the wisdom teeth
was in order. Upon her visit there, the surgeon confirmed
that both wisdom teeth would need extraction at a later date,
and that tooth #2 did need root canal therapy. The patient
returned the same day to initiate treatment. At that time,
even though she would need root canal on tooth #2, and
probably to tooth #3, she felt very comfortable with the
treatment plan. A level of trust and confidence had been
built between us because I had not rushed to initiate
treatment on the teeth but instead took care to ensure that
therapy was a necessity.
In her case, root canal therapy was the answer. However,
there are other reasons for odontogenic pain, which are not
pulpal in origin. It is important to understand the other
causes of odontogenic pain while diagnosing. The factors
that can provoke pain include postural changes, occlusal
disharmony, sinus involvement, and hormonal changes. Of
course, an accurate history describing the pain must be taken;
this can help in diagnosing non-odontogenic facial pain,
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad25treat.html[2/21/2011 10:25:02 ]
which may be caused by trigemial neuralgia, cluster

headaches, acute otitis media, acute maxillary sinusitis, or
temporomandibular joint, to name a few. Making the right
decision creates a better bond between you and the patient
while the patient gains trust in your diagnostic skill.
November - December 2005
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ad25treat.html[2/21/2011 10:25:02 ]
Broken Endodontic Instruments
Allan S. Deutsch, D.M.D.
Broken Endodontic Instruments: Watch Out!
Allan Deutsch
f all the complications that might occur while you are

doing an endodontic procedure, one of the very worst
is instrumentation breakagein other words, file
separation in the canal. Throughout my more than twenty
years of practice, breaking an instrument in the canal has
always been a major no-no for anyone doing endodontics.
Recently, with the advent of rotary NiTi instruments, the
manufacturers of these instruments seem to want us to
believe that breakage is not such a problem anymore.
Unfortunately, that is not the reality of the situation.
Breakage is a problem, it remains a problem, and with the
advent of NiTi instruments it is becoming an even larger
problem.
If it were just the instruments breaking in the canal and
there were no consequences, breakage would not really mean
too much. However, when we break a small-size instrument
(#08 through #25), we effectively block the canal. When the
canal is blocked, we cannot remove all the dead or infected
pulp tissue. Necrotic tissue in the canal leads to infection or
chronic inflammation and endodontic failure. If we break or
separate a larger-size file, the broken section is usually easier
to get around or bypass, and we can clean out the canal
adequately. However, sealing the canal well may be difficult.
Poor sealing will also ultimately lead to endodontic failure.
By the way, there is really no foolproof way to remove
broken instruments. Removal must be approached on a caseby-case basis with a great deal of patience, skill, and luck in
the equation.
ENDO TIP
To keep
breakage at a
minimum,
examine every
file before use,
don't overuse
them, and don't
overstress
them.
The Strength of Stainless Steel

STAINLESS STEEL instruments are the most resistant to
breakage, and reamers are more resistant to breakage than
files. Therefore, more than 25 years ago we switched over to
using stainless steel reamers as the mainstay of our
instrumentation. However, even these instruments break.
In Figure 1, we see the most common form of deformation
of the stainless reamer, the shiny spot.
FIGURE 1: The shiny spot
on the reamer is caused
by the unraveling of the
reamers flutes.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd01brokeninst.html[2/21/2011 10:25:02 ]
Figure 1
Here the flutes of the reamer (which form the cutting edge)
are starting to unravel. The flutes usually unravel if the tip
binds and we continue to rotate the reamer in a
counterclockwise direction. If they are left to unravel more,
they will eventually break.
In Figure 2, just the opposite is happening. The flutes are
knotting up. Once again the tip usually binds or wedges in the
canal, and if we keep rotating the file in a clockwise direction
the flutes will eventually break.
FIGURE 2: Near the tip of
the reamer we can see the
flutes of the reamer
knotting up like a twisted
rubber band.
Figure 2
Only 1mm to 3mm of the instrument should be binding or

doing work at the apical end. If more than that is binding, the
instrument can easily lock into the canal and deformation can
occur. Therefore, it is imperative to use the Peeso to prepare
the coronal end of the canal, as described in the S.E.T.
technique.
The Peeso enlarges the canal so that the coronal end of the
file or reamer does not engage the dentinal walls and hence
the instrument only cuts at the apical 2?3 mm. This reduces
the chance of breakage dramatically.
Cutting in a wet canal also reduces the incidence of file or
reamer breakage. Therefore, always keep the access opening
wet with irrigating solution while you are debriding the
canal.
When stainless steel instruments do bind, luckily, we can
see the deformation and act in time to throw out the
instrument before it breaks in the tooth. Therefore, I strongly
suggest that after each withdrawal of the instrument from the
tooth the dentist should examine the file or reamer closely.
Look for a shiny spot or a knot. If you see either of these,
discard the instrument before it breaks in the patients root.
Endodontic files and reamers should be considered
disposable instruments. One to three uses and then out. Plan
on spending approximately a total of $20 to $30 for all (SS
and NiTi) instruments per endodontically treated tooth.
The Weaknesses of NiTi

UNFORTUNATELY, the instruments least resistant to
breakage are the NiTi files, especially the rotary files. It has
been reported in the literature that NiTi begins to
microfracture as soon as it is used in the root. No matter how

light your touch, the NiTi microfractures. It is just a matter
of time before the instrument fractures all the way.
In the rotary handpiece, the combination of compressive
and tensile stress causes the file to break even sooner. The
faster you rotate the file and the more you bend the rotary
instrument, the quicker it fractures. Unfortunately, NiTi
instruments tend to fracture with no visible warning. The
instrument may look perfectly normal, yet fracture in the
tooth.
In Figure 3, we are actually lucky enough to see a
deformed NiTi file of Greater Taper before it has fractured
in the root. This is a very rare event. Certainly, if we place
this instrument back in the root it would fracture.
FIGURE 3: Notice the
slight deformation in the
flutes near the apical end
of the NiTi Greater Taper
file. Next stop: breakage!
Figure 3
We can do two things to help reduce the risk of NiTi

fracture:
1. Examine the file for deformations every time before
placing it into the patients mouth.
2. Bend the file to at least an 80-degree angle, every time
before placing it into the root, to see if it will fracture
(see Figure 4).
Figure 4
If you are diligent and examine every file before use, dont
overuse them, and dont overstress them, then you will keep
your breakage to a minimum. If you use rotary NiTi files be FIGURE 4: Bending the
NiTi file before placing it
very careful, because these are the easiest of all the
into the root.
instruments to break. Good Luck!
ENDO TIP
Every time you remove a file or
reamer from the canal, clean it off
and examine it. If there are any shiny
spots or knots, throw the instrument
out. Consider endodontic instruments disposable!
FEEDBACK?
Peeso and Gates Glidden Drills
Peeso and Gates Glidden Drills:

Theyre Not Just for Post-Hole Preparation!
Allan Deutsch
bet that if you look on your bur stand you will find either
a Gates Glidden drill or a Peeso reamer there. If you are
like most of us, you have used them to make your posthole preparations for years. These burs cut well, are reliable,
and are relatively inexpensive. If they break, they break high
up on the shaft next to the part that fits into the slow hand
piece. Because they break so high up on the shaft they are
usually very easy to remove from the tooth. Gates Gliddens
and Peesos are not end-cutting, making them by definition
reamers not drills. There is a nipple at the end of these
instruments that prevents them from cutting at their tip.
When the nipple engages the wall of a curved canal, the drill
just spins and does not cut apically (see Figure 1).
Figure 1
FIGURE 1: Gates Gliddens and Peesos do not cut at their tips.
Figure 3
Consequently, Gates Gliddens and Peesos will not
perforate the canal in an apical plane. All in all they are very
good instruments.
Figure 2 shows a Gates Glidden drill on the left and a
Peeso on the right.
In Figure 3, we show an illustration of the main parts of
each instrument. The differences are:
1. The cutting head is much smaller on the Gates vs. the
Peeso.
2. The shaft is thinner on the Gates vs. the Peeso
3. The diameters of the heads are different for the same
number instrument.
FIGURE 3: The main parts

of the Gates Glidden drill
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd02peesoandgates.html[2/21/2011 10:25:03 ]
Figure 2
For example, the numbers on both the Gates and the Peeso
are denoted by the number of circumferential grooves located
on the shaft just below the cutout for the latch.
FIGURE 2: A Gates
Glidden drill on the left and
a Peeso on the right.
Usefulness in Preparing Root Canals
Figure 4
The Crown-Down Technique in S.E.T.
FIGURE 4: A typical
mesial canal of a
mandibular molar.
(left) and the Peeso (right).
Not only are these instruments good for making post-holes

but they are exceptionally good for preparing root canals in
an easy and reliable manner. They are especially good to use
in a modified crown-down technique.
Several years ago the crown-down method of root canal
preparation was introduced. It stated that you should not
prepare the apical end of the canal first, but rather that you
should prepare the coronal end of the canal first. The dentist
should use a large diameter instrument to go only 2-3 mm
into the coronal end of the canal. Then the dentist should
switch to a slightly smaller instrument and go a little deeper
into the canal. This sequence is repeated until the apical
terminus of the canal is reached with a small instrument.
Over the years we have found this to be a very time
consuming, not very predictable, and a fairly difficult
technique to master. However, we did notice that Peeso and
Gates reamers do offer a terrific way to use the crown-down
technique to speed up instrumentation for the rest of the
canal.
Figure 5
In other words, we use the crown-down technique as just one

part of the overall S.E.T (Simplified Endodontic Technique).
In essence, the Peeso and Gates Glidden drills represent the
rotary instrumentation sequence in the Simplified Endodontic
Technique.
In the S.E.T. sequence, we first clean and shape the apex
to a size number 20 (yellow) stainless steel instrument. If we
would continue instrumentation without altering the canal at
this stage, it would become more and more difficult to
manipulate the larger number files or reamers in the canal.
This would occur because the coronal end of the canal would FIGURE 5: A larger file in
a typical mesial canal of a
still be narrow, and the larger files would bind and work
along their entire length, both at the apical and coronal ends. mandibular molar.
Figure 4 shows a typical mesial canal of a mandibular
molar. It has a 60 curve within a very short or small radius.

Figure 5 demonstrates a larger file in that canal. You can see
that the file binds over almost the entire length of the canal
and it is very bent or curved in that canal. Binding and
bending are two situations that lead to instrumentation
breakage. To lessen the chance of breakage, the file should
only work or bind in the apical 2-3 mm of its flutes at any
one time and the straighter the canal the better. This can
easily be accomplished by using the Peeso or Gates to open
up the coronal end of the canal to let the subsequent
endodontic instruments do their job more easily. In essence
we are doing a modified crown-down technique, using the
Peeso or Gates.
Figure 6
Straightening the Canal

Once the apex has been instrumented to a size # 20 stainless
steel instrument a number 2 Peeso or number 3 Gates is
introduced into the canal. These instruments cut much better
and more easily when used wet (Figure 6). If you do not
have a slow speed with water spray use xylocaine, water
from the triple syringe, or even irrigating solution.
The instrument is introduced into the canal while it is
spinning in the handpiece. Cut only 2-3 mm in depth, then
remove the drill from the canal. Once the drill is out of the
canal, clean the flutes of the drill with a wet gauze pad to
remove the cut dentin.
Now go back into the canal and cut another 2-3 mm
deeper, as shown in Figures 7 and 8.
FIGURE 6: Peeso and

Gates instruments cut
better and more easily
when used wet.
Figure 7
FIGURE 7: Cutting deeper into the

canal.
FIGURE 8: Cutting deeper

still.
Continue in this manner until you have gone one-third to

one-half of the way down the canal wall. The result will be
that you have done two very good things:
1. You have lessened the curvature of the canal, usually
from a 60 curve to roughly a 45 curve (see Figure 9).
Figure 9
Figure 10
2. You have straightened out the canal, so there is less of

a radius and the endodontic instruments do not have to
bend as much.
FIGURE 9: Decreased
curvature and a straighter
canal.
The # 2 Peeso or number 3 Gates is equivalent to a # 90

instrument (0.90 mm). Therefore using these instruments
opens the coronal 1/3 to 1/2 of the canal to 0.90 mm. This
will easily let any stainless steel instrument from # 25 to # 45
into the canal without binding in the coronal section of the
FIGURE 10: Wider canal
canal.
results in less binding.
Figure 10 illustrates a larger instrument in the canal that is
loose in the coronal 1/2 of the canal. Because these larger
stainless steel instruments now only bind in the apical 1/3 of
the canal they can and do cut much or easily and with much
less chance of breakage. Because they cut more easily, the
instrumentation of the canal goes much faster. The
instrumentation in general becomes much more predictable
and easy. Predictable behavior and ease of use: a very good
combination.
Once the canal is instrumented in a step-back fashion (see
Introduction to Simplified Endodontic Techniques) to a #
40 or # 45, the Peeso or Gates can be re-introduced into the
canal to deepen the coronal flare closer to the apex by 1 to 2
mm if desired. The dentist can even widen the coronal flare
at this point by using a # 3 Peeso or # 4 Gates if so desired.
Figures 11 and 12 represent the canal in the before and
after stages of Peeso or Gates preparation.
Figure 11
Figure 12
FIGURE 11: The canal before

prepartation.
FIGURE 12: The canal after

preparation.
In Conclusion . . .
The use of these drills results in several good things:
easier preparation of the coronal half of the canal

easier preparation of the middle third of the canal by
larger-diameter instruments.
overall, a more predictable endodontic preparation
in a shorter length of time
more easily and with less hand manipulation and
fatigue.
So many positivesno negativeswhat are you waiting for!
FEEDBACK?
Endodontic Retreatment: Removing Posts
Allan Deutsch
e have found that in the last five to seven years we

are doing fewer and fewer endodontic-type surgeries,
that is fewer apicoectomies. The endodontics is
becoming more and more predictable, and with the advent of
better technology conservative endodontic retreatment has
become the procedure of choice.
However, in many instances before we can redo the endo
we must first disassemble the restoration. This disassembly
procedure can oftentimes be tougher than redoing the root
canal. We have found out that clinicians across the country
are charging a separate fee for disassembly.
Removing a post in order to gain access to the root canal
system and still leaving a restorable tooth is no easy task.
We used to just drill the posts out. However, the bur would
often slip off the metal post and gouge out the post hole,
sometimes dangerously thinning out the root to the point
where it was not restorable. Now we have the microscope,
and we are able to use a 1/2 or 1 round bur and see where to
place it on the post. This has made drilling out the posts
much easier. However it is still no picnic.
Initial Steps
Before we begin removal, we must consider several factors in
order to obtain a successful result. First, what type of post is
it? Is it passive or active. Passive posts are held in with
cement. Two typical passive post types are cast posts and
paraposts. Active posts are typically threaded posts, like
Dentatus, Vlock and Flexi-post.
With both types of systems (active and passive), the first
step is to expose the cement. Carefully remove all the core
material around the post and expose as much of the post as
possible right down to the coronal dentin of the post hole.
Next, break the cement seal if possible or at least disturb
it. It is at this stage that some new technology comes in
handy. I just came back from Dr. Cliff Ruddles Endodontic
retreatment course in Santa Barbara. He advocates, and we
here on 57th street use, the Spartan Ultrasonic unit. Dr.
Ruddle has designed a series of very thin and long Ultrasonic
tips to be used in removing posts as well as separated
endodontic instruments (see Figure 1).
The Spartan ultrasonic is used dry at the lowest power
setting. It cuts the dentin like the thinnest bur you can
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd03retreatment.html[2/21/2011 10:25:03 ]
imagine. We now trough around the post and break up the

cement. As you use this instrument, your assistant should be
blowing air on the field to maintain your visibility. Naturally,
since everything is so small you must use either some type of
magnifying glasses or a microscope. In many instances, once
the cement seal is broken the post will begin to vibrate and
soon come out, if it is a passive post.
Removing Threaded Posts

If it is a threaded post , you can now place either the wrench
or a hemostat on the post and thread it out of the root. If the
post is not moving, you can apply a thicker ultrasonic tip
directly to the post and let it vibrate the post for several
minutes. You can even hold the post with a forceps and
touch the ultrasonic tip to the forceps and hence the post.
If the post still wont budge, you can use the Ruddle post
removal system made by Analytic Technology. Here a
trephine is drilled over the post to standardize the posts
diameter. Next, a tap is threaded onto the post. Finally, the
extraction plier is placed onto the tap. At this point, an
ultrasonic tip can be placed onto the tap and again loosen or
disturb the cement seal. Now the extraction plier is activated
and the post is removed. Yes, this really does work!
The beauty of all these procedures is that the post is
removed without bombing out the inside of the root.
Because if you cant restore it, what good are you really
doing for the patient?
FEEDBACK?
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd03retreatment.html[2/21/2011 10:25:03 ]
EZ-Change Overdenture Attachment
Allan S. Deutsch, D.M.D., F.A.C.D.
The New EZ-Change Overdenture Attachment:

Maximum Retention with Minimum Stress
Allan Deutsch
nlike most articles that appear in Endo-Mail, this

article does not have anything to do with endodontics
directly. However, when we developed the Flexi-Post,
we also made an overdenture attachment to go along with it.
That overdenture attachment is affixed to an endodontically
treated tooth. Voila! Thats the connection between this
article and endodontics.
This simple ball-and-nylon-socket attachment has been
successfully used around the world for the past fifteen years.
Many articles about the attachment and the technique have
been published in international dental journals. The EZChange Overdenture Attachment has been found to have the
highest retention among all overdenture attachments being
sold. Yet installing it is a very simple and direct technique to
do. So why am I talking about it here? Recently, we have
improved it and now offer it as an implant attachment.
Advantages of the EZ-Change Overdenture

Attachment
Unfortunately, not every root canal is a success, and many
patients come to us with only a few teeth left in the arch. In
addition, there are implant cases that start out with many
implants placed and end up with only a few that have
integrated.
Also, many patients would like the convenience and
esthetics of fixed restorations, but can only afford removable
restorations for their implants. The restoration of implants
with fixed cases is a time-consuming procedure that is
difficult for the dentist to master. The operatory and
laboratory aspects of these cases are quite complicated, and
the majority of dentists in the United States dont perform
restorations of implant cases yet.
The placement of the EZ-Change Implant Overdenture
Abutment Attachment (from Essential Dental Systems) truly
is easy. Its a simple technique even if you have not
restored implant cases before. It gives your patient a
restoration that looks great and works even better.
The Placement Technique

O.K., so what do you need to perform this technique? Well,
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd04ezchange.html[2/21/2011 10:25:04 ]
Figure 1
you dont need teeth. If your patient has an existing denture,
even better. If not, hold on to the bridgework that the patient
currently has as a temporary restoration until the implants
have integrated and are ready to be loaded (usually
approximately six to nine months). Talk to your oral surgeon
or periodontist to determine which implant type they are most
comfortable in placing. Generally, they will be placing either
FIGURE 1: A healing
FIGURE 2: H indicates the
a; Branemark , 3i, SteriOss, Calcitek, IMZ, or Paragon
screw allows the gingiva to
gingival cuff height.
implant.
heal in the desired shape.
We have overdenture attachments that are compatible with
these implants.
Once the implant has integrated, whoever placed it will
now surgically uncover it. A healing screw can now be
placed to allow the gingiva around the implant to heal in the
desired shape. The shape that we want is just a parallel
cylinder from the top of the implant to the top of the gingiva
(see Figure 1). Once the gingiva has healed, you will need to
know the height (thickness) of this gingiva to determine the
gingival cuff height of the implant overdenture attachment
(labeled H in Figure 2). When you know the implant type
(Branemark, 3i, Paragon etc.), and the gingival cuff height of
the attachment , you will be able to pick out the exact implant
OVD attachment from the catalog for your case.
Before placing the attachment, the denture is constructed.
You can let the patient wear it for several weeks until all the
soft tissue is compressed and any wear spots are relieved.
You can now remove the healing screw from the implant
and, using the appropriate wrench, screw in the E-Z Implant
Overdenture Attachment into the implant (Figures 3 and 4).
Then the rubber band is placed over the ball attachment to
block out the height of contour of the ball and prevent the
acrylic from locking under the ball. Once the rubber band is
in place the EZ-Change nylon cap and keeper are placed onto
the ball (Figures 5 and 6).
Figure 3
Figure 4
Figure 5
Figure 6
FIGURE 4: Screwing the E-Z Implant

Overdenture Attachment into the
implant.
FIGURE 3: Removing the
healing screw from the
implant.
FIGURE 5: The EZChange nylon cap and

keeper.
FIGURE 6: The cap and

keeper in place on the
ball.
Some marking paste or Occlude marking spray is placed

on top of the keeper. The denture is seated and then

removed. The marking paste indicates the area in the denture
that must be relieved to make room for the female nylon cap
and keeper part of the attachment. The denture is then
relieved. The denture is placed over the attachments and
checked to make sure that it seats passively in place (Figure
7). Pink cold-cure acrylic is mixed and poured into the
relieved areas in the denture.
The denture is seated while the cold-cure acrylic sets. After
eight to ten minutes, the denture is removed. The metal
keeper that holds the nylon cap is now incorporated into the
denture permanently. The excess flash is removed, and the
denture smoothed and polished. You can now remove the
rubber band that is still under the ball and dismiss the
patient.
The nylon caps last about eighteen months to two years
before they wear out and lose their retention. At that time, a
special wrench is used to unscrew the nylon cap from the
keeper and a new nylon cap can be threaded in its place.
This takes about thirty seconds to do and is a really simple
and easy technique to start you off with implants. The
attachments have a fifteen-year clinical history of happy
patients and, consequently, happy dentists.
Figure 7
FIGURE 7: The denture is

placed over the
attachments and checked
to make sure that it seats
passively in place.
11/02/1999
FEEDBACK?
Irrigation: The Key to a Clean Canal

HE PROCESS OF cleaning and shaping the canal is
one of the key components of endodontic therapy.
Currently, we dentists seem to be devoting a very large
amount of our time to learning which file or reamer to use
and how to use them. With this emphasis on instrumentation,
another aspect of endodontic cleaning is often overlooked.
That aspect is irrigation.
Allan Deutsch
Why Irrigate?
WE IRRIGATE for several important reasons.
1. to lubricate the canal to make instrumentation easier
2. to remove the debris that is generated from
instrumentation
3. to dissolve the tissue that adheres to the canal wall and
in the nooks and crannies
4. to kill any bacteria that are living in the canal and
dentinal tubules
No one irrigant does it all, but there is one that comes
close. That irrigant is the old standby sodium hypochlorite.
This chemical is the real hero behind a successful endodontic
treatment. It comes very close to doing all the things we just
mentioned and doing them very well.
Sodium hypochlorite has only one big contraindication.
Do not get it past the apex! If the hypochlorite is expressed
past the apex, it causes an immediate inflammatory reaction.
The patient will be in great distress due to severe pain and
almost immediate edema (swelling), along with the good
chance of ecchymosis. These sequelae unfortunately have
been very well documented.
An Ounce of Prevention
FIGURE 1: A 30 gauge
needle, below, with a 23
gauge needle, above.
THE BEST TREATMENT is prevention. When we

understand how the irrigant works, preventing mishaps
becomes easy. Our main aim is to really use the chemical
nature of the irrigant to do the work. We do not want to
wash the canal with the irrigant; we merely want to place the
hypochlorite atraumatically into the canal and let it sit there.
We can most easily place it in the canal a few drops at a time
using a 30 gauge needle. This needle (see Figure 1) facilitates
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd05irrigation.html[2/21/2011 10:25:04 ]
placement of the irrigant far up into the canal. Just express

one or two drops and let it sit there. According to the
FIGURE 2: The Vista
literature, it does its job in about ten minutes. The free
syringe
warmer; perfect for
oxygen and chlorine do the work, not the flushing action of
warming
5 ml syringes of
squirting it into and out of the canal.
hypochlorite.
Keeping the hypchlorite in the canal for ten minutes does
two things. One, it dissolves the tissue tags of pulp that are
inaccessible to instrumentation (and there is a lot of this
tissue around). Two, it will also kill all bacteria that it comes
in contact with in this ten-minute period.
The hypochlorite will work faster and better if it is
warmed. A nice syringe warmer made by the Vista company
in California (shown in Figure 2) will easily keep five 5 ml
syringes at around 105 degrees F. The hypochlorite works
very nicely at this temperature. The easiest way to keep the
hypochlorite in the canal for ten minutes is to leave it in the
FIGURE 3: Instrumenting
access cavity while you instrument the tooth, as shown in
through the irrigant that
Figure 3. Each time you introduce an endo instrument into
fills the access cavity of a
the canal it goes through the hypochlorite and will drag some
molar.
along down into the canal by capillary action.
It is a good idea to change the irrigant in the access cavity
frequently, because it accumulates debris. I will sometimes
change the irrigant each time I shift to a different size of file
in a three-canal or four-canal molar. On the other hand, I
may change the irrigant only once or twice in a single-canal
anterior tooth. With irrigation, the more the better.
Sometimes you may want to use different concentrations
of the sodium hypochlorite. Straight from the Clorox bottle it
is 5.25 percent. This is pretty strong and is good for treating
lower second molars with C shaped canals. These canals
are very difficult to clean well with files alone, because the
canal is not oval or circular in shape. The canal may have a
lot of fins and outpocketings and may even be a web shape
anatomically. The 5.25 percent hypochlorite, if left for longer
than ten minutes, will dissolve the tissue tags that it comes in
contact with and give you a better, cleaner result.
Believe it or not, irrigation is just as important for cleaning
the canal as instrumentation. You can never over-irrigate, so
the more the better. For disinfection and cleaning, irrigation
is the key to success.
Endo-Tip
When the length of a tooth approaches the maximal

depth of a 25-millimeter instrument, the interference
of tooth structure or a metallic restoration may make
placing the probe of the apex locator difficult. In such
cases, it is easier to attain proper measurement
control using a 31-millimeter instrument rather than a
25-millimeter instrument.
Doug Kase
FEEDBACK?
We welcome your
responses and
questions.
Please feel free to visit
the Endo Forum and
add your comments
about any of the articles
in Endo-Mail.
New EZ-Fill SafeSider Endodontic Instruments
Allan Deutsch
E HAVE been explaining, demonstrating, and teaching a new

sequence of endodontic instrumentation for more than three years
now. This sequence of instrumentation uses stainless steel
instruments, Peeso reamers and NiTi instruments. Unfortunately, these
instruments had to be purchased separately from different manufacturers
and combined to perform the sequence in the dentists office. Not only
was this inconvenient, but the instruments did not cut any better or easier
than any other conventional instrument.
After several years of development and testing, Essential Dental Systems
has developed an endodontic instrument with a different geometry.
These new SafeSiders have a flat that extends uninterrupted the entire
length of the cutting edge (see Figure 1). If we look at any other
endodontic instrument in cross section, we see that it has a circular
profile. When we look at the SafeSiders in cross section, we see that they
look like the letter D because the circular configuration has one side that
is flat.
Figure 1: An ISO #25 stainless steel instrument, showing the position of the flat.
What the Flat Does

THIS FLAT does several good things: it makes the instrument easier to
use, prevents the accumulation of dentin debris, reduces stress on the
instruments, and increases the flexibility of the instruments.
1. Because the flat reduces the amount of the instruments cutting
surface in contact with the canal wall, less dentin is engaged during
each cutting stroke. This decrease in the engaged area results in a
slightly less efficient instrument but one that is easier to use in the
canal because it is not fully engaging the canal wall
circumferentially. You may have to turn the instrument a few extra
turns to completely instrument the canal, but turning it within the
canal is much easier now because the entire instrument is no longer
cutting the root. You will notice much less hand fatigue.
2. The flat gives the dentin debris that is generated during cutting
someplace to go. The debris accumulates in the space between the
flat and the canal wall. Therefore, the debris does not wedge
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd06safesiders.html[2/21/2011 10:25:05 ]
between the instrument and the canal wall making the instrument
more difficult to turn in the canal. As the instrument is turned, the
debris falls into the space created by the flat, and you do not have
to work against the accumulated debris. Because less dentin is
being cut at any one time and the debris has someplace to go, you
will find that the clinical effect is that it feels about 25 percent
easier to instrument the canal using the SafeSiders.
3. Because less of the instrument is cutting at any one time, less stress
is placed on the instruments. Lowering the stress lowers the chance
of instrument breakage, and consequently the instruments last
longer. They do not have to be replaced as often as conventional
instruments.
4. The flat is not cut deeply into the core of the metal of the
instrument, so it increases the flexibility of the instruments without
sacrificing strength. The flat removes some metal from the length
of the cutting edge to the tip, resulting in more flexibility, but the
durability and strength of the instrument are maintained.
Two NiTi Instruments

FIGURES 2 AND 3 show the configuration of the two NiTi instruments
in the series. The Orange 30/.04 is an ISO standardized #30 at the apex
with a .04 taper up the shaft. The flat can easily be seen to extend the
entire length of the cutting surface to the tip. The other NiTi instrument
is the Brown 25/.08. It is an ISO standardized #25 at the apex with a .08
taper up the shaft. This is the last instrument in the sequence; once the
canal is prepared with this instrument it is ready to be obturated with a
medium gutta-percha point. Once again we can see the flat extending the
entire length of the cutting edge of the shaft.
Figure 2: Note the flat extending the entire length of the cutting edge
of the NiTi 30/.04 instrument.
Figure 3: Note the flat extending the entire length of the cutting edge
of the NiTi 25/.08 instrument.
The Proper Cutting Stroke

ALL THE INSTRUMENTS in the sequence are meant to be used with a
circular cutting stroke. An up-and-down filing stroke is not the way to
go! Use a wrist-watch-winding motion while applying slight apical
pressure. During the clockwise winding motion, a point will come when
you feel resistance from the flutes of the instrument cutting into the
dentin. At that point, go to a counterclockwise motion. When you now
rotate the instrument counterclockwise, you will cleave off the dentin that
was engaged between the flutes, and the instrument usually will move
about 0.5 mm closer to the apex.
Remove the instrument from the canal, clean off any debris, and
inspect the instrument for any deformation. If the instrument looks fine,
repeat the cutting procedure until the instrument goes to the desired
length in the canal. When the instrument is spinning freely (in a

clockwise direction) and does not engage the dentin, it is time to move to
the next size instrument in the sequence.
Always cut wet! It will make instrumentation much easier. Keep the
canal flooded with irrigant at all times. When the canal is dry, you will
find that binding, ledging, and other bad things occur far too easily.
Remember, there is a learning curve to all new techniques. After
completing four or five anterior cases, you will be surprised at how much
easier endo will have become.
March-April 2001
Endo-Tip
FEEDBACK?
Please feel free to visit the Endo Forum and add your comments about
any of the articles in Endo-Mail.
Never place a
straight instrument
into the canal.
Always bend the
instrument slightly.
This will lessen the
chance of ledging
the canal wall.
May the Sequence Be with You
Allan Deutsch
VEN OBI WON KANOBI and Darth Vader, who

both had their light sabers, would have been nothing
without the years of Jedi training that taught them
how to use those weapons. We are much luckier; it will
not take years to learn the correct use of the SafeSiders
in endodontics. After you have used the SafeSiders on
perhaps two or three anterior teeth, you will wield them
with the skill of the StarWars characters. When you use
the SafeSiders, its not the force that holds the key to
success, but the sequence.
First, unsheathe your number 08 or number 10
instrument to measure the length of the canal. The best
and most accurate way to perform this measurement is
with a third-generation apex locator (Endex or Root
ZX). Next, instrument to the apex up to the EZ-Fill
SafeSider number 20. These stainless steel instruments
up to a size 20 are as flexible as NiTi. Always use a
wrist-watch-winding motion, never an up-and-down
stroke. The up-and-down stroke is much more likely to
push debris toward the apex and block it. That stroke can
also more easily ledge, eliptisize, and distort the apex.
SafeSiders Sequence
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd07sequence.html[2/21/2011 10:25:06 ]
When you have instrumented up to number 20, you are

ready to open the coronal end of the canal with a number
two Peeso reamer. This instrument widens and
straightens the canal. Always use the Peeso wet. Go in
with a pecking motion, never all at once, and slowly gain
depth in the canal. When you are a third of the way to
halfway down and feel resistancestop. You can now
recapitulate to the apex with a number 20 to make sure it
is open.
At this point, we use the step back technique. We
instrument 1 mm from the apex with a number 25, then 2
mm from the apex with a number 30. We then
instrument 3 mm from the apex with a number 35 and 4
mm from the apex with a number 40. This part of the
procedure goes very quickly.
We then take the Peeso again and go into the canal to
gain another 1 or 2 mm in depth. We can then open the
apex to the number 25 and then the number 30
instrument.
We are then ready for the final shaping of the canal
with the NiTi instruments. We use the Orange 30/.04
NiTi instrument to the apex, and then we use the Brown
25/.08 instrument to the apex to give the canal its final
shape. This shape allows a medium or medium-large
gutta-percha point to fit wonderfully well in the canal.
Figure 1 summarizes the various steps in the sequence.
Good luck, and may the sequence be with you!
May-June 2001
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd07sequence.html[2/21/2011 10:25:06 ]
One-Visit Treatment Using EZ-Fill Root Canal Sealer

Summary of a Recently Published Study
Allan Deutsch
Figure 1
N THE COURSE OF the last twenty years, Barry
Musikant and I have published well over 125 articles in
the top dental journals around the world. We have had
articles about posts, cores, endodontics, composites, and even
hand cream published in journals ranging from the Journal of
Dental Research, the Journal of Prosthodontics, and the
Journal of Endodontics, to Dentistry Today. But just
recently, we published what I consider to be one of the most
interesting and relevant articles we have written in the last
twenty years. The article, A study of one-visit treatment
using EZ-Fill root canal sealer was published in the June
2001 issue of Endodontic Practice. This article is important
for us on two levels. First, it validates the clinical techniques
of doing endodontics in one visit and using the EZ-Fill
technique. Second, it gives us a yardstick to measure how
well we are doing for our patients (your patients) on a
FIGURE 1: The EZ-Fill bisuccess-versus-failure level. I find it interesting to note that
directional spiral spinning
we could practice for more than 25 years and not know
the cement laterally, not
scientifically how successful our treatment has been for our
apically.
patients. We could know it empirically from what we saw on
a daily basis in our office, but here is our first opportunity to
actually quantitatively tabulate our clinical results. It was
Figure 2A
interesting to note that most of the failures (9 cases) were due
to fractured teeth. In the remainder of this article, I will give
you the highlights of this recently published paper.
Introduction
VER the last fifty years, endodontics has seen the
advent of many new techniques and devices that have
been aimed at making the procedure easier and
increasing the success rate of the treatment. Some have
worked well; others appeared to work well when the
academic literature was reviewed, but in clinical practice
success was not apparent. 1 As with any technique in
dentistry, clinical success is the acid test.
Many investigators have reviewed the literature on
endodontic success vs. failure and have reported similar
ranges of results. Pekruhn in 1986 reported on 15 studies. 2
He found a failure range of 2.3 percent to 30 percent. This
corresponds to a success range of 70 percent to 97.7 percent.
FIGURE 2A: Tooth

number 30, old root canal,
under treated and
underfilled.
Figure 2B
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd08onevisit.html[2/21/2011 10:25:06 ]
Friedman in 1997 reported on 37 success vs. failure studies

done from 1956 to 1996.3 He found a reported success
range for these studies of 59 percent to 98 percent. Weiger
et al. studied the literature and reported a success range
between 70 percent and 90 percent. 4 Hepworth and
Friedman reviewed studies of orthograde retreatment and
found a range of success of 70 percent to 90 percent. 5
Success for single-visit endodontic treatment falls in the
high end of the ranges studied by these authors. Pekruhn
reported a failure rate of 5.2 percent or a success rate of 94.8
percent in his study on one-visit root canals. 2 Soltanoff in
his single-visit study reported a success rate of 85 percent. 6
Oliet reported a success rate of 89 percent for single visit
endodontic treatment, 7 and Jurcak et al. in their one-visit
study on soldiers also reported a success rate of 89 percent. 8
Naturally, the optimum success rate, the one we all strive
for, is 100 percent success. Unfortunately, there are too many
variables in treatment, materials, diagnosis, and reporting
methods to make this a reality. Certainly new endodontic
techniques that report success rates in the high end of the
ranges previously reported should be considered clinically
successful treatments.
Obturation of the root canal space has always been an
arduous task with unpredictable results in two aspects. One
aspect is how to thoroughly fill the canal lumen and the other
is how to accurately and repeatedly place the root canal
filling to the anatomic apex of the root. Poor results in either
of these two critical areas can ultimately lead to endodontic
failure.6,7
A new obturation technique, EZ-Fill epoxy resin root canal
cement and bi-directional spiral system from Essential Dental
Systems (S. Hackensack N.J.) has been developed. This
technique achieves the desired results in a predictable easy
fashion. The aim of this study is to evaluate completed EZFill endodontic cases for a successful outcome over a sixmonth to two-year time period.
Materials and Methods
FIGURE 2B: Root canal

retreated and refilled using
EZ-Fill obturation
technique.
Figure 2C
FIGURE 2C: Two-year

recall showing complete
healing.
Figure 3A
FIGURE 3A: Typical vital

case at completion. No
periapical pathology.
Figure 3B
FIGURE 3B: Six-month

recall showed no
pathology developed,
healed and asymptomatic.
HE TEST SAMPLE consisted of 145 patients seen in a

private endodontic practice in New York, New York.
Non-surgical root canal therapy was performed on 153 teeth
in one or more visits during the time period from 1/1/97 to
12/31/97 by three endodontic practitioners. Each endodontic
Figure 4A
specialist had more than twenty years of experience in a
very New York City endodontic practice.
The following patient factors were also collected: age; sex;
whether or not the tooth was vital; if non-vital, whether there
was PAR (periapical area of radiolucency); number of visits
to complete treatment (1, 2, or more); radiographic findings;
type of failure; fracture status; extraction status.
The instrumentation technique for the endodontic
FIGURE 4A: Typical
procedure was the same in all teeth studied. All teeth were
treated with a rubber dam in place using an aseptic technique.
Access was achieved and the working length was determined
using the Endex apex locator (Osada, Los Angeles, CA)
During instrumentation the canals were irrigated frequently
with 2.5 percent sodium hypochlorite. The apex was
instrumented to a size #20 stainless steel .02 tapered
instrument. Next the canal was widened with a number 2
Peeso reamer, no closer than 3 mm from the apex. Thereafter
the step-back technique was used to taper the canal. A size
#25 stainless steel Flexo-reamer (Dentsply/Maillefer, Tulsa
OK) was used 1 mm short of the apex. Then a size #30
stainless steel flexoreamer was used 2 mm short of the apex.
Next a size #35 stainless steel flexoreamer was used 3 mm
short of the apex. Then a size #40 stainless steel flexoreamer
was used 4 mm short of the apex and finally a size #45
stainless steel flexoreamer was used 5 mm short of the apex.
Once the canal had been grossly prepared, either an .06 or
.08 nickel titanium file of greater taper (Dentsply, Tulsa OK)
was used to give the final shape to the canal. This sequence
of instrumentation is known as the Simplified Endodontic
Technique or S.E.T. 9-11 The canal was then filled with
either a fine-medium or medium gutta-percha point.
The canal was obturated using the EZ-Fill system, which
consists of a bi-directional spiral paste filler and epoxy root
canal cement. The cement is an epoxy resin based cement
like AH-26 but much more radiopaque. It is also very
biocompatible.9-11 The bi-directional spiral of this system
ensures that the canal walls are covered with cement and that
there is no or minimal cement past the apex. This controlled
coverage is achieved because the spirals at the coronal end of
the instrument spin the cement down the shaft toward the
apex while the spirals at the apical end spin the cement
upward toward the coronal end. Where they meet (about 3-4
mm from the apical end of the shaft), the cement is thrown
out laterally (Figure 1). A prefitted single gutta-percha point
was placed to the apex. The tapered shape of the canal lets
the excess cement escape coronally. The cement in the canal
seals the apex and all lateral and accessory canals. 12 The
excess gutta-percha was seared off, and the access cavity was
sealed with either glass ionomer cement or zinc phosphate
cement.
At the end of the appointment, the patient was given both
the cardiac dosage of antibiotic and 600 mg of ibuprofen for
pain management. The patient was then instructed to return
to his or her general dentist, who would restore the tooth.
completion x-ray of a onevisit vital case using the

EZ-Fill obturation
technique.
Figure 4B
FIGURE 4B: Nine-month

recall x-ray showing intact
lamina dura and healing.
Figure 4C
FIGURE 4C: Two-year

recall x-ray showing
normal bone anatomy
being maintained.
Figure 5A
FIGURE 5A: Tooth

number 15 showing
excess EZ-Fill epoxy resin
cement past the apex of
the palatal canal.
Figure 5B
Clinical and Radiographic Examination

RECALL CARDS were sent and telephone reminders were
made to 363 patients. We were able to recall and evaluate
153 treatments in this study.
At the recall examination, from six to twenty-four months
after treatment, we recorded pain; tenderness to percussion,

palpation, or both; fistula development; and swelling.
Radiographic examination, using the long cone technique
with a Siemens Heliodent x-ray unit, was carried out using
an x-ray film positioning device by Rinn (Rinn Corp., Elgin
IL).
Success was defined as:
On radiograph a preexisting lesion had gotten smaller or
healed completely.
On radiograph no new lesion had formed where there was
no lesion before.
The patient upon questioning at the recall examination was
asymptomatic.
The patient was functioning well with the tooth.
All radiographs were examined by a single endodontist, and
patients were clinically examined at recall by the endodontist
who did the treatment.
FIGURE 5B: Two-year

recall x-ray showing
complete resorption of
cement and healing.
Statistical Methods
THE FISHER EXACT TEST was used to determine whether
outcome (success, non-success), was associated with sex,
number of visits, vital status, and, among non-vital teeth,
presence of PAR. Due to the small number of unsuccessful
outcomes, a multivariate analysis could not be carried out.
Results
RECALL CARDS were sent and telephone reminders were
made to 363 patients. We were able to recall and evaluate
153 treatments in this study. This was a recall rate of 42
percent.
Baseline Characteristics
MEAN AGE of the patients was 53 and ranged from 20 to
85. There were 61 percent females and 39 percent males in
the study. There were 57.2 percent vital teeth and 42.8
percent nonvital teeth in the study. Of the non-vital teeth, 66
percent did not have a PAR and 34 percent did have PAR.
Outcomes
THE OVERALL TREATMENT estimated success rate was
94.1 percent. This was found at the exact 95 percent
confidence interval: 89.1 percent to 97.2 percent. There was
a frequency of 9 unsuccessful and 144 successful endodontic
treatments.
There was strongly no significant association between
success rate and each of the following variables:
number of visits
vitality
P = 0.442
P = 0.757
sex
P = 0.707
Therefore there was a 94.1 percent success rate regardless of

whether treatment took one or more visits, whether the tooth
was vital or nonvital, and whether the patient was male or
female.
Discussion
IT WAS STRONGLY FELT that clinical success was an
important aspect of a successful outcome. Success rates
reported over the last twenty years have ranged from 78
percent to 95 percent. Our result of 94.1 percent success fits
well within this range. Differences in the definition of
success most probably would alter the overall result of each
study. However, it is difficult to determine by how much
each studys results would change. Our feeling is that
individual studies may change slightly, but the overall range
would most likely be the same due to other variables. These
other variables include the skill of operators, who and how
many people review the x-rays and cases, the techniques
used, the materials used, and the time frame of the recall
exam.
In this study, three endodontists who each have more than
twenty years of experience in private practice treated all the
patients. This high level of clinical experience could
possibly be one reason the success rate was on the high end
of the scale. In a study by Sjogren et al., undergraduates at
the University of Umea did the endodontic therapy and had a
91 percent success rate. 13 We used one endodontist to read
the x-rays and evaluate the patients clinically. This helped
reduce the variable of different opinions by different
evaluators as described in the articles by Goldman and
Seltzer. 14,15
The authors tried to eliminate the variables of technique
and materials in this study by using the same instrumentation
technique and materials for each patient. We followed the
S.E.T. technique for instrumentation and used the EZ-Fill
epoxy resin root canal cement and bi-directional spiral
obturation technique with a single gutta-percha point.
Friedman et al. reported on a clinical study to assess the
treatment results following endodontic therapy using a glass
ionomer cement sealer (Ketac-Endo, ESPE Gmbh, Seefeld,
Germany).16 They found a 78.3 percent success rate and
concluded that their results were compatible with those found
in the literature and that this supports the clinical use of
Ketac-Endo as an acceptable endodontic sealer.
In this study, EZ-Fill epoxy resin root canal cement (a
derivative of AH 26 root canal cement) was used; Figure 5B
illustrates complete resorption of excess cement after a twoyear recall.
The recall time frame shows the majority of patients at six
months, with the next highest groups at one-year and twofile:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd08onevisit.html[2/21/2011 10:25:06 ]
year recalls.
We were able to recall and evaluate 153 treatments out of
363 in this study. This was a recall rate of 42 percent. This
correlates well with a mean recall rate of 43 percent for other
studies as reported by Pekruhn. 3
In agreement with other studies, there was strongly no
significant association between success rate and:
the number of visits
vitality
patient sex
Whether the tooth was treated in one visit or in more than
one visit did not affect the success rate. Teeth treated in one
visit were equally as successful as teeth treated in more than
one visit. Whether the tooth was vital or nonvital did not
affect the success rate, and whether the patient was male or
female did not affect the success rate in this study.
Interestingly, in a study by Vire of 116 extracted
endodontically treated teeth, failure that led to extraction of
these teeth occurred due to endodontic causes in only 8.6
percent of the population. 17
Conclusions
A SUCCESS RATE of 94.1 percent was found for this study
using the EZ-Fill bi-directional spiral and epoxy resin root
canal cement to obturate the canals. This correlates very well
with reported success rates of between 78 percent and 95
percent in other studies.
There was no significant association between success rate
and each of the following variables: number of visits, sex,
and vitality. These results support the clinical use of the EZFill obturation system as an acceptable endodontic technique
and sealer.
References
1. Orstavik D, Kerekes K, Eriksen HM. Clinical
performance of three endodontic sealers. Endod Dent
Traumatol 1987; 3:178-86.
2. Pekruhn, RB. The Incidence of Failure Following
Single-visit Endodontic Therapy. J Endodon 1986;
12:68-72.
3. Friedman S. Success and Failure of Initial Endodontic
Therapy. Ontario Dentist 1997; 74:35-38.
4. Weiger R, Axmann-Kremar D, Lost C. Prognosis of
conventional root canal treatment reconsidered. Endod
Dent Traumatol 1998; 14:1-9.
5. Hepworth M, Friedman S. Treatment Outcome of
Surgical and Non-Surgical Management of Endodontic
Failures. Journal of the Canadian Dental Association
1997; 63:364-371.
6. Soltanoff W. A Comparative Study of the Single-Visit
and the Multiple-Visit Endodontic Procedure. J
Endodon 1978; 4:278-281.

7. Oliet S, Single-visit Endodontics: A Clinical Study. J
Endodon 1983; 9:147-152.
8. Jurcak JJ, Bellizzi R, Loushine R. Successful SingleVisit Endodontics During Operation Desert Shield. J
Endodon 1993; 19:412-413.
9. Musikant BL, Cohen BI, Deutsch AS. Rethinking
endodontics: Attaining total obturation of the root canal
system with a simplified system. General Dentistry
1999; Jan-Feb: 73-82.
10. Seidman D. A General Dentists Viewpoint of Two
New Endodontic Techniques. Compendium 1999; 20:
921-932.
11. Musikant BL, Cohen BI, Deutsch AS. Report of a
Simplified Endodontic Technique. Compendium 1999;
20: 1088-1094.
12. Cohen BI, Pagnillo MK, Musikant BL, Deutsch AS.
The evaluation of apical leakage for three endodontic
fill systems. General Dentistry,1998; Nov/Dec:618623.
13. Sjogren U, Hagglund B, Sundqvist G, and Wing K.
Factors Affecting the Long-term Results of Endodontic
Treatment. J Endodon 1990; 16:498-504.
14. Goldman M, Pearson AH, Darzenta N. Endodontic
success: whos reading the radiograph? Oral Surg
1972; 33:432-7.
15. Seltzer S, Bender IB, Smith J, Freidman I, Nazimov H.
Endodontic failures-an analysis based on clinical,
roentgenographic, and histologic findings. Part II. Oral
Surg 1967; 23:517-30.
16. Friedman S, Lost C, Zarrabian M, Trope M. Evaluation
of Success and Failure after Endodontic Therapy Using
a Glass Ionomer Cement Sealer. J Endodon 1995;
21:384-390.
17. Vire DE. Failure of Endodontically Treated Teeth:
Classification and Evaluation. J Endodon 1991;
17:338-342.
July-August 2001
FEEDBACK?
Fitting the Gutta-Percha Point
Allan Deutsch
Figure 1
HE ENTIRE endodontic procedure, from diagnosis
through instrumentation, can be said to be just a
prelude to the fill. The filling of the canal with guttapercha visually displays to everyone all your preceding
efforts and work that have led to this last step in completion
of the root canal therapy. The most important part of this last
step is the fitting of the gutta-percha point. The point must
FIGURE 1: Tapered guttafit well enough so that you know with the utmost
percha points.
predictability what the final result will look like, even before
you complete the procedure. If the preceding instrumentation
has been done well the point will be very easy to fit and the
result will be predictably excellent. So, exactly what do we
do in fitting the point?
Figure 2
Constant modification of our instrumentation over the
years has led us to the EZ-Fill SafeSider technique. This
sequence of instrumentation allows us to fill the canal with
gutta-percha easily, effectively, and quickly. The key to the
fill is to make sure that the last two nickel-titanium
instruments, the orange 30/.04 and the brown 25/.08, go to
the apex easily with no binding. Once this is accomplished,
we can fit the gutta-percha point and fill the canal.
I use the tapered gutta-percha points (Figure 1). The
25/.08 prepares the canal to a .08 taper. Therefore, I use a
.06 tapered gutta-percha point. Each manufacturers point
varies slightly from the others, but most of the .06 tapered
points are very close to specifications. I use either a 25/.06
or a 30/.06 gutta-percha point. I select the point depending
on how easy it was to instrument to the apex with the 30/.04.
This instrument opens the apex to a #30.
FIGURE 2: Gutta-percha
I now take a gutta-percha point out of the box and place it
point fitted in the canal.
in the canal. I use a locking forceps and grasp and lock the
point at my reference mark. I remove the point and measure
it on a finger ruler. Lets assume for demonstration purposes
that the working length of the canal is 20 mm. When I
measure the point, it will either be right on the mark, long, or
short of the measurement. If it measures 20 mm (about 80
percent of the time) you are now ready to fill (Figure 2). If it
is long (usually by about 1 mm), just take a pair of scissors
and cut off the extra mm. Replace the point in the canal, lock
it at the reference point, and measure it again. Usually it will
now fit. If it does not, just repeat the cut step.
If it is short by 1 to 2 mm, you have a little work to do.
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd09fittingpoint.html[2/21/2011 10:25:07 ]
There is an area in the canal that is a little difficult to clean.

It is located about 5 to 8 mm from the apex. With our
technique, you have instrumented 4 mm short of the apex to a
40 and you have gone down as far as you can go with the #2
Peeso. This sometimes leaves a no mans land in that 5 to 8
mm zone from the apex. This is usually where the guttapercha point is binding. There are two ways to handle this :
Select a different gutta-percha point. They are not all
exactly alike and one point may be more or less
tapered than another.
Reinstrument this 5 to 8 mm area.
You can reinstrument by :
1. going deeper with the #2 Peeso if possible
2. going 5 mm short of the apex with a #45 stainless
instrument then
instrument then
instrument then
5. going back to the apex with the 25/.08.
Once the no mans land is reinstrumented, a new guttapercha point should fit to the measurement.
Now that you have fitted the gutta-percha point to the
canal, you are ready to place cement into the canal and
permanently seal the root-canal system.
FEEDBACK?
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd09fittingpoint.html[2/21/2011 10:25:07 ]
Bead Sterilizers: An Endangered Species?
Allan Deutsch
HERE IS A PROBLEM looming on the horizon. That Figure 1

problem is, How will we sterilize our endodontic
reamers and files? You may answer, Thats no problem.
Ill use my bead sterilizer. (See Figures 1 and 2.) Herein
lies the problem. Thanks to the local manicure salon, the
FDA has stopped the sale of new bead sterilizers by the
manufacturers. These nail salons were and are using bead
sterilizers to sterilize large hand instruments. These
instruments include nail scissors and cuticle cutters.
Unfortunately, the beads did not do a great job on those
instruments, and many customers had their nail beds infected
by bacteria or fungus. Certainly, this was and is a problem.
The FDA received enough complaints to warrant an
FIGURE 1: One type of
investigation. They determined that if a manufacturer wanted
bead sterilizer.
to make and sell bead sterilizers they would now have to file
for a PMA (Pre-Market Approval) with the FDA. This
requires rather large sums of money for testing. Many
manufacturers logically decided that the expense was not
worth it for a $100 device. Therefore, the manufacturers of
Figure 2
bead sterilizers are no longer making these sterilizers for
dental or nail use.
So, what can you do? The problem isnt a crisis yet. We
still have a few years supply of bead sterilizers left. If you
are worried, try to stock up on as many old units as you can.
However, good luck, because there do not seem to be many
around. And when our sterilizers burn out, what are our
options?
We could pre-package setups of sizes 08 through 25/08
FIGURE 2: Another type of
SafeSiders, in foam sponges in sterilizer bags. Along
bead sterilizer.
with the assorted sizes, we would need separate bags of
perhaps three or four of one size of the smaller-sized
instruments, in case they bend or become distorted.
We could use covered metal sterilizer organizers.
These are filled with assorted instruments, the cover is
closed, and then the organizer is bagged. When the
bag is opened after sterilization, the box and its
contents are sterile. When you remove the cover and
turn it over, it can be used as a sterile tray when placed
on the bracket table. I used this type of setup when I
first started to practice. It takes some getting used to.
The problem here is that unused instruments are exposed to
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd10beadsterilizers.html[2/21/2011 10:25:07 ]
repeated sterilization cycles. This tends to heat-harden the

instruments and in many cases may make them more brittle.
It seems to me that we will be going through a lot more
instruments per case.
All in all this is a problem that will not go away and is
getting worse. What will the manufacturers come up with to
help us out?
If you have any ideas, please contribute them to our EndoMail Forum.
The most common source of post-operative pain after
endodontic treatment is pressure brought on by hyperocclusion. Before releasing your patient, be sure to check the
bite with the patient in a reclined and upright position and
relieve any high spots. If the tooth is going to be restored with
full coverage, you can even take the tooth totally out of
occlusion.
FEEDBACK?
We welcome your
responses and questions.
the Endo Forum and
add your comments
in Endo-Mail.
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd10beadsterilizers.html[2/21/2011 10:25:07 ]
Apex Locators: A Mechanical Method of Controlling Post-Operative Pain
Apex Locators:
A Mechanical Method of Controlling Post-Operative

Pain
Allan Deutsch
OR MANY YEARS, I thought the definition of

endodontic esthetics was the filling of the root canal to
the radiographic apex. Little did I realize that I was creating
unneeded post-operative pain and possibly setting up a
chronic inflammatory response, which might lessen the
chances of a successful endodontic treatment for my patients.
The inflammatory response triggers the type of pain that
occurs immediately after the anesthetic wears off. This pain
is characterized by a sharp intense quality with throbbing in
the affected area. Where was I going wrong?
The endodontic literature during the 1990s reported that
the anatomic apex is often (at least 50 percent of the time) 0.5
to 1.0 mm short of the radiographic apex. The anatomic apex
is usually defined as the apical constriction in the canal at the
cemento-dentinal junction. If the canal is instrumented and
filled to this level, the instrumentation and filling material
will not impinge on the periodontal ligament or the alveolar
bone.
The problem was that I was instrumenting and filling to the
radiographic apex (Figure 1). Consequently, I was
instrumenting at least 50% of the time from 0.5 to 1.0 mm
past the apex and into the ligament and bone. For thirty to
forty-five minutes, I was using my reamers to poke tiny holes
and rip the periodontal ligament. The result of this was nasty
pain as soon as the anesthesia wore off.
Using an apex locator will enable you to determine
accurately where the anatomic apex is located. An x-ray will
not permit you to locate the anatomic apex. We do not
routinely take working-length x-rays any longer. Because we
are no longer instrumenting to the radiographic apex but
rather to the anatomic apex, the amount of post-operative
pain has been substantially reduced.
Now that we are filling to the anatomic apex, we are
experiencing an increase in success rate. Figure 2 shows a
gutta-percha filling pushing through the anatomic apex,
which is approximately 2.00 mm short of the radiographic
apex. We recently published our office success rate in a
study in the June 2001 issue of Practical Endodontics. In the
article we reported a 94.1 percent success rate. This is at the
Figure 1
FIGURE 1: Endodontic
instrument past the
anatomic apex going to the
radiographic apex. (Ouch!)
Figure 2
FIGURE 2: The guttapercha point is fitted to the

radiographic apex and
consequently it is 1 mm
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd11apexlocators.html[2/21/2011 10:25:08 ]
Apex Locators: A Mechanical Method of Controlling Post-Operative Pain
very high end of the reported literature. You never get 100
percent success because cases fail due to root fracture and
inadequate or failing restorations.
Figure 3 is a radiograph of a tooth that is rotated, showing
the bucco-lingual view. You can see that the anatomic apex
is at least 1 mm short of the radiographic apex. Figure 4
shows a dot of gutta percha at the apical end of the palatal
canal. This dot is approximately 1 mm short of the
radiographic apex. The dot tells us that the canal is curved at
a 90-degree angle facing the buccal, so in actuality you are
looking at the end of the gutta percha facing directly buccal.
If you tried to reach the radiographic apex, you would have to
perforate the root and come out the top.
Figure 3
long.
Figure 4
FIGURE 4: The palatal canal is

curved at a 90 degree angle to the
buccal. The end of the gutta percha is
seen as a dot.
FIGURE 3: The anatomic

apex is at least 1 mm
short of the radiographic
apex.
The moral of this article is: if you do more than 3 or 4 root

canals per week, go buy an apex locator. I recommend at
least a third-generation locator, Endex by Osada, Root ZX by
Morita, or the locator made by Analytic Technologies.
Happy measuring.
FEEDBACK?
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd11apexlocators.html[2/21/2011 10:25:08 ]
Which Burs to Use for Endo?
Allan Deutsch
lthough completing a molar endo may take up to one

hour, the time I actually spend drilling on the tooth is
relatively short. Out of that one hour I may only take
five to eight minutes drilling with my high-speed burs.
However, like many other preliminary procedures those
initial minutes are exceedingly important to setting up the
final result.
What do we want to accomplish when using our highspeed handpiece?
Figure 1
1. We want to gain access to the pulp chamber (without

perforating the chamber floor).
2. This access will enable us to find all the canals (even
the ones that are hiding!)
3. We want to have straight line access so that we can use FIGURE 1: The ceiling of
the pulp chamber
our Peeso or gates to its full extent without having it
measured
from an occlusal
break.
cusp
corresponds
to length
4. We want to reduce the occlusion somewhat to avoid
L
of
the
bur.
post-operative biting trauma and inflammation.
In golf, a good grip enables a good swing, which gives us
a good game (we hope). In endo, finding the chamber
enables us to find the canals, which enables us to complete
Figure 2
the root canal therapy. To this end I use two burs. These
burs accomplish 95 percent of my drilling.
The first is a high-speed carbide number 4 round bur.
With this bur, I outline the chamber occlusally and remove
enough dentin until I am in the pulp chamber. This bur can
actually help you avoid perforations. Figure 1 shows the
critical measurements on the bur. It turns out that the ceiling
of the pulp chamber measured from an occlusal cusp
corresponds to length L of the bur. When you hold the bur
up over an accurate x ray you can see that when the ball is
FIGURE 2: The end of the
placed on the chamber ceiling the end of the taper of the
taper of the shaft
shaft corresponds to the cusp tip (see Figure 2). I now for the
corresponds to the cusp
first time have a measurement guide as to how far down I am
tip.
to drill into the tooth with my #4 round bur.
When I look at the diagnostic x ray, one of things that I am
looking at is the occlusal gingival height of the pulp
chamber. If the chamber is calcified, and therefore very
narrow, I know I will not feel a drop when my bur reaches
the chamber. I therefore drill down to the line on the bur
where the taper and parallel parts of the shaft meet and stop
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd12whichburs.html[2/21/2011 10:25:08 ]
when this line is level with the cusp tip. I now know I am a
little below the ceiling of the pulp chamber. This has given
me the depth and a very rough outline of the chamber, I must
now refine this preparation.
I refine the preparation with the use of a high-speed coarse
barrel diamond (Figure 3). I lean the diamond against the
axial wall and go around the outline of the prep (Figure 4).
Figure 3
Figure 4
FIGURE 3: a high-speed coarse FIGURE 4: smoothing the wall

barrel diamond used to refine the
and allowing light into the
preparation.
chamber.
This smooths the wall and allows a great deal of light into the
chamber. I next rinse the pulp chamber with Sodium
Hypochlorite. I remove the irrigant with a high-speed endo
suction tip. I can now easily see whether I have removed the
entire ceiling of the pulp chamber. Now I first start looking
for the canals. I also use this barrel diamond later to reduce
the occlusion to avoid post-op pain due to prolongation of
inflammation due to a high bite. The barrel diamond is also
used to push back the mesio-palatal axial wall in maxillary
molars. Along this mesio-palatal line in about 4060 percent
of the cases there is an extra canal. This canal is called the
MB2 or mesiobuccal prime canal. It is responsible for a lot
of molar endo failures if it is missed and not cleaned out.
Simplifying your armamentarium down to two burs will
speed up and simplify your endodontics.
May-June 2002
Endo Tip
Would you like to learn an easy, thorough,

and economical technique for obturating
canals?
Take our free hands-on endo course.
Click here for details.

FEEDBACK?
Relief of Dermal Sensitivity Caused by Latex Gloves
Allan Deutsch
INCE THE ADVENT of universal precautions

against infection has led to the routine wearing
of latex operating gloves, concern regarding
hypersensitivity reactions to these gloves has been
increasing. This concern can be seen in the
numerous articles now being published on this
topic. In November 1994, Gordon Christensens
CRA newsletter reported on a survey of dermal
sensitivity. Twelve percent of 28,858 respondents
reported experiencing some type of reaction to
various types of operating gloves. Latex gloves
were by far the most common cause of problems,
but vinyl and nitrile rubber also caused some
problems. The most common reactions were
Figure 1
FIGURE 1: Cracking of the skin due

to dryness.
itching, redness on the contact area, or both

dry skin on the contact area
cracking skin on the contact area
What Causes Dry Skin?

IN HIS CLASSIC STUDY, Blank showed that lack
of water, not lack of oil, was the primary cause of
dry skin, proving that the softness and flexibility of
the stratum corneum was a direct function of the
moisture in it. Blank concluded that cornified
epithelium required 10 percent to 20 percent water
content to feel and look normal, since water was
the most effective plasticizer for cornified tissue.
Blank emphasized that neither an externally applied
oil, nor the natural oils, can keep the stratum
flexible without the aid of water.
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd13dermalrelief.html[2/21/2011 10:25:09 ]
Figure 2
FIGURE 2: Layers of the epithelium.
Flesch in a discussion of the chemical basis of

emollient in the horny layers, found evidence that
the skin contains hydrophilic nitrogenous substances
as well as other hydrophilic substances, which
enhance the ability of the skin to hold water. When
these substances are extracted from the skin, its
ability to hold moisture is greatly diminished. In
addition, in various skin conditions associated with
scaling, the scales appear to have lesser amounts of
these substances as well as a low capacity to bind
moisture.
Figure 3
FIGURE 3: Structure of the skin.
Recent work has brought to light a number of

interesting facts concerning hydration of the stratum
corneum. For example, it has been found that the
stratum corneum contains water-soluble compounds
responsible for the wetability, water-holding, and
water-absorbing capacities of this tissue, which are
called collectively the natural moisturizing factor
of the skin, or NMF. Thus, the stratum corneum
contains 58 percent keratin, 11 percent lipid, and 30
percent water-soluble NMF. Table 1 gives the
chemical composition of NMF.
The presence of NMF in the stratum corneum
Table 1
serves a triple purpose:

1. It picks up moisture through its hygroscopic
properties.
2. It lowers the surface tension of the skin
surface, overcoming the normal water
repellency of the keratin.
3. It will absorb liquid water present on the skin
surface from perspiration or from outside
sources.
We can conclude that NMF regulates the water
content of the stratum corneum.
Striase concludes, from all of the data disclosed, that
an occlusive agent alone would not perform as the
ideal moisturizer, nor would a hygroscopic
moisturizer alone act as the ideal moisturizer.
However, a proper balance of the two might achieve
the desired result. Thus the ideal moisturizer
should have the following properties:
It must regulate and maintain the water
content of the stratum corneum, but not to
such a degree as to induce superhydration.
Its effectiveness should be independent of
environmental changes.
Its continued application must not cause
damage to the stratum corneum by the
removal of or interference with the natural
moisturizers present therein.
It must be nonirritating and nonsensitizing.
It must be stable in cosmetic formulations.
It must be economical and readily available.
At present, it is not certain which of the various
components of MNF plays the most significant
role. In the past, urea was apparently considered
important, resulting in a plethora of dry skin
remedies containing urea.
Using in vitro experiments, Hellgren and Larson
concluded that:
The long-term use of urea-containing

dermatologic preparations may reduce and
damage the horny layer of the skin.
Sodium chloride does not damage the skin.
Sodium chloride has twice the water-binding
capacity of urea and thus should be
considered a superior moisturizing agent.
It has long been known that the presence of
sodium chloride in water tends to retard its
vaporization. The use of sodium chloride
by Ljungstrom in 1941 predates the employment of
urea for dry skin and ichthyosis by Rattner in 1943.
Ljungstrom achieved good results in a patient with
ichthyosis using baths containing 3 percent salt
water, followed by inunction of 10 percent sodium
chloride in lanolin.
Gordon, employing Ljungstroms regimen in one
case of ichthyosis vulgaris and in another of
ichthyosis hystrix, reported that both responded
dramatically. He claimed that the patient with
ichthyosis hystrix, who looked like a porcupine
man, was rehumanized.
Despite such glowing reports, sodium chloride
ointments were not employed extensively because
patients were reluctant to consent to the use of the
thick, greasy ointments then available.
Dead Sea Salt Cream for Dry Skin

(Gloven Care)
BECAUSE topical preparations containing urea
were not particularly effective in some patients with
dry skin and also sometimes caused stinging,
burning sensations, we undertook an investigation of
the use of creams containing sodium chloride,
which have been shown to be more effective and
less irritating than creams containing urea.
Without understanding the exact physiology of
healing, we do know that the Ancients discovered
the beneficial effects of the waters of the Dead Sea
more than four thousand years ago. These benefits
included a therapeutic improvement in such skin
disorders as psoriasis and eczema as well as an
enhancement of normal skin. The Dead Sea was
actually the site of a major cosmetic industry in
Ancient times. Queen Cleopatra enjoyed the
benefits of Dead Sea cosmetics so much that she
persuaded Mark Antony to establish control over
portions of the sea and then give them to her as a
gift.
Because Europe was the focal point of western
culture, the Dead Sea remained for a long period
obscure and almost unknown in the backwaters of a
provincial people. It was not until the formation of

the modern state of Israel that the waters of the
Dead Sea became recognized worldwide for their
therapeutic value. Today more than 600,000 tourists
travel to the Dead Sea annually. In fact, for those
traveling from Northern Europe, a trip to the Dead
Sea is a recognized medical expense.
Goldberg and Sagher state that the Dead Sea has no
drainage and therefore contains a very high
concentration (up to 30 percent) of minerals,
including sodium, potassium, magnesium, calcium
(and halogens), chlorine, bromine, and others.
At the suggestion of Essential Dental Systems, a
processed and purified concentrate of Dead Sea
water (5 percent) was incorporated into a waterbased emulsion. The emulsion was water-based so
that it would not compromise the integrity of the
latex glove or interfere with adhesive dentistry. It is
of interest that Gloven Care hand cream contains
all of the minerals present in NMF (see Table 1).
From theoretical and practical viewpoints,
Gloven Care hand cream has many of the virtues
that Striase enumerated as the properties of an ideal
moisturizer:
It contains an effective hygroscopic
moisturizer: water of high saline content.
It does not cause burning, stinging, or other
unpleasant sensations and is well tolerated on
the lips and skin.
It is nonsensitizing and nonirritating and does
no damage to the stratum corneum, even after
repeated applications.
By hydrating the stratum corneum, it quite
effectively relieves the scaliness, dryness, and
pruritus associated with dry skin, with
resultant softening and increased pliability of
the skin.
It is stable chemically and physically for long
periods of time, requires no preservatives, and
is free of perfume, thus lessening the
possibility of allergic contact dermatitis from
such added ingredients.
It is inexpensive.
It seems to prove that the dermatologists of
the good old days were correct when they
claimed that sodium chloride is an excellent
moisturizer.
It contains the electrolytes present in NMFsodium, chloride, calcium, potassium and
magnesium.
It contains a high concentration of sodium,
which possibly enhances the moisturizing
effect of PCA in NMF, since it is sodium
PCA, not PCA alone that is hygroscopic.
References
1. Blank JH: Factors which influence the water
content of the skin. J Invest Dermatol 18:
433, 1952 [BACK]
2. Flesch P: Chemical basis of emollient
function in horny layers. Proc Sci Sect TGA
40: 12, 1963 [BACK]
3. Flesch P, Jackson-Esoda EC: Deficient
water-binding in pathologic horny layers. J
Invest Dermatol 28: 5, 1957 [BACK]
4. Striase S J: The search for the ideal
moisturizer. Cosmet Perfum 89: 57, 1974
[BACK]
5. Hellgren L, Larson K : On the effect of urea

on human epidermis. Dermatologica 149: 289,
1974 [BACK]
6. Ljungstrom C E: A simple and effective
treatment of ichthyosis. Acta Med Scand 108:
98, 1941 [BACK]
7. Gordon H: Treatment of ichthyosis. Arch
Dermatol 52: 178, 1945 [BACK]
8. Goldberg L H, Sagher F: Psoriasis treatment
at the Dead Sea. Cutis 16: 61 1975 [BACK]
Endo Tip
Do not use Septocaine on

patients who are allergic to
sulfur medication. The sulfur
compound from the
preservative in Septocaine is
different from the sulfur compound in other
anaesthetic solutions.
Septocaine contains sodium metabisulfite, a
sulfite that may cause allergic reactions
including asthmatic episodes in susceptible
people.
FEEDBACK?

Replacement Insert Makes Denture and Post Connection Easier
Replacement Insert Makes Denture and Post

Connection Easier
Allan Deutsch
Figure 2
FIGURE 2: Prepare the

initial post hole with Gates
Glidden reamers.
OR MANY RESTORATIONS in dentistry, what fits Figure 1

so well initially may, depending on a patients
occlusion, deteriorate over time. The weak point in all
overdenture systems is the connection between the
denture and the post. It wears out and must be
replaced. The Flexi-Overdenture System from
Essential Dental Systems is no different. However, an
addition to the system, the EZ-Change Keeper and Cap
Insert (Figure 1), allows for replacement in less than one
minute.
Following is the placement procedure for the post,
keeper, and cap insert:
1. Prepare the initial post hole with Gates Glidden
reamers (Figure 2).
2. Size the post hole with the primary reamer of
choice. Note that you can eyeball the choice by
placing either a post or a template over an
undistorted X-ray. The minimum requirement for
FIGURE 1: The EZplacement is 1 mm of lateral tooth structure at the
Change Keeper and Cap
most apical placement of the post within the root
Insert.
(Figure 3).
3. After you have created the primary post hole, use
Figure 3
the countersink/root facer to form the final posthole shape (Figure 4). Because the
countersink/root facer is not self-limiting, you can
drill the dual preparation (preparation for the flange
and second tier of the Flexi-Overdenture post)
fairly deeply into the root. Drilling deeply has the
major advantage of shortening the lever arm of the
attachment to a bare minimum. The shorter the
lever arm, the less the forces of occlusion are
magnified. Having a short lever arm may become
particularly important if the abutment root is
periodontally compromised.
4. Assuming that the primary reamer went the full
length, make a trial seating of the post to its full
depth (Figure 5).
5. If the post hole is prepared short of its full length,
the post will not completely seat. To ensure seating
file:///D|/.../DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd14replacementinsert.html[2/21/2011 10:25:09 ]
Figure 4
6.
FIGURE 4: Use the

countersink/root facer to
form the final post-hole
shape.
Figure 6
FIGURE 6: Shorten the

post apically enough to
allow for full insertion plus
an additional 1 mm.
7.
8.
9.
10.
11.
of the posts flange, shorten the post apically

enough to allow for full insertion plus an additional FIGURE 3: Size the post
hole with the primary
1 mm to make sure that the blunt apical end of the
reamer of choice.
post does not impinge on the tapered end of the
post-hole preparation (Figure 6).
Figure 5
Before cementing the post, place an assembled EZChange keeper and cap insert onto the ball of the
attachment (Figure 7). Place marking paste onto
the keeper and place the denture over it. Remove
the denture and see where the marks are impinging
the denture (Figure 8). If the keeper impinges to
the point where the denture must be perforated for
the keepers clearance or the keeper impinges in an
aesthetically compromising fashion, you may
deepen the preparation into the root with the
countersink/root facer to gain an extra millimeter or
two.
After you have established clearance, place FlexiFlow Cement with Titanium into the canal with a
lentulo spiral reamer. Place about three increments
of cement with an up-and-down motion; this
technique will ensure complete coating of the canal
FIGURE 5: Make a trial
walls. In addition, coat the shank of the post. The
seating
of the post to its
cement acts as a lubricant, further easing the
full
depth.
insertion of the post (Figure 9).
Before cold-curing the keeper into the denture,
make sure that the rubber band covering the
undercut of the ball attachment is in place. Place
pink acrylic into the denture and seat the denture
for about five minutes or until the acrylic sets.
Remove the denture and relieve the excess acrylic
around the keeper (Figure 10). You can now safely
remove the denture from the undercut of the ball
attachment. With this system you may never need
to cold-cure any worn-out attachments again.
Place the denture in the patients mouth. The
relationship should be the same as before cold
curing the keeper into the denture.
If at some point the cap insert wears out, take the
two-pronged wrench provided in the kit and place it
in the holes inside the cap insert and rotate out the
old cap with a counterclockwise motion (Figure
11). At times the cap insert may wear out in such a
way that the internal prong holes wear away. If this
is the case, heat the wrench in a flame until the
prongs are red and then insert the wrench anywhere
into the nylon cap insert. Wait several seconds

while the melted nylon solidifies around the prongs
and again rotate counterclockwise for removal.
12. To place a cap insert (figure 12) , place the prongs
of the wrench into the holes inside the insert, line
up the thread of the insert with that of the keeper
and rotate in with a clockwise motion. You will
feel a tactile click when the cap is fully inserted.
Replacement is complete within about 30 seconds
chair time and there is no need for cold curing.
13. Reseat the denture. It should fit as before without
any change in alignment.
Figure 7
Figure 8
Figure 9
FIGURE 8: Remove the

denture and see where the
marks are impinging the
denture.
FIGURE 9: Place cement
FIGURE 7: Before cementing the
into the canal, coat the
post, place an assembled EZshank of the post, and
Change keeper and cap insert onto
insert the post.
the ball of the attachment.
Figure 11
Figure 10
FIGURE 10: Remove the

denture and relieve the
excess acrylic around the
keeper.
Figure 12
FIGURE 11: Use the two-pronged

wrench to rotate out the old cap.
FIGURE 12: To place a cap insert, rotate in with a
clockwise motion.
FEEDBACK?
Restoring a Tooth with Little or No Coronal Dentin

Figure 1
HE FLEXI-FLANGE patented split-shank threaded
post system provides maximum retention and minimum
insertional and functional stress in cases with little or no
coronal dentin. Following are step-by-step instructions for
restoring a tooth with little or no coronal dentin using the
Flexi-Flange system (Figure 1).
Allan Deutsch
Figure 2
FIGURE 2: The
countersink drill creates a
second tier and a flange
seat.
Figure 4
1. Use the depth gauge in conjunction with an x-ray to

determine proper post size.
2. Begin the post-hole preparation by removing the root
filling material. Use a Gates Glidden drill to establish
100 percent of the post-hole length and 90 percent of
the post-hole width.
3. Use the primary reamer to achieve 100 percent of the
post-hole width. Note: Because the Flexi-Flange fits
optimally within a concentric hole, the number of
FIGURE 1: Flexi-Flange
entries into the post-hole with the primary reamer
post system.
should be limited. Lubricating the canal with water or
Figure 3
another suitable wetting agent makes post-hole
preparation easier.
4. Use the countersink drill (Figure 2) to cut two tiers in
one operation; this prepares a seat for the second tier
and the seat for the flange.
5. Determine full seating of the post by making certain
that the flange fits flush within the preparation (Figure
3). Note: To achieve complete seating in highly curved
canals, use a diamond disk to remove sufficient apical
post length to allow full seating of the second tier and
flange. Shorten only the legs of the post after trial
seating to ensure the creation of threads in the canal
with minimal stress.
FIGURE 3: Fully seat
flange into the dentin.
6. Trial-insert the Flexi-Flange with the appropriate
wrench.
7. Unthread the post from the canal completely and place Figure 5
Essential Dental Systems Flexi-Flow Cem composite
resin cement in the post-hole and on the post shank.
8. Thread the post back into the post-hole with light
pressure. Note: The post will seat completely with
minimal resistance.
9. Remove excess cement to prepare for the core buildup.
10. Use a bonding agent to facilitate retention between the
coronal dentin, the post, and the core buildup material.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd15restoring.html[2/21/2011 10:25:10 ]
FIGURE 4: Use an
opaquing agent for
aesthetic restorations.
Figure 6
Note: Use an opaquing agent for aesthetic restorations

(Figure 4).
11. Using a core matrix, place and shape Essential Dental
Systems Ti-Core Natural core buildup material
(Figure 5).
FIGURE 5: Example of TiCore Natural core buildup.
Figure 6 shows the final x-ray of the Flexi-Flange split-shank

threaded post system in place. The Flexi-Flange system is
designed for cases with little or no coronal dentin. It is a
variation of the Flexi-Post system, which has brought
practitioners clinical success for decades. These post systems
provide maximum retention with minimal insertional and
function stress.
February-March 2003
FIGURE 6: The FlexiFlange split-shank
threaded post system in
place.
ABOUT: Flexi-Flange
Flexi-Flange
Flexi-Flange patented split shank post incorporating a

flange to provide additional stability in situations where
there is inadequate coronal dentin and excessive
occlusal forces anterior and posterior.
Features
Stabilizing Flange maximizes dentin-to-metal contact,
distributing functional stresses over a larger area to
minimize stress concentrations at any one point.
Split shank design closes on insertion to deliver
maximum retention with minimal stress.
Triple tier design provides resistance to post loosening
and root/post fracture.
Manufacturer
Essential Dental Systems, Inc.
89 Leuning Street
South Hackensack, NJ 07606
Toll Free: 800-223-5394

Tel. 201-487-9090
Fax: 201-487-5120
eds@pipeline.com
www.edsdental.com
FEEDBACK?
Product Review: VibraJect

Product Review
VibraJect
Allan Deutsch
THINK THAT all of us have wanted to learn how to give

a painless injection. I certainly have. Long ago someone The VibraJect
taught me to shake and push and rotate the mucosa that
the needle was going to penetrate. This effectively was using
the Gate Control Theory of pain as first proposed by
Melzak and Wall in the 1970s. It works well for the
maxillary arch, where you can grab the mucosa, but not too
well for a mandibular block injection.
Now the first major advancement in this area is being
marketed. It is a device called the VibraJect. The VibraJect FIGURE 1: The VibraJect.
clips onto any type of syringe that you are currently using for
anesthesia. It causes the entire syringe to vibrate . The
vibration feels like that from a pager or cell phone, but the
amplitude is not as large. The device appears to vibrate at a
high frequency and does not affect the positioning of the
needle at all.
I have been using it for approximately three months now.
The vast majority of patients report either not feeling the
mandibular block injection or just feeling it ever so slightly.
Certainly, that represents a vast improvement over the
reduction in pain from a preliminary topical and a little
shaking. This device is now part of my regular
armamentarium and remains on the bracket table at all times.
It has not been relegated to the drawer of useless devices.
The VibraJect clipped in place on a syringe
FIGURE 2: The VibraJect clipped in place on a syringe.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd16vibraject.html[2/21/2011 10:25:10 ]
Product Review: VibraJect
The VibraJect is an excellent product, and I recommend it

highly if you want to reduce the pain of injections in your
practice. The price is around $250. It can be purchased
from:
Ron Wasserman
Metropolitan Dental Supply, Inc.
35-02 Crescent Street
Long Island City
NY 11106
Phone: (718) 706-6677.
May-June 2003
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd16vibraject.html[2/21/2011 10:25:10 ]
Three-Rooted Bicuspids (Theyre Out There)
Allan Deutsch
T HAS BEEN my experience that the most common

cause of clinical failure in endodontics is missed or
uninstrumented canals. In other words, anatomy is king
in endodontics. If you do enough root canals and you are on
the lookout for three-rooted maxillary bicuspids, you will see
them. The key is to get into a routine that makes it easy to
spot them.
I recommend that you take two starting films for each
tooth. These x-rays have a twofold purpose. The first is for
diagnosis and to establish etiology that justifies root-canal
therapy as the correct treatment for this tooth. The second
purpose is to gain as much information about the tooth as
possible in order to facilitate the treatment. You will want to
know:
How big is the pulp chamber?
Are the canals open or calcified?
How many roots (and canals) does the tooth have?
Does decay go directly into the canal? This will make
the canal orifice harder to find.
Are there any bent or malformed or malposed roots in
the tooth?
One of these x-rays should be straight on, preferably using
a Rinn aiming device, and the other x-ray should be angled
from the mesial or distal to look for extra roots. Teeth that
commonly have extra roots are: mandibular molars,
mandibular bicuspids, and maxillary bicuspids.
This case report deals with a maxillary first bicuspid
(tooth #12). The patient presented with hot and cold
sensitivity and sensitivity to biting and tapping on the tooth.
A new composite inlay had been placed one month earlier.
Diagnostically, the tooth was yelling for endodontics. On the
starting x-ray (Figure 1) we could see a hint of three roots.
This does not occur too frequently. We took another x-ray,
angled this time. However, my regular assistant was on
vacation and my temporary assistants x-ray was overlapped
and diagnostically useless. Rather than expose the patient to
more x-rays, I made the assumption that this was a threerooted bicuspid and decided that I would look for all three
canals when I opened the tooth.
When looking for extra canals or roots it is almost
mandatory to employ some type of optics. I use Designs for
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd17threerooted.html[2/21/2011 10:25:11 ]
Figure 1
Vision loupes. I use a 2.5 x wide-field to find the mouth, and
a 4.5 x wide-field when I am looking for canals. The
microscope comes in handy for calcified canals. These optics
will save you subsequent visits and consequently earn you
more money on your cases.
I made the access cavity in the standard oval shape for a
bicuspid. The oval went from just before the buccal cusp tip
to just in front of the palatal cusp tip (Figure 2). I used a
number 4 round bur to make the rough prep, and then I used
a non-end-cutting barrel diamond to smooth and shape the
axial walls of the access prep. A drawing of the floor of the
pulp chamber when I first opened it up can be seen in Figure
2. Upon initial opening, I could probe only a single canal. I
found it in the mesial buccal area of the chamber floor. O.
K. I said to myself, Ive got one canal. Where are the
others?
If this was truly a minimolar, there should be a palatal
canal somewhere. On the palatal side I just saw a dark line
(Figure 2). Since most canals are found directly under the
cusp tips and along the dark lines, I decided to push the
access opening more toward the palatal. I was happy to find
the canal directly under the cusp tip where it should have
been. I then proceeded to clean out and instrument both the
MB and palatal canals. I have found that once the canals are
instrumented the large orifices make it easier to place and
find the missing canal. Also, during the course of
instrumentation, the sodium hypochlorite cleans out all the
debris and stops any bleeding. This gives you a very clear
field to look for the missing canal.
All canals in general can be found in or along the dark line
or area found on the chamber floor. I now took my barrel
diamond and opened the area around the dark line on the
disto-buccal side of the tooth. Since there was vital tissue in
the canal, I could see a blood spot. The rest of the floor had
been cleaned by the sodium hypochlorite. That was the
canal. I now instrumented it fully using the EZ-Fill
SafeSiders technique. The instrumented floor of the canal
can be seen in Figure 3. The tooth has a compressed molar
appearance. The orifices for the buccal canals were about 1.5
millimeters apart in a mesial distal direction.
The tooth was filled with gutta percha and EZ-Fill resin
cement using the EZ-Fill bidirectional spiral. The tooth was
closed with glass ionomer cement, the patient was sent back
to the referring general dentist for a permanent restoration,
and Figure 4 shows the end of another happy tale of
endodontic therapy.
FIGURE 1: The starting xray showed a hint of three

roots.
Figure 2
FIGURE 2: Showing the

access cavity and the floor
of the pulp chamber.
Figure 3

instrumented floor of the
canal.
Figure 4
FIGURE 4: The end result.
FEEDBACK?
Esthetic Post Placement
Allan Deutsch
OSTS are not generally considered an esthetic part of

restorative dentistry, merely the foundation for what the
dentist hopes will be esthetically pleasing. However,
there are times when roots are thin and the metal of a post
may show through the exposed root or even the thin gingival
layer over the root, making for less-than-ideal esthetics. In
the same fashion, many of the restorations built on
endodontic posts are ceramics that allow light and the
metallic color of the posts to show through.
Flexi-Flow & Ti-Core
Figure 1
FIGURE 1: Flexi-Flow
Natural Composite
Cement.
Recognizing the need to improve these situations, Essential

Figure 2
Dental Systems, Inc., developed tooth-colored, long-term
(>10 years), fluoride-releasing composite cements and core
materials: Flexi-Flow Natural and Ti-Core Natural (Figures 1
and 2). Together with an opaquing layer, such as C&BMetabond (Parkell), these products mask the color of the
metal post (Figure 3) and improve its esthetics (Figure 4). In
addition, Ti-Core and Flexi-Flow also come in gray
(reinforced with titanium) to differentiate from the lighter
FIGURE 2: Ti-Core Natural
tooth structure when necessary.
Core Material.
Stability
Figure 3
One might ask, Why bother with metal posts that require
masking when a new generation of ceramic posts has been
introduced that are tooth-colored to start with and do not
need masking? The answer is that the first and most
important function of the post is not esthetics, but supporting
the restoration with the greatest long-term stability.
Stability is based on the degree of retention and the even
distribution of insertional and functional stresses. The most
efficient way to gain higher retention is to engage the dentin
via a threaded shank. However, conventional solid-threaded
shanks, whether tapered or parallel, create stresses that could
lead to fracture.
Flexi-Post & Flexi-Flange
FIGURE 3: The color of

the metal post is masked.
Flexi-Post and Flexi-Flange, also manufactured by Essential

Dental Systems, Inc., are split-shanked, parallel-threaded
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd18esthetic.html[2/21/2011 10:25:11 ]
posts with the proven ability to achieve maximum retention

with insertional stresses no greater than those of a passive
post. Of equal importance is the ability of the post to
distribute the functional stresses along the entire length of the
shanka requirement that the parallel-threaded, split-shank
design of the Flexi-family fulfills most efficiently.
Figure 4
Bendability
When the posts are made of stainless steel, they impart a
bendability almost equal to the flexibility of dentin,
reducing the chances of gap formation between the core and
the body of the root. The bendability of a material is a
function of the modulus of elasticity and the cross-sectional
area of the material being tested. These dynamics are quite
different from the limited resilience of ceramics. Because of
the nongiving nature of the ceramic material, ceramic posts
transmit most functional stresses to the root rather than
absorbing them in the material itself.
FIGURE 4: The esthetic

results are improved.
Highest Recorded Retention

The split-shank design of Flexi-Post and Flexi-Flange
ensures that the threads engage the dentin with minimal
lateral stress, yet produce the highest recorded retentions
found in the literature. The even distribution of stresses
optimizes the long-term success of the underlying support
and makes the final restoration more predictable.
Conclusion
Success is the ultimate esthetic challenge. Nothing looks
worse than a fractured root. Loosened or fractured posts do
not look good either. Like beauty, esthetics is truly in the eye
of the beholder but the esthetic success of a restoration is
usually noted and enhanced when form follows function.
The split-shank design of the Flexi-family of posts creates
an architecture that integrates the needs of a supportive post
and high retention with those of the root, minimal insertional
stresses. Harmony like this can also be called esthetic.
For infected casesinstrument fully,
open the tubules with 18 percent
EDTA and let Peridex
(Chlorhexidine) sit in the canal for 10
minutes, then obturate. This
procedure will disinfect most infected
cases, with resulting healing of the
lesion.
FEEDBACK?
We welcome your
the Endo Forum and
add your comments
in Endo-Mail.
Irrigation Update
Irrigation Update
ECENTLY, several new articles have been
published that add valuable information as
to which irrigant to use and for how long.
Currently, I use the following protocol:
Allan Deutsch
1. I irrigate with 5.25 percent sodium

hypochlorite into the canals and leave
some irrigant in the pulp chamber when
using all the stainless steel SafeSiders,
from size #08 to size #40.
2. I change the irrigating solution in the
canals and in the pulp chamber every time
I change the instrument size.
3. When I reach the NiTi SafeSiders (30/.04
and 25/.08), I flood the canals (which have
already been opened with the number 2
Peeso, with 17 percent EDTA in an
aqueous solution.
4. I now intrument the final canal shape with
the EDTA in the canal and the NiTi
SafeSiders. This will remove the smear
layer and open up the dentinal tubules.
5. After instrumentation, I give the canal a
final rinse with 5.25 percent hypochlorite
to remove and neutralize the 17 percent
EDTA.
6. I dry and fill the canals next.
7. However, if this is a retreatment, or if
there has been a longstanding infection
(longer than 3 months), I will now irrigate
with 0.12 percent chlorhexidine
(Peridex). I let the chlorhexidine sit in
the canals for approximately five minutes.
8. After five minutes, I dry the canals with
paper points and fill the canals with GP
and cement. I do not irrigate with NaOCl.
In a study reported in the International
Endodontic Journal, N. Habahbeh, et al, reported
that all concentrations of NaOCl were effective
in the elimination of E. faecalis but that different
concentrations required different lengths of time
to achieve the result; 5.25 percent was the most
effective, killing 100 percent of bacterial cells in
two minutes. The time required by 2.5, 1.0 and
0.5 percent was 5, 10 and 30 minutes
respectively. 1
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd19irrigationupdate.html[2/21/2011 10:25:12 ]
Irrigation Update
In another study, L. M. Sassone, et al, showed

that 0.12 percent chlorhexidine (CHX) did not
eliminate E. faecalis in any time interval. One
percent CHX eliminated all strains, as did
NaOCl at both 1 percent and 5 percent
concentrations. Therefore, under the conditions
of this study, a 0.12 percent CHX solution was
ineffective at killing E. faecalis.2
A third study, reported by O. Oncag, et al,
compared the antibacterial properties and
toxicity of 5.25 percent NaOCl, 2 percent
chlorhexidine gluconate, and 0.2 percent
chlorhexidine gluconate plus 0.2 percent
cetrimide (Cetrexidin: Vebas, San Giuliano,
Milan, Italy). In the laboratory study, the 2
percent CHX gluconate and Cetrexidin were
significantly more effective on E. faecalis than
the 5.25 percent NaOCl at 5 minutes. Similarly,
in the in vivo study, 2 percent CHX gluconate
and Cetrexidin were significantly more effective
on anaerobic bacteria than the 5.25 percent
NaOCl at 48 hours. The authors state that 2
percent CHX gluconate and Cetrexidin had more
antibacterial effect on anaerobic bacteria than
5.25 percent NaOCl because of their active
cationic properties, which enable their adsorbtion
by the dentine surface and their substantive
antibacterial effect.3 It is surmised that this
cationic effect leaves a long-acting antibacterial
action on the dentinal tubules.
After reading these articles I must now say
Oops!
My NaOCl protocol is OK. I am certainly
leaving my 5.25 percent solution in the canal for
greater than two minutes. This will kill almost
all the bacteria and remove the tissue debris and
consequently the organic load. However, I am
certainly not leaving the 0.12 percent
chlorhexidine Peridex (Figure 1, left) in the canal
long enough. According to the article by L. M.
Sassone, et al, 0.12 percent CHX would never
entirely get rid of the bacteria, no matter how
long you left it in the canal! To get rid of 100
percent of the bacteria within five minutes you
need a solution of CHX greater than 1 percent.
Consequently, I have now bought 2 percent
chlorhexidine by Vista (Figure 1, right). I have
retained the same protocol as above with the
exception of using 2 percent chlorhexidine
instead of 0.12 percent.
Lets hope this kills all those bugs!
References
1. Habahbeh N, Drucker DB, Qualtrough JE,
Korachi M. Abstract R95. International
Endodontic Journal 2003;36(12):950.
2. Sassone LM, Fidel R, Fidel S, Vieira M,
Irrigation Update
Figure 1
Hirata R, Jr. The influence of organic load

on the antimicrobial activity of different
concentrations of NaOCl and
chlorhexidine in vitro. International
Endodontic Journal 2003;36(12):848-852.
3. Oncag O, Hosgor M, Hilmioglu S,
Zekioglu O, Eronat C, Burhanoglu D.
Comparison of antibacterial and toxic
effects of various root canal irrigants.
International Endodontic Journal
2003;36(6):423-432.
FIGURE 1: 0.12 percent chlorhexidine from Peridex

and 2 percent chlorhexidine from Vista.
February-March 2004
FEEDBACK?
Please feel free to visit the Endo Forum and add
your comments about any of the articles in
Endo-Mail.
IADR Meeting in Honolulu
Allan Deutsch
T WAS TOUGH DUTY, but somebody had

Figure 1
to do it. That is, go to the IADR
(International Association of Dental
Research) meeting in balmy, 80-degree,
downtown Honolulu, Hawaii. Naturally, I
volunteered for this assignment. Every year the
international dental research community holds its
annual conference at a city somewhere around
the world. This year we were lucky that the host
city was Honolulu; next year it will be not-sobalmy Baltimore.
Researchers submit abstracts of their research
FIGURE 1: Posters set up before
in the year preceding the convention. The
viewing time.
abstracts are reviewed and either accepted or
rejected. The accepted abstracts are presented at
the convention either as fifteen-minute oral
Figure 2
presentations or as poster presentations. This
year we gave two poster presentations (Figures 1
and 2).
Instrumentation Time: Conventional

Instruments versus Non-interrupted
Flat-sided SafeSiders
B. L. Musikant, B. I. Cohen, and A. S. Deutsch,
Essential Dental Systems, South Hackensack, NJ,
USA
BARRY MUSIKANTS RESEARCH showed
that flat-sided SafeSiders reamers are much
faster at instrumenting the canal than
conventional files or even conventional reamers.
Therefore, less engagement with the dentin as a
consequence of the flat-sided SafeSiders reamer
actually decreases the time needed to clean the
canal. As we have seen clinically for more than
ten years, the SafeSiders are very fast; for me,
they are even faster than rotary!
FIGURE 2: Previewing hours, with the

crowd starting to come in.
Figure 3
Objective
The purpose of this in vitro experiment was to
FIGURE 3: The PulpOut Bur, showing
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd20iadrmeeting.html[2/21/2011 10:25:12 ]
compare the time (in seconds) needed to create

the flat and the 7 mm fixed stop.
an .08 tapered canal preparation utilizing
conventional hand instruments versus a new noninterrupted flat-sided hand instrument design, the Figure 4
SafeSiders (EDS).
Method
This study was divided into four groups with ten
samples per group; group 1, conventional files
(Dentsply), group 2, SafeSiders files, group 3,
conventional reamers (Dentsply) and group 4,
SafeSiders reamers. Rectangular blocks made of
a resilient acrylic resin that mimics the physical
properties of dentin were used. Time to the apex Figure 5
was measured under four experimental
conditions. One-way analysis of variance
(ANOVA) was used to compare mean times
across conditions. Upon finding a significant
difference, the Newman-Keuls (NK) test was
used.
Results
ANOVA showed a significant difference
between groups (P < 0.0001). NK tests showed
that the conventional files in group 1 (275.2
42.19) had significantly longer times than the
conventional reamers in group 3 (183.9 42.24)
or SafeSiders files in group 2 (182.5 17.70)
(those two groups not being different from one
another), and that SafeSiders reamers in group 4
(128.3 14.07) had the shortest times, which
were different from all of the other instruments.
FIGURES 4 and 5: Discussing the

research with anyone who would listen.
Figure 6
Conclusion
The conventional designs for both reamers and
files result in slower, less-efficient
instrumentation to the apex compared with their
SafeSiders counterparts. The SafeSiders design
reduced dentinal engagement, reduced resistance
of the instruments within the canal, and
shortened the time needed for canal preparation.
FIGURE 6: Only in Hawaii!
Morphological Measurements of Molar

Pulp Chambers
A. S. Deutsch, B. I. Cohen, and B. L. Musikant,
Essential Dental Systems, S. Hackensack, NJ,
USA
MY RESEARCH, although simple in design, led
to some amazing findings. We found that on all
molar teeth the distance from the cusps to the

ceiling of the pulp chamber is very constant.
This distance is approximately 6.50 mm. With
this number in mind, we designed a new dental
instrument that we named the PulpOut Bur. This
bur is a number 4 round bur with a flat side and
a fixed stop at 7 mm (see Figure 3). The flat lets
the bur cut exceedingly well, and the fixed stop
will prevent the dentist from perforating into the
furcation. Say goodbye to iatrogenic furcation
perforations! Even on calcified canals, the
PulpOut Bur will place you at the level of the
chamber without worrying about perforations.
Pretty amazing stuff.
Objective
The aim of this in vitro study was to determine
and measure critical morphological anatomy of
pulp chambers.
Method
One hundred random human maxillary and one
hundred random human mandibular molars were
used. Each molar was affixed to a millimeter xray grid and x-rayed in the mesio-distal plane
using a parallel long cone technique. The x-rays
were examined under a stereomicroscope and the
measurements were read to the nearest 0.5 mm.
Results
Maxillary = Max, Mandibular = Mand, Mean
(mm): Pulp Chamber Floor to Furcation; Maxi =
3.05 0.79, Mand = 2.96 0.78; Pulp Chamber
Ceiling to Furcation; Max = 4.91 1.06, Mand =
4.55 0.91; Buccal cusp to Furcation: Max =
11.15 1.21, Mand = 10.90 1.21; Buccal cusp
to pulp chamber floor; Max = 8.08 0.88, Mand
= 7.95 0.79; Buccal cusp to pulp chamber
ceiling; Max = 6.24 0.88, Mand = 6.36 0.93;
pulp chamber width; Max =1.88 0.69, Mand =
1.57 0.68. The pulp chamber ceiling was
found at the level of the cemento-enamel
junction in Max = 98%, Mand = 97% of the
specimens. The measurement with the highest
percentage of variance was the width of the pulp
chamber (Max = 37% and Mand = 43%).
Conclusion
The measurements obtained were very similar
for both maxillary and mandibular molars. The
measurements with the lowest percentage
variance were: buccal cusp to furcation

(approximately 11%) and buccal cusp to pulp
chamber ceiling (approximately 14%). The pulp
chamber width varied the most, due to various
types of calcifications found in the pulp
chamber.
Figures 4 and 5 show me (in the Hawaiian spirit)
talking about our research (to anyone who would
listen). After a few hours of talking I was feeling
no pain. (Wonder why? See Figure 6.)
Summer 2004
When using the PulpOut
Bur to gain access, always
cut wet to prevent the
nylon fixed stop from
melting.
In endo, cutting wet is a
good idea for all burs.
Every bur will cut better
when wet, even slow
speed burs.
FEEDBACK?
We welcome your responses and
questions.
Please feel free to visit the Endo
Forum and add your comments
about any of the articles in EndoMail.
To smooth and remove

excess Cavit, use a Q-Tip
wet with water.
To smooth and remove
excess glass ionomer or
zinc oxyphosphate, use a
Q-Tip wet with alcohol.
Allan Deutsch
Dont Perf Out . . . PulpOut!
Allan Deutsch
Figure 6
FIGURE 6: Cutaway view.
N THE SUMMER 2004 issue of Endo-Mail,

I talked about the research we presented at
the IADR meeting in Honolulu. The
morphological research on molars was just
published in the June issue of The Journal of
Endodontics (2004;30(6):388-390). This
research showed that there are some very
consistent measurements when it comes to molar
pulp chambers. These measurements in
conjunction with the use of the PulpOut bur will
allow you to gain access to the chamber (even in
calcified chambers), easily, quickly, and without
perforating into the furcation.
Some measurements to remember are:
1. The pulp Chamber Ceiling is just about
always at the level of the CEJ! See Figure
1.
2. The height of the pulp chamber is between
1.5 mm and 2.0 mm for the average noncalcified tooth. See Figure 2.
3. The average distance from the floor of the
pulp chamber to the furcation is about 3.0
mm. See Figure 3.
4. Last but not leastthe distance from the
cusp tips to the ceiling of the pulp
chamber in molars is approximately 6.30
mm. See Figure 4. This is the most
critical distance of all. Using this
measurement, we have developed an
instrument that will allow you to find the
pulp chamber in all teeth, (normal or
calcified)!
That instrument is the PulpOut bur. It is a
number four round bur with a hard plastic nonmovable stop fixed at 7.0 mm from its tip. See
Figure 5. The 7 mm distance enables you to gain
access to the pulp chamber without risk of going
through the pulpal floor and into the furcation.
For teeth with average-size pulp chambers, the
PulpOut bur will place you somewhere in the
middle of the pulp chamber. See Figure 6.
Figure 1
FIGURE 1: The pulp chamber ceiling is

found at the level of the C. E. J. 98
percent of the time.
Figure 2
FIGURE 2: The average height of a pulp

chamber (F) is 1.5 to 2.0 mm.
Figure 3
FIGURE 3: The distance between the

pulpal floor and the furcation
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd21dontperf.html[2/21/2011 10:25:13 ]
Figure 7
FIGURE 7: The PulpOut

bur in a calcified pulp
chamber.
Figure 8
FIGURE 8: Preparing the

axial walls of the chamber.
(measurement A) equals 3.0 mm on

For teeth with calcified chambers, it will place
average for both mandibular and
you on the floor of the chamber. See Figure 7.
maxillary molars.
As we age, the pulp chamber normally
calcifies from the floor up. Therefore, the 7 mm
distance will place the bur in what used to be the
middle of the chamber but now is the floor. This Figure 4
will then enable you to find the canals much
more easily. Once the general outline of the
access is made with the PulpOut bur, the
diamond shaper is now used. The diamond
shaper is a non-end-cutting coarse barrel
diamond. It is placed against the axial walls and
moved around the entire access opening. This
will smooth the axial walls and let more light in
to the floor. See Figure 8.
FIGURE 4: The mean distance (E) from
The diamond is extra long so that the entire
the cusp tip to the pulp chamber ceiling
axial wall from floor to occlusal surface can be
is 6.36 mm in mandibular molars and
cut in one operation. The non-end-cutting tip of
6.24 mm in maxillary molars.
the shaper will not cut or gouge the floor of the
chamber.
Once these burs are used, finding canals without Figure 3
perforating the furcation becomes very
predictable and easy.
Fall 2004
FIGURE 5: The PulpOut burs nonmovable stop is fixed at the critical 7.0
mm pulp chamber depth.
FEEDBACK?
Endo-Mail.
Dont Perf Out . . . PulpOut . . . for Bicuspids, Too!
Allan Deutsch
N THE FALL 2004 ISSUE of Endo-Mail I described the

clinical technique for use of the PulpOut bur in
molars. The technique is based on our recently published
research (June 2004) in the Journal of Endodontics. This
research shows that the distance from the cusp tip to the
ceiling of the pulp chamber in molars is approximately 6.5
mm. That 6.5 mm distance is very consistent in all molar
teeth. We made the fixed stop on the PulpOut bur at 7 mm.
Locating the stop there assured that access into the chamber
would always be made without perforating the floor of the
pulp chamber.
We have just had our second morphological research paper
accepted for publication in the Journal of Endodontics. We
reasoned that if all furcated molars had a very consistent
measurement from the cusp tip to the pulp chamber ceiling,
maybe the furcated bicuspids did also. We got a little fancier
in this study and used the Trophy RVG digital imaging
system to radiograph the bicuspids. Once the digital x-rays
were processed, we measured them using the Digipan
measuring mode of the Trophy system (Figure 1).
We measured the same anatomic landmarks for bicuspids
as we did for molars. These measurements can be seen in
Figure 2.
The measurement that we were most interested in is D.
This is the measurement from the cusp tip to the chamber
ceiling. This measurement in bicuspids was 6.94 mm.
Although this number is statistically different from the
average of 6.3 mm for molars, it is smaller than the 7.0 mm
of the PulpOut bur. Consequently, the PulpOut bur will work
very nicely for bicuspids as well as for molars. Statistically,
based on a bell curve, there will always be some bicuspids in
which the PulpOut bur will get very close to the ceiling of
the bicuspid but not penetrate it. In these instances, you will
be only about 0.6 mm away from penetrating the ceiling.
Clinically, the PulpOut bur will get you very close to your
objective.
As an aside, it is very interesting to note that the one
measurement that was the same for molars and bicuspids was
measurement B. Measurement B is the distance from the
pulp chamber ceiling to the furcation. This seems to be a
constant number for all teeth with furcations. Why this is so,
I have no idea.
Figure 1
FIGURE 1: An example of
the measurements for a
bicuspid, taken in a buccal
palatal view.
Figure 2
FIGURE 2: Anatomic
measurements for
bicuspids.
file:///D|/.../DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd22dontperfbicuspids.html[2/21/2011 10:25:13 ]
So remember: Dont perf out . . . PulpOut!

Winter 2004
FEEDBACK?
file:///D|/.../DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd22dontperfbicuspids.html[2/21/2011 10:25:13 ]
New Material, New Use
Allan Deutsch
SSENTIAL DENTAL SYSTEMS recently released an

Figure 1
upgraded and improved Ti-Core. This new material
is called Ti-Core Auto E. The Auto stands for automix and the E stands for esthetic. This composite core
material is a dual-cured hybrid composite reinforced with the
lanthanide series of metals. Using proprietary chemistry and
manufacturing processes, we were able to keep
approximately 90 percent of the physical properties of the
original Ti-Core natural yet make Ti-Core Auto E less
viscous. The lower viscosity enables us to package the
material in a dual-barrel syringe with an auto-mix stator and
very small delivery tip (See Figure 1). This material can
easily be extruded and mixed all in one operation. The Vita
A2 color enables the material to be used in any situation
where esthetics is a concern. A 24 mm increment will lightFIGURE 1: Ti-Core Auto
cure in approximately 20 seconds. The material will finish
E.
self-curing in approximately six minutes.
I have been working with this material for several months
now. About two months ago, it occurred to me that since this
material was so easy to use and relatively inexpensive there
was another great use for it in addition to building up cores. I
have been using Ti-Core Auto E as a temporary material to
close the access opening. I etch all the dentin and surface
enamel with 37.5 percent phosphoric acid for approximately
20 seconds. This procedure removes the smear layer and
opens up the tubules. It also etches the intertubular dentin
itself. Since the composite has a low viscosity and flows
very well, it will flow into the tubules and also form resin
tags into the etched intertubular dentin. The net effect of all
of this is a very good seal. This seal will stop coronal
leakage after the endodontics is completed. Sometimes the
patient does not have the tooth restored for months. If the
temporary material leaks or wears away during that time and
the root becomes infected, the endodontics must be redone.
Ti-Core Auto E will not leak since it is mechanically bonded
into the tubules and the intertubular dentin, and since it is a
hybrid composite it certainly will not wear away in a matter
of months.
Cavit also seals well coronally. However, the problem
with this material is that it is rather soft and prone to wear.
Sometimes when used as an occlusal seal between visits it
washes out, and the tooth often becomes infected between
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd23newmaterial.html[2/21/2011 10:25:14 ]
appointments. We long ago stopped using Cavit as a primary

interappointment sealing material because there were too
many unnecessary infections.
The clinical technique is very simple and quick. First fill
the entire access cavity with the 37.5 percent phosphoric acid
(Figure 2). Let this etch the dentin and coronal enamel for 20
to 30 seconds. Then wash off the etchant with water.
Assemble the syringe and express the Ti-Core Auto E
through the auto-mix syringe and small placement tip,
directly into the access cavity (Figure 3).
Figure 2
FIGURE 2: First fill the

entire access cavity with
the 37.5 percent
phosphoric acid.
Figure 3
FIGURE 3: Express the Ti-Core Auto

E through the auto-mix syringe and
small placement tip, directly into the
access cavity.
Smooth and shape the occlusal surface with an instrument.

Light-cure the Ti-Core Auto E for 20 to 40 seconds,
depending on the thickness of the temporary seal you want to
create (Figure 4).
Figure 4
Figure 5
FIGURE 4: Light-cure the Ti-Core Auto E for 20 to 40 seconds,

depending on the thickness of the temporary seal you want to
create.
You are now done! This is a very quick and easy approach
to temporization of the access cavity for any root-canal
treatment. No fear of infection, and esthetically pleasing
results also!
January-March 2005
FEEDBACK?

Hands-On Lectures at HODEC
Allan Deutsch
ODEC, our hands-on lecture facility, has now been operating for
about six months. We have given half-day, full-day and two-day
courses. From our point of view and from the point of view of
those who have attended, HODEC is an unconditional success.
All courses, no matter the length, have both a didactic and hands-on
component. The lectures are to the point. That is, they describe the
techniques that the dentist participant will practice and perform in the
hands-on section that occurs immediately after the lecture.
The half-day course (four hours) lets the dentist get a taste of one-visit
endo using the SafeSiders technique with the reciprocating EndoExpress handpiece. After instrumentating a natural bicuspid tooth, the
dentist then obturates the instrumented canal with the EZ-Fill singlecone technique. Lastly, the participant gets to close the access opening
with Ti-Core Auto E, a dual-cure metal-reinforced composite, and learns
how to place a Flexi-Flange post and build up the core. The morning
flies by as we do all these procedures.
The one-day and two-day courses give the students more of everything
and in greater detail. The didactic part of the course goes into the where
and why of doing endo quickly and easily while maintaining excellent
results with a high success rate for the patient. The focus of the hands-on
part of the courses is to shorten the learning curve for doing SafeSiders
cases using the reciprocating Endo-Express handpiece. The dentist
accomplishes this by instrumenting multiple bicuspid and curved molar
teeth. After the teeth are instrumented, they are obturated using the EZFill single-cone technique. Once the endodontic procedure is completed,
we take digital x-rays of the finished teeth. The digital x-ray is then
highly magnified and displayed using our LCD projector. The dentists
can then immediately see how their technique is improving. The
participants at HODEC have all loved this instant feedback teaching aid.
Once you see how you are doing, it is very easy to modify your technique
to achieve the best results possible. In these longer courses we also offer
the opportunity to try the endo microscope and ultrasonics, important
adjuncts in learning a sound endo technique.
If you want to do one-visit endo using the SafeSiders/Endo-Express
technique and earn CE credits, HODEC in South Hackensack is the place
for you. It is extremely close to New York City, just ten minutes over the
George Washington Bridge. Call us at 201-487-9090 or see us on the
web at edsdental.com.
I know these courses will pay for themselves after you have done just
one or two endo cases in one visit in your own office.
See you at HODEC.
Kudos for HODEC

Treat yourself to a
course with Barry
Musikant who will
teach you more in
2?3 hours than you
will learn in a year.
He has made my
endo much more
enjoyable.
Louis
Malchmacher, DDS
Bay Village, OH
The course was
designed so that
participants felt
confident performing
procedures as
taught immediately.
Robert Saukas
Stanton, MI
Success!!! Yes!!!
You gave an inhouse lecture back
in December and I
wanted to let you
know how things
are going. I am on
cloud nine today. I
feel like I can be
confident that I can
deliver a superior
service to my
patients with your
technique.
Lance Fallin, DDS
Zachary, LA
Very informative,
practical &
enjoyable. I feel
confident enough to
use the procedure
first thing Monday
morning. This is the
best Ive ever taken!
Ronald Petrosky,
Tuckerton, NJ
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd24handson.html[2/21/2011 10:25:14 ]
Thanks so much for

your generosity in
offering your course
and Id recommend
that anyone
contemplating endo
or a new way of
doing such, take
Barrys course as it
was worth the trip.
Ron Schalter, DDS
Hudson, MI
FIGURE 1: Allan Deutsch overseeing FIGURE 2: Hands-on instruction

hands-on practice at HODEC.
is up close and personal.
Best endo course

Ive ever taken.
Ed McElroy El
Paso, TX
Run, dont walk, for
the chance to meet
and listen to Barry!
Howard Farran,
DDS, Phoenix, AZ
The best endodontic
course Ive
attended.
Alan Stott
Lancaster, CA
FIGURE 3: Barry Musikant lecturing at HODEC.

April-June 2005
FEEDBACK?
Please feel free to visit the Endo Forum and add your comments about
any of the articles in Endo-Mail.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd24handson.html[2/21/2011 10:25:14 ]
Simple Overdenture Technique, Lasting Results
Allan Deutsch
MPLANTS have, in the last 15 to 20 years, paved the

way to restoration of the edentulous and partially
edentulous mouth. However, many patients cannot afford
the time or money required to complete this treatment
successfully. Making an Overdenture (OVD) using a simple
ball-and-socket type of attachment for extra retention is a
proven and easy alternative treatment to implants.
The Flexi-Overdenture attachment is based on the
patented split-shank Flexi-Post for the highest retention of
the post in the root and the fewest problems. The ball-andsocket attachment delivers high retention for full and partial
dentures, providing a simple, inexpensive overdenture at
chairside. The Flexi-Overdenture supports a nylon attachment
that is incorporated into an overdenture (Figure 1).
Alternatively, and for great ease of replacement, a threaded
version of the nylon attachment can be threaded into an EZChange metal receptacle (keeper) that in turn is
incorporated into the denture (Figure 2). The post allows the
dentist to utilize remaining roots to support the retention of a
denture.
Figure 1
FIGURE 1
Figure 2
FIGURE 2
The Steps for Placement of the FlexiOverdenture

Try to retain two canine teeth in each arch for the abutments
for the OVD. If canines are not available, try to use
bicuspids next. However, any tootheven just one tooth
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd25simple.html[2/21/2011 10:25:15 ]
will provide additional retention for the OVD.

Determine the optimum post size by placing the plastic
template over an undistorted x-ray. There should be at least
one millimeter of lateral tooth structure at the most apical
placement of the post.
After determining the correct post size, prepare the post hole,
using a sequence of Gates Glidden drills followed by the
color-coded primary reamer exactly correlated to your post
size (Figures 3 and 4).
Figure 3
FIGURE 3
Figure 4
FIGURE 4
After using the correct primary reamer, prepare the

countersink/root facer preparation with the
countersink/rootfacer drill (Figure 5).
Figure 5
FIGURE 5
Try placing the post that corresponds to your preparation. It

should be fully seated (Figure 6).
If the post does not seat fully, shorten the apical end of the
post the appropriate amount for full seating (Figure 7).
Figure 6
FIGURE 6
Figure 7
FIGURE 7
Coat the internal surface of the post hole and the shank of the
post with Flexi-Flow Auto reinforced composite cement
and place the post into the root.
Let set for four minutes.
Place the nylon cap on the ball of the Flexi-Overdenture
attachment. Make sure that the colored rubber band is on the
ball of the attachment. The rubber band blocks out the
undercut of the ball (Figure 8).
Mark the top of the nylon cap with a disclosing paste and
place the denture over the root (Figure 9).
Figure 8
Figure 9
FIGURE 8
FIGURE 9
Remove the denture, noting where it has been marked with

the paste (Figure 10).
Figure 10
FIGURE 10
Relieve enough acrylic from the denture to allow the denture

to sit passively over the nylon cap (Figures 11 and 12).
Figure 11
FIGURE 11
Figure 12
FIGURE 12
Once you have confirmed that the denture is sitting passively

supported only by the ridges, place a doughy mix of acrylic
into the relieved site, place the nylon cap over the acrylic and
keep it in position until the acrylic hardens (Figure 13).
Remove the denture and relieve the excess underlying acrylic
(Figure 14).
Figure 13
FIGURE 13
Figure 14
FIGURE 14
The denture now has the added retention supplied by the

ball-and-socket attachment provided by the FlexiOverdenture attachment. Over time, the nylon attachment will
wear, out reducing the amount of retention it provides. The
nylon attachment can be replaced by drilling out the old
attachment and cold-curing a new one in. To reduce the time
and effort necessary for replacement, Essential Dental
Systems, Inc., has developed the EZ-Change attachment for
rapid replacement of the worn nylon attachment. To
incorporate it into the denture do the following:
Instead of the nylon attachment, place the EZ-Change
attachment, which consists of a metal receptacle (keeper) and
a threaded nylon attachment within it (Figure 15).
The two components of the EZ-Change attachment are
incorporated into the denture in the same manner as the
original nylon cap.
When the nylon attachment now wears out, it is a simple
matter to use the EZ-Change wrench to unthread the wornout nylon cap from the metal insert and thread in a new one
(Figure 16). No cold-curing is necessary, the entire process
taking only a few seconds.
Figure 15
Figure 16
FIGURE 15
FIGURE 16
The ball-and-socket is very user-friendly for the patient. It

snaps in easily, the patient can both hear and feel when the
ball is seated, and there are no components to bend or break.
This is a viable and time-tested alternative technique for
those who cannot have implants.
July-September 2005
FEEDBACK?
Basic Research Points the Way to Improved Results
Allan Deutsch
HY do some cases fail even if all the canals were found and the mechanical
instrumentation and shaping were successful? The answer is usually quite simple:
infection. In the article Effect of endodontic procedures on enterococci, enteric bacteria
and yeasts in primary endodontic infections, in the International Endodontic Journal 2005,
38;372-380, Ferrari, Cai, and Bombana concluded that enterococci, enteric bacteria, and yeasts
were present in primary endodontic infections. Enterococci, particularly Enterococcus faecalis and
E. faecium were resistant to removal by root canal preparation followed by intracanal dressing.
This article could very well explain the results obtained by Siqueira and Rocas. In their article
Polymerase chain reaction-based analysis of microorganisms associated with failed endodontic
treatment, OOO, 2004 97;85-94, Siqueira and Rocas concluded that microorganisms occurred in
all cases of root-filled teeth associated with periradicular lesions, which lends strong support to the
assertion that treatment failures are rather of infectious etiology, caused by persistent or secondary
intraradicular infections. E. faecalis was the most prevalent species, followed by four other
anaerobic species: P. alactolyticus, P. propionicum, D. pneumosintes and F. alocis. All examined
samples harbored at least one of the following gram-positive bacterial species: E. faecalis, P.
alactolyticus, or P. propionicum. So the evidence is mounting that E. faecalis is a very nasty bug
and probably responsible for most endodontic failures and problems. The question then becomes,
how do you get rid of it clinically?
Since Ferrari et al. showed that instrumentation did not get rid of all the bacteria, it is up to the
irrigants we use to do the job! The key questions are What should we use? and How should we
use it clinically? We know that we must use sodium hypochlorite, because it has the greatest
efficacy in removing tissue debris. However it does not kill E. faecalis. This was shown in an
article by Menezes et al. In vitro evaluation of the effectiveness of irrigants and intracanal
medicaments on microorganism within root canals, International Endodontic Journal
2004,37;311-319. In this article they concluded that 2 percent CHX solution was more effective
than 2.5 percent NaOCl against E. faecalis. We are starting to build a case for 2 percent CHX
(chlorhexidine gluconate). See Figure 1.
Figure !
FIGURE 1: Two percent CHX solution was more effective than 2.5 percent NaOCl against E. faecalis.
It turns out that the percentage of CHX is crucial! Sassone et al. in their article The influence
of organic load on the antimicrobial activity of different concentrations of NaOCl and
chlorhexidine in vitro, International Endodontic Journal, 2003,36;848-852 concluded that a 0.12
percent CHX solution did not eliminate E. faecalis at any time interval. One percent CHX
eliminated all strains. The 0.12 percent is equivalent to Peridex mouthwash. Many other articles
point to a 2 percent solution for clinical use in endodontics. At a 2 percent level the antimicrobial
effect of CHX can be achieved in 12 minutes of contact.
At this point you may be saying to yourself, This is very nice, but I still like to put calcium
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd26basic.html[2/21/2011 10:25:15 ]
hydroxide in the canal in between visits to kill the bacteria. Really amazing research has just
been published concerning calcium hydroxide. Kayaoglu et al. in their article Growth at high pH
increases Enterococcus faecalis adhesion to collagen, International Endodontic Journal,
2005,38;389-396, conclude that a minor increase in pH up to 8.5, which may be a consequence of
insufficient treatment with alkaline medicaments such as calcium hydroxide, increases the
collagen-binding ability of E. faecalis, in vitro. This can be a critical mechanism by which E.
feacalis predominates in persistent endodontic infections. Wow! Taken clinically, if you dont get
enough calcium hydroxide into the canal to raise the pH enough, you make the infection worse
(harder to get rid of). An additional two articles (Lin et al. JOE, 2003,29;565-566 and Basrani,
OOO, 2003,96;618-624) showed that CHX was effective against E. faecalis and Ca(OH)2 was not.
So for me, no more calcium hydroxide antibacterial therapy; it may make matters worse, not
better!
The article Effect of root canal dressings on the regeneration of inflamed periapical tissue, by
Dammaschke et al. in Acta Odontologica Scandinavica, 2005, 63;143-152, concluded that
chlorhexidine used as an intracanal medicament showed good periapical regeneration, suggesting
that this may be an alternative to calcium hydroxide root canal dressing. OK, now we know that
the tissue heals with this stuff!
There is a bonus effect with chlorhexidine use. Rosenthal et al. in Chlorhexidine substantivity
in root canal dentin, OOO, 2004;98:488-492, concluded that the results of their study indicate
that CHX is retained in root canal dentin in antimicrobially effective amounts for up to 12 weeks.
A fabulous property for an antimicrobial agent! They also said, CHX is known to be particularly
effective against many strains of bacteria found in infected root canals, including E. faecalis. In a
study comparing common endodontic disinfectants, 0.5 percent CHX was also significantly more
effective at killing C. albicans than Ca(OH)2, 5 percent and 0.5 percent NaOCl and 2 percent IKI.
While these substantive and antimicrobial properties of CHX found here are promising, it does not
have the tissue-dissolving properties of NaOCl. Although NaOCl is still considered the irrigant of
choice, the use of CHX may be considered advantageous as a treatment prior to obturation, an
alternative irrigant during retreatments, or even incorporated into antimicrobial dressings.
The take-home lesson is that CHX is good stuff, but how should we use it clinically? It appears
that the key is the use of 1517 percent aqueous solution of EDTA before the use of CHX. A large
percentage of the bacteria causing the problem reside in the dentinal tubules. After
instrumentation, the bacteria are covered by the smear layer of dentin. If we do not remove this
layer, our 2 percent CHX cannot get to the bacteria and consequently will not kill them.
Conversely, as shown by Clark-Holke et al. in Bacterial penetration through canals of
endodontically treated teeth in the presence or absence of the smear layer, Journal of Dentistry,
2003, 31;275-281, when the smear layer is removed and the canal is obturated with gutta percha
and an epoxy resin cement (like EZ-Fill), there was no leakage of bacteria through the apical
foramen. The presence of the smear layer resulted in leaking in 60 percent of the model systems
over the experimental time period. So it is a good thing to remove the smear layer:
1. before CHX application
2. before obturation with an epoxy cement.
Clinical Procedure in Conjunction with SafeSiders / Endo-Express Technique

1. While instrumenting from #08 to #40 Stainless steel SafeSiders, use NaOCl 5 percent as the
irrigant
2. While instrumenting with the 30/.04 and 25/.08 NiTis, use 17 percent aqueous EDTA
(removes the smear layer)
3. Rinse out EDTA with water or anesthetic. Both EDTA and NaOCl form a precipitate and
inactivate CHX! Therefore, do not let the CHX contact either EDTA or NaOCl.
4. Irrigate with 2 percent CHX and let sit in the canals for at least two minutes.
5. You can leave the canal slightly damp with CHX if obturating with EZ-Fill sealer. The
epoxy EZ-Fill will set even under water. This will ensure prolonged maximum antibacterial
activity.
6. Obturate the canals.
Figure 2
If the canal has a difficult curve, you can pre-bend a stainless
SafeSiders instrument (08-40), place it in the canal, and then insert it
into the reciprocating handpiece (after the instrument is in the canal).
FEEDBACK?
We welcome your
the Endo Forum and
add your comments
in Endo-Mail.
New Diagnostic Cat Scan Great for Endo
Allan Deutsch
Figure 1
hile I was in Philadelphia for the 2005
ADA Convention, Dr. Victor Sendax
(inventor of the mini temporary implant)
introduced me to Imtecs Iluma FlashCT
scanner. The machine itself is about the size of a
Panorex and is entirely open. The total radiation
dose is slightly more than a Panorex. However,
the amount of information is mind blowing. You
can see the entire head with all the blood vessels
and soft tissue. You can see just the hard tissue
in 3D. You can see how the roots curve and in
what plane and direction. However, the best
information for me is that you can slice the teeth
in the horizontal plane in 0.1mm sections and
see:
1. the actual canals in the root
2. whether there is an MB2 in the maxillary
molars
3. how many canals are in a bicuspid (max
and mand)
4. whether the canals are calcified
5. whether any canals were missed in
retreatment cases
6. PARs while they are still confined to the
medullary bone (wow!)
This instrument is a major step forward in
endodontic diagnosis!
What makes this all work is the pricing of the
machine by Imtec. Instead of a flat dollar price
or lease for the machine, you can opt for a dollar
amount for each scan that is taken. There is a
minimum of $3,000 per month. On this page are
some examples of what we have to look forward
to.
Figure 1 shows a 3D picture of all the bony
and hard structures. This view can be rotated
and moved in any plane to see the relationship of
various anatomic landmarks.
Figure 2 shows a slightly magnified view of
the maxillary arch in a horizontal slice. Each
slice is 0.1 mm thick. The resolution is amazing.
FIGURE 1: A 3D picture of all the bony

and hard structures.
Figure 2
FIGURE 2: A slightly magnified view of

the maxillary arch in a horizontal slice.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/asd27catscan.html[2/21/2011 10:25:16 ]
Figure 3
Tooth #3 shows the MB2 canal. On tooth #2 I

cannot see the DB canal.
Figure 3 shows a greatly magnified view of
teeth numbers 2 and 3. The MB2 on tooth #3 is
FIGURE 3: The beginning of the
very evident. When I scrolled through the slice,
maxillary sinus.
I could see that the MB2 joined the MB near the
apex. At the apex there was only one MB canal. Figure 4
This is very good information to know.
Figure 4 shows the beginning of the maxillary
sinus. As we scroll through the slices, we can
see whether the root tips are in the sinus or not.
We can also see whether the sinus is cloudy or
not. If there were a PAR between the root tip
and the sinus, we could see that also.
This instrument promises to kick endodontic
diagnosis and treatment into the 21st century. We
are currently on a waiting list for delivery of our
new diagnostic instrument.
November-December 2005 FIGURE 4: A greatly magnified view of
teeth numbers 2 and 3.
It is important to
continually disinfect the
surface of your finger
ruler. Placing an
instrument from an
infected canal on the
surface to check or
change the measurement
control can lead to crosscontamination of new
instruments and guttapercha cones.
Doug Kase
FEEDBACK?
questions.
NewTom 9000 Accuracy
Alan Winter, D. D. S.
Product Review

ENTAL CAT SCANS are becoming endo friendly!
New technology and software are allowing a virtual 3D view of the roots and surrounding bone. Better diagnosis
makes better treatment. Dr. Alan Winter, a New York
periodontist whom many of you know, describes it in detail
below.
Allan S. Deutsch
THE NEWTOM 9000 is not a GPS guided missile system,
but it does have pinpoint accuracy. NewTom is an
abbreviation for new tomography, a technology with great
promise. Until now, computed tomography (CT) imaging,
also known as CAT (computed axial tomography) scanning,
has been ordered primarily by dentists who place implants,
and in certain diagnostic situations where 3-D imaging helps
formulate a diagnosis. Dental CT scans reformat a series of
spiral images into recognizable dental structures. The result
is a series of transaxial and axial views that enable us to
locate the mandibular nerve, observe the size and shape of
the maxillary sinus, determine whether a cyst has broken
through the cortical plate, note the dimensions and placement
of atrophic ridges, and do so much more as well.
What does the NewTom 9000 offer beyond all that?
Plenty.
Accuracy
The first thing that impresses us is NewToms accuracy.
Although dental CT scans provide detailed information,
dimensions can be off by as much as 1.5 mm. That may not
seem to be much, but when there is only 10 mm above the
mandibular nerve, technical errors on the magnitude of 1.5
mm cannot be overlooked. Why does the error occur?
Dental CT scans take a series of parallel spirals and convert
them into specific images by sophisticated algorithms. The
computer compensates for the small gaps between the spirals,
but these gaps accumulate into a margin of error. The
manner in which a technician places the patients head also
contributes to the error.
The NewTom differs from a traditional dental CT scan in
the way it captures an image; it does so by cone beam
volumetric tomography. The X-ray tube revolves around the
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/aw01newtom.html[2/21/2011 10:25:16 ]
patients head in a single spiral, capturing a volume with

each of the 360 degrees it rotates. Added together, the
volumetric cone images are reformatted without any
discernible error. In fact, the NewTom is accurate to 0.1 mm.
Reduced Radiation
Accuracy is good, but what else separates the NewTom from
a traditional dental CT scan? In two words, less radiation.
While a dental CT scan takes ten minutes of working time
and exposes the patient to two minutes of radiation, the
NewTom scan takes 70 seconds and exposes the patient to 17
seconds of low-dose radiation. The radiation from a
NewTom scan is comparable to the radiation from a single
Panorex, while a dental CT scan is roughly equivalent to 6?8
times that amount, depending on bone density.
More Information
Another difference is that a dental CT scan shows only what
is prescribed: either the mandible or maxilla. If a patient
needs both a maxillary and mandibular CT scan for implants,
the total radiation is equivalent to about 15 Panorexes. The
NewTom, however, takes both the maxilla and mandible with
a radiation dose equivalent to that of a single Panorex. In
addition to both jaws, the NewTom scan displays both TMJs
and the sinuses, as well. Another advantage of the NewTom
is that the fees are much less for much more information.
Tomographic Images and Endodontics

Okay, so were talking about greater accuracy, more
information, less radiation, quicker scans, but why would
endodontists be interested in dental tomographic images?
The answer is evident once you see what this machine is
capable of doing. For example, consider the following:
An axial cut on the NewTom easily identifies a second
hidden canal in the MB root of a maxillary first molar.
Actually, the axial cuts of the NewTom cut through
each root, millimeter by millimeter, depicting every
canal of every root of every tooth.
Transaxial cuts reveal hidden roots or untreated roots

that require endodontic treatment.
Coronal cuts are so specific that they can separate the

MB from the DB root of a maxillary molar, permitting
an accurate diagnosis of which root has periapical
pathology and which doesnt. Extrapolate this to the
next step, and the NewTom distinguishes between
sinus and dental infections.
You can see why we are so excited about the NewTom. It

gives more information about the teeth, the root canals,
condyles, mixed dentitions, impacted teeth, and
supernumeraries than conventional CT imaging does, and it
helps detect and diagnosis pathology with greater accuracy
than anything else currently out there. It wont solve every
problem for us, but in an age that demands greater precision
and predictable results, the NewTom brings us one step
closer to the elusive gold ring of 100 percent detection and
diagnosis that we all strive to grab.
For those needing one more reason to try this technology,
the NewTom 9000 can produce studies in both NewTom and
SimPlant formats. Implant studies can be ordered along
with views of the TMJ; chronic pain sufferers can get specific
pictures along with detailed panoramic cuts; and patient
studies are always on file for future review.
If the NewTom interests you as much as it has captivated
us, call me at APW Dental Services, PC, (212) 838-8302,
and request a descriptive brochure. Not only do we have the
first NewTom 9000 in New York City at APW, but we have
the only one on the East Coast. We are located in a historic
townhouse at 34 East 62nd Street, and we would be pleased
to have you visit our office or arrange for a personal in-office
demonstration. Dr. Herbert Frommer, director of radiology at
NYU Dental Center and the only board-certified oral and

maxillofacial radiologist in New York City, reads every scan
for pathology including the structures of both jaws, the
sinuses, airway space, and temporomandibular joints. APW
is a radiology lab run by dentists for dentists.
May-June 2003
FEEDBACK?
A New Standard of Care?
Alan Winter, D. D. S.

T HAS BEEN SAID that an endodontic filling is
equivalent to an angiogram; each depicts the nuances,
constrictions, and patency of its respective organ.
Graphic representations of a three-dimensional anatomic
structure, be it an accessory canal or collateral circulation,
will provide more information and data to help diagnose or
treat both medical and dental problems than will conventional
X-rays.
With the increasingly common placement of dental
implants, the use of three-dimensional data from computed
tomography (CT) and cone beam volumetric tomography
(CBVT) is invaluable in dental implant treatment planning,
temporomandibular joint (TMJ) dysfuntion, pathology, and
orthodontic evaluations. While CT scan technology has been
available for twenty years, a number of considerations limit
its use in dentistry. In addition to inflicting high-dose
radiation exposure on the patient, CT scans only take one
arch at a time. A patient who needs the opposing arch
scanned would be exposed to the same exposure again (equal
to ten panoramic films). CT scans create so much scatter that
it may limit the quality of an image and make visualizing
atrophic ridges or key anatomy difficult.
By comparison, the CBVT scanner (e.g., the NewTom
9000) significantly reduces the radiation exposure (by 80 to
90 percent). In addition, it significantly reduces scatter from
existing restorations. The NewTom 9000 CBVT scanner
takes both arches at the same time, reduces the patients
exposure to unnecessary radiation, is available for future
studies, and saves a great deal of time.
APW Dental Services, located in midtown Manhattan, is
the only dental radiology center in the tri-state area that has
the NewTom 9000 CBVT scanner. Their tomographic
services exceed expectations when it comes to providing
scans for comprehensive treatment planning, TMJ,
endodontic lesions, orthodontics, pathology, third molar
cases, and pre-surgical considerations for dental implants. In
fact, so much information is included in their cone-beam 3D
volumetric tomograms that it may very well become a new
standard of care for pre-surgical analysis for dental implants,
chronic dental pain, recalcitrant endodontic lesions, TMJ
dysfunction, and more.
Like a well (laterally) condensed root canal, a 3D
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/aw02newstandard.html[2/21/2011 10:25:17 ]
tomogram can give more information than any of us may

have dreamed of when it comes to seemingly routine clinical
situations. Consider Figure 1; the bridge had failed and the
dentist wished to place implants in the edentulous area. This
is a panoramic view of a 3 mm slice with a 12 mm trough.
This means that everything 12 mm buccal and lingual to the
center 3 mm cut is captured in this view.
Figure 1
FIGURE 1: A panoramic view of a 3 mm slice with a 12 mm

trough.
Consider that the information in these 25 mm is more

precise than a conventional panoramic radiograph, and that
both are good screening devices to observe impacted teeth,
supernumerary teeth, retained root tips, most periapical
radiolucencies, and most anatomic structures. But is this
image, along with a dental periapical X-ray, enough to place
a dental implant? Perhaps not.
Figures 2 and 3 represent a 1 mm slice with a 1 mm
trough, which equals a 3 mm view through the mandible.
Figure 2
FIGURE 2: A 1 mm slice with a 1 mm trough.
Figure 3
FIGURE 3: Showing major and minor branches off the nerve.
Notice how well-defined the mandibular nerve is and notice

what appear to be major and minor branches off the nerve.
Figure 3 marks these branches, which can easily be seen in
transaxial (sagittal) slices. Based on the analysis and report

provided by APW Dental Services, the dentist informed the
patient that nerve damage could be expected if implants were
placed. Instead, an alternative treatment plan was designed
for the patient that would not jeopardize the nerve.
In a different but similar case, teeth were removed in the
mandibular left. In preparation for implant placement, the
dentist referred the patient to APW for a 3D tomographic
study. While the panoramic view (Figure 4, which is a 3 mm
slice with a 12 mm trough) did not raise any alarms, the 1
mm slice with the 1 mm trough (Figure 5) indicated that
placing an implant in the area of the mental foramen, which
the dentist intended to do, could be a problem.
Figure 4
Figure 5
The transaxial (Figure 6) cut demonstrates an atypical mental

foramen that extends to the lingual cortical bone.
Figure 6
FIGURE 6: Transaxial cut demonstrates an atypical mental

foramen that extends to the lingual cortical bone.
The distance from the crest to the nerve was 9.3 mm. When
the dentist indicated that he planned to place a 10 mm
implant, it was suggested that he alter his treatment plan. In
the past, this dentist had used only periapical films to
determine where to place a dental implant. With this added
information, he was able to prevent a potential problem and
render better care to his patient.
In less than a year, APW Dental Services has brought a
welcome change, enabling tri-state dentists to provide better,
more accurate pre-surgical analyses for their patients. Not
only are implant patients better served, but APW has assisted
surgeons in isolating impacted teeth, cysts, retained roots,
oral-antral communications, and more. When it comes to
implant cases, APW provides a unique service: they highlight
and identify the mandibular nerve in the 1 mm panoramic
frames and in all transaxial views. Upon request, they will
provide measurements of the amount of bone above the
mandibular nerve in appropriate sites. In addition, a formal
oral radiological report (provided by Dr. Herb Frommer,
director of radiology at the New York University College of
Dentistry) may be requested for each patient.
APW Dental Services is located in a historic landmark
brownstone at 34 East 62nd Street. APWs fees are highly
competitive, and they offer one-day service. They are open
Monday through Friday and can be reached at 212-838-8302.
February-March 2004
FEEDBACK?
Thoughts on Recent Academic Proceedings
Barry L. Musikant, D.M.D.

Barry Musikant
he speakers at the Fifth International Symposium on

Endodontic Biology included academic researchers of
world renown. The meeting was dedicated to the discussion
of single-visit versus multiple-visit endodontics. In a certain
sense, it was like going back in time, because as researchers
they were discussing sterile and non-sterile canals, which
brought up the specter of culturing, something that most of us
considered a nightmare in dental school.
Researchers General Conclusions

Barry Musikant
While the speakers were not recommending culturing, they

generally came to the following conclusions:
1. All vital cases should definitely be done in one visit for
less post-operative pain. This conclusion is partially
based on the following one.
2. All temporary filling materials leak; cavit allows the
least amount of leakage.
3. In multiple visits, any reduction in bacteria as a result
of the first visit will be repopulated with bacteria by the
second visit.
4. The toughest cases to achieve success are not
bacterially infected but fungally infected.
5. If some bacteria are left after adequate obturation, they
are generally
entombed
subjected to reduced nutritional conditions
incapable of reaching vital tissues
rendered non-viable by the canal medications
in a small percentage of cases, capable of
survival and able to prevent healing
The survival of fungi offer the poorest long-term success
rate because fungi interact with the macrophage cells
periapically to increase the release of calcium inducing bone
and root resorption. This is often a low-grade chronic process
occurring over a number of years, often without symptoms.
Researchers General Recommendations

The reality of endodontic therapy is that we do not know if
we have all of the bacteria or fungi in the root canal after
treatment and if we do, what specific organisms they are. The
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm01thoughts.html[2/21/2011 10:25:18 ]
researchers generally offered these recommendations:

1. Widen the apices of canals to at least a #30 instrument
with a significant coronal flare. This not only
physically removes bacteria and disengages dentin, but
allows adequate space for NaOCl irrigation.
2. Have an excellent coronal seal, because data shows that
long-term success is as dependent on the prevention of
coronal leakage as it is on an apical seal.
3. Prevent gutta percha from going over the apex. Most of
us originally learned that one of the reasons gutta
percha makes an ideal filling material is its inert nature
when in contact with periapical tissues. Research was
presented that shows gutta percha over the apex has the
potential to also interact with the macrophage cells to
induce bone and root resorption. This detrimental effect
is enhanced when the gutta percha has been degraded
into a less stable structure as a result of chemical
softening with chloroform or the application of heat
during thermoplastic obturation procedures.
4. NaOCl is used in concentrations ranging from 2.6% to
a full 5.25%. The higher the better as long as the
application does not allow for periapical extrusion
under pressure.
5. Ca(OH)2 is a good inter-visit medication when a case
is highly infected.
My Conclusions
Some of my own thoughts on what I heard at this meeting
include:
1. Our practice is on the right track in using our
Simplified Endodontic Technique, (S.E.T.) as our
endodontic guide because it widens and tapers the
canals enough to efficiently irrigate them with NaOCl
5.25%.
2. S.E.T. places a gutta percha point thoroughly coated
with an epoxy resin (EZ-Fill) into the confines of the
canal. Because it is a single cone system, the gutta
percha is not subject to vertical or lateral condensation
that could force the point into the periapical tissues,
inducing a macrophage interaction resulting in bone
and root resorption.
3. Epoxy resins have their own anti-bacterial and antifungal properties as the material sets, rendering any
remaining bacteria and fungi less viable.
4. Epoxy resin cements offer the most resistance to
coronal leakage due to their polymer structure, unlike
ZOE based cements that are particulate in structure and
disintegrate far more readily in the presence of
moisture.
Single-Use Endodontic Instruments

One of the researchers brought up the idea of using

endodontic instruments for only one visit and then discard
them because they incrementally dull with usage and are
more prone to fracture over time.
I strongly object to this idea!
The advent of Ni-Ti instruments has given the dentist an
armamentarium that has increased the cost of each instrument
from approximately $.70 per instrument to $7.00 per
instrument.
Unlike tough and inexpensive stainless steel, Ni-Ti is
vulnerable to fracture, especially when instrumenting curved
canals. Yet the instrumentation of curved canals are where
they are most needed to prevent canal distortions such as
transportations and zipping. The fact that Ni-Ti instruments
have their greatest potential to fracture in these situations
where they are most needed represents an ironic paradox set
before us.
The manufacturers of these Ni-Ti instruments would love
us to use systems composed of expensive and vulnerable
instruments and to dispose of them after one visit to reduce
the fracture incidence during their usage and the potential for
subsequent lawsuits. Rather, I strongly believe that using a
hybrid system of stainless steel and Ni-Ti that takes
advantage of the strengths of each and de-emphasizes the
weakness of each represents a far more rational system than
the wholesale replacement of Ni-Ti files after a single usage.
S.E.T. specifically addresses these issues. Those using the
system have found that fracture of the few Ni-Ti files used is
a rare occurrence and when it does occur it is generally in
your hand and not in the root. The simple bending test that
we do before placing a Ni-Ti instrument into the canal
quickly determines if the instrument has enough strength for
use in shaping the canal without fracture. Because of our
emphasis on stainless steel and the high number of times we
can use Ni-Ti instruments before discarding them, the cost of
S.E.T. instrumentation is minimal compared to all of the
systems being advocated today.
Interestingly, the viewpoint of single usage derives from
the academic circles where instruments are often donated to
the dental schools by the manufacturers in the hope of
influencing dental students to become future customers. It is
far easier to advocate single usage when the economic impact
of that decision does not hit you directly.
I know that I am not alone in rebelling against a system
that increases the cost more than ten-fold without any effort
to see whether the end point of the instrumentation, namely
the shape of the canal, could be attained in a more efficient
and economical manner as advocated by S.E.T. We are far
better off as practitioners when we exchange and develop
information about techniques rather than rely solely on
facts that are presented by manufacturers and marketers.
FEEDBACK?

We Use What Works
We Use What Works

Barry Musikant
e have all taken many courses in our quest to do

things better, easier, or faster. Yet, often we never
incorporate what we recently learned. Certainly, I
took a number of endodontic courses over the years that
emphasized rotary Ni-Ti instrumentation and thermoplastic
obturation. They did not become part of my techniques and I
started to analyze why this was the case.
Departures from Established Procedures

Barry Musikant
One of the main reasons we do not apply new information is

is that it may represent a sharp departure from the existing
knowledge base. For example, a switch from manual stepback endodontic instrumentation to a rotary crown-down
technique, or lateral condensation with a change to a heatcarrying applicator. Both represent a significant departure
from the way things were done.
Rotary crown-down presents itself as a superior technique,
but is it better, easier or faster to learn, and is it truly superior
enough to justify its incorporation into your daily routine?
The rotary Ni-Ti crown-down technique has requirements
that the step-back technique does not, including:
1. a light touch that never binds the instrument to the
point where it cannot be pulled out or drawn in
2. a technique that requires constant motion of the
instrument
3. frequent replacement of instruments even though you
do not see obvious distortion to them
4. a technique that requires clear tactile perception of
when and to what degree the instrument is binding
Some thermoplastic obturation techniques require the
following to be newly incorporated:
1. the application of a high heat source for a very short
time; approximately 2 seconds to a fitted gutta percha
point followed immediately by
2. a 3 mm apical push for 5 seconds more after the heat
has been applied followed by
3. reapplication of high heat and withdrawal of the
instrument
It Takes Time and Practice

file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm02whatworks.html[2/21/2011 10:25:18 ]
We Use What Works
Time and practice are required to achieve the skill to

incorporate these new procedures. Poor application of any of
these skills severely affects the outcome of the procedures.
In other words, these new techniques that might produce a
superior result over more traditional techniques also carry
with then the burden of a narrow window of success. A series
of difficult tasks must all be performed well to get a good
result.
Potential negative results from the rotary crown-down
techniques include instrument fracture and subsequent
blockage of the canal. Potential negative results from heat
application techniques include excessive heat to the root and
periodontium producing pain and tissue necrosis, possible
extrusion of softened gutta percha, and shrinkage of the
heated gutta percha mass yielding a poor dentin-cement
interface, something that may occur without the dentists
awareness of it.
Therefore, the desire to accept a new technique and, thus,
be motivated to learn it, at some point is determined at least
in part by the difficulty of the technique with all its potential
drawbacks versus the predictability of higher quality results.
The greater the predictability of excellent results the more
likely the technique will be used again. If the quality of the
results vary widely, the poor predictability of the technique
makes for less acceptance by the practitioner.
The advantages of rotary Ni-Ti crown-down over step
back include:
the avoidance of hand fatigue
the elimination of distorted curved canals
The advantages of thermoplastic obturation over lateral
condensation include:
better adaptation of the gutta-percha to the walls of the
root (discounting shrink-back)
less mechanical stress to the root during obturation
better looking x-rays, often including lateral canals in
non-vital cases
The Ultimate Decision

Ultimately for any procedure, the practitioner must decide
whether the advantages outweigh the disadvantages.
For endodontics, the practitioner can make this decision in
light of the EZ-Shape and EZ-Fill techniques that are easy to
learn. These techniques vary little from the previously known
manual step-back techniques, yet deliver wider tapered
canals. These canals are shaped to exactly fit a fine-medium
or medium gutta percha point. This precise shaping allows
the canals to be obturated with a single room-temperature
master point and an epoxy-resin cement of varying thickness
that is routinely delivered as an interface between the gutta
percha and the walls of the root.
The simple reason that EZ-Shape and EZ-Fill are being
We Use What Works
adopted by the dental community is that they are in phase

with previously learned knowledge, doing away with
traditional shortcomings and adding those few features that
allow the dentist to predictably do endodontics as well as the
best endodontist simply, quickly, and cost effectively.
11/02/1999
FEEDBACK?
Proper Diagnosis of Teeth
Proper Diagnosis of Teeth: Making Sure Youre

Doing the Right Tooth!
Barry Musikant
lthough Simplified Endodontic Technique (S.E.T.)

gives you a cookbook approach to achieving excellent
endodontics, the original diagnosis is critical in
applying S.E.T. to the right tooth. A sequence of twelve steps
helps you correctly diagnose most teeth.
1. Take a good history.
Barry Musikant
Listen to everything the patient wants to say. Not only will

you get useful information, but you are letting the patient
know that you have time and concern for him or her.
Depending upon the information the patient supplies, you
can often shorten the diagnostic procedure. Good questions to
ask are:
What do you think the problem is?
Does it hurt to hot or cold?
Does it hurt when youre chewing?
When does it start hurting?
How bad is the pain?
Does anything relieve it?
How long has it been hurting?
2. Take a radiograph.
It may show a periapical or periodontal area, decay,
resorption, deep fillings, fracture, or thickened PDL.
Radiographs are indispensable. No diagnosis should be made
without them.
3. Employ percussion-tapping.
Percussion-tapping with the mirror handle on the tooth in a
vertical direction often allows you to identify the tooth that
has inflammation in the ligament and, consequently, hurts the
most to tapping.
If two teeth together hurt to tapping, immobilize one with
your finger while tapping the other and then reverse the
process. Often you will find that one hurts significantly more
than the other and will be the more suspicious of the two.
4. Employ palpation.
Press into the fold above the apex of the root or roots. Often
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm03properdiagnosis.html[2/21/2011 10:25:19 ]
the endodontically involved tooth will be more tender than

the others if the inflammation has extended into the
periapical region, and palpating in this way will produce a
greater sensation. You should also be able to detect any
swellings or fistulas that may be present. Palpate the lingual
of teeth with the same goals in mind
5. Apply the cold test.

This is simply done with cylindrically shaped ice sticks.
Make them by placing water in empty anesthetic carpules and
adding a piece of dental floss that extends to the bottom of
the carpule and has a handle on the open end of the carpule.
Keep them in the freezer and withdraw the frozen cylinder
when needed.
A good site of cold application is generally the buccal
surface as close to the cemento-enamel junction as possible.
If a metal crown restoration is on the tooth, attempt to apply
the ice on the lingual metal collar, an area where the cold
travels most easily.
If a tooth has irreversible pulpitis it will either give a
prolonged response, possibly after some delay, or no
response. Transient pain (less than ten seconds) after the
application and removal of ice is normal. No response may
mean the tooth is endodontically involved, especially if all
other teeth respond to cold.
If sharp transient pain occurs that is greater than the pain
felt in surrounding teeth, check to see if the bite is high. Root
canal is probably not needed and the bite adjustment will
eliminate the hyper response to cold.
6. Apply the heat test.

Using a ball of hot gutta percha on the tip of a plastic
instrument, place the gutta percha onto the tooth the same
way you would the ice. Wait approximately 15 seconds
between teeth to assess the possibility of a delayed, but,
prolonged response.
Compare the results from other tested teeth. If one tooth
gives a prolonged response, whether immediate or delayed, it
is a most suspicious candidate for endodontics. If the pain is
immediately relieved by cold, the tooth probably needs root
canal.
7. Apply the electric pulp test (EPT).

This test should be used when the hot and cold tests fail to
give clear information on the state of vitality of the tooth.
Again, the information supplied by the electric pulp test must
be weighed against the response from other teeth. the fact
that a tooth does not respond to the EPT has little meaning if
all the other teeth also do not respond, unless of course this is
the only tooth with a well-defined area at the apex or is quite
tender to percussion.
8. Use bite sticks.
Use bit sticks to check for incipient fractures that are causing
pain to a tooth when under function. By having a patient bite
on each cusp and laterally move the lower jaw, each cusp is
subjected to lateral stresses. If a section of the tooth under a
cusp has an incipient fracture it will often hurt when pressure
is applied.
If a fracture does exist, the tooth may not need endodontics
if the fracture does not extend into the pulp. The pain
generally disappears if the fractured portion of the tooth can
be cleaved off.
9. Employ transillumination.
Transillumination often confirms the portion of the tooth that
has the fracture. By placing the transillumination light source
on the lingual side of the tooth and turning out the chairside
light source, fractures may be picked up as a dark horizontal
line against a light amber background. Transillumination can
sometimes differentiate between vital and non-vital teeth
with the non-vital appearing duller than the surrounding ones
when the light source is applied.
10. Use the binocular microscope.

It is excellent for picking up incipient fractures simply
because you can look at teeth magnified up to 30 X with
excellent illumination.
11. Apply selective anesthesia.

It should be applied with an intraligamentary gun. If specific
anesthesia to one tooth makes all pain disappear for a short
time and the effect is repeatable, the anesthetized tooth is
probably endodontically involved.
12. Drill a test cavity.

If you believe that a non-vital tooth is causing symptoms, but
cannot confirm non-vitality with assuredness, a test cavity
without anesthesia may allow entry into the pulp without any
pain, thus confirming your suspicions.
Even after using all these tests we may find at times that we
are still not confident in making a definitive diagnosis.
Realize that some pain that appears to be dental in origin is
not. Problems involving the temperomadibular joint, sinuses
and the trigeminal nerve often mimic endodontic pain, but,
will not disappear after treatment. If you suspect non-dental
causes, refer the patient to the appropriate specialist (medical
or dental) unless you are knowledgeable in these areas
yourself.
Good diagnosis comes from using as many of the above
tools as are necessary to confirm as solidly as possible your
opinion on what should be done. My experience is that
patients truly appreciate the time you take to confirm what
should be done.
This is especially true when a patient comes in with a
strong feeling that one specific tooth is the source of the
problem, but your diagnosis says that it is another and after

treatment you are right. If it turns out that you are wrong, that
is the subject of another article!
11/02/1999
FEEDBACK?
The Fallacies of Non-Metallic Posts
Barry L. Musikant, D.M.D., Brett I. Cohen Ph.D., Allan S. Deutsch D.M.D., F.A.C.D.

Barry Musikant
t would appear that the recycling of old ideas packaged in

the guise of new technology shows up every now and
then to make a case for its superiority over proven
techniques and devices. Non-metallic posts are an excellent
example of this process. Unsupported claims are made that
the retention is optimal because the posts take advantage of
the greater adhesion produced by etching and bonding,
something all passive posts do.
The Modulus of Elasticity Fallacy

Barry Musikant
Allan Deutsch
In addition, a marketing innovation includes great emphasis

that the post are made of materials that endow them with a
modulus of elasticity equal to that of dentin. This implies that
because of the similarity, the post will bend in unison with
the tooth, reducing functional stresses to the root that would
have been far greater if a metal post had been inserted into
the canal.
The claim of similar flexibility of the post and the tooth is
very attractive for the long-term success of the postsupported restoration. The reality of the concept is false,
however, and not supported by the logical analysis of its
claims. First of all, when claims are made that the materials
have the same modulus of elasticity, it means that the
samples tested have the same cross-sectional area. This
should immediately become clear if one realizes that a
redwood tree and a redwood tooth pick both have the same
modulus of elasticity. The tree is immovable, while the
toothpick can be snapped in two between your fingers.
Obviously, the cross-sectional area affects the resistance to
bending.
A post going into the root of a tooth has by necessity a
much smaller cross-sectional area than the root it is being
placed into. The smaller the cross-sectional area, the greater
the flexibility, just as in the case of the toothpick. Because all
posts are thinner than the roots they are going into, a similar
modulus of elasticity will produce a post that bends far more
than the root it is in. The claim of similar moduli of elasticity
is a weakness, not a strength, and a post that bends
significantly more than its supporting root will not bring
longevity to the overlying restoration.
More specifically, the modulus of elasticity of dentin is 8.
The diameter of the shank of the average post going into a
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm04nonmetallic.html[2/21/2011 10:25:19 ]
root is generally between 20 and 25 times smaller than the

host root. To compensate for this smaller diameter, the
modulus of elasticity should be proportionally higher,
producing a stiffer material. A stiffer material that has a
thinner cross-sectional area could bend in a fashion similar to
the bending of the root, if it has the proper modulus of
elasticity. The modulus of elasticity of stainless steel is 200,
25 times that of dentin.
Yet, if the cross sectional area of the stainless steel post is
about 25 times thinner than the root, the bending of both the
post and the root will be the same when subjected to an
outside force (200 / 25 = 8). A careful analysis of the
original claims for non-metallic posts not only demonstrates
that they bend far more than the roots that they are in, but
also that stainless steel, rather than being too stiff, has in fact
an excellent modulus of elasticity for compatibility between a
post and supporting root.
The Composite Core Fallacy

While claiming the benefits of a lower modulus of elasticity,
a further part of the technique includes the addition of a
composite core. the claim is made that the combination of
the two creates a mono-block that bends like a tooth,
something that the post was supposed to be able to do on its
own. The term mono-block implies a homogeneity of
materials, suggesting that the post and core are so similar that
they act as one unit. However, the postthough flexibleis
highly resistant to fracture because of carbon fibers palced in
parallel in the matrix.
The composite core is not endowed with such fractureresistant components and is subject to degradation under
function from a post that bends far more than the root. In
fact, the first area of degradation would be along the
composite core dentin interface producing a gap formation
susceptible to decay and further widening. For the concept to
produce longevity, the core would also need the incorporation
of parallel carbon fibers, a product that does not exist today.
The Superior Esthetics Fallacy

A newer generation of non-metallic posts which are
composed of either a reinforced composite or ceramic are
making claims of superior esthetic results. They are being
advocated when the teeth are being restored with the new
ceramic crowns. The solidity of the final restoration is based
on the bonding ability of the new adhesives. As any
endodontist will tell you, endodontically treated teeth do not
make ideal abutments!
If possible when they are used, additional teeth that have
not had endodontics are incorporated into a restored span for
greater stability. It is traditional, unchallenged knowledge that
when endodontically treated teeth are crowned, the margin
should include a long bevel onto the root surface to create a
superior ferrule effect. The new ceramic crowns, like their
predecessors, require a butt joint. These restorations should
not be placed on endodntically treated teeth, especially those

with a post-supported core. If the better restoration is a
porcelain fused to metal crown with a long bevel, the need
for an esthetic post does not exist, and the post that is placed
can have higher retention and better stress distribution pattern
than any of the non-metallic posts can deliver.
The one area where a tooth-colored post might have some
irreplaceable benefit is thin roots covered by a thin labial
gingiva where the color of the metallic post might show
through. The incidence of this particular situation is very
small and even there can be modified by the use of opaquing
cements over the shank of the metal post when it is placed
within the root.
Conclusions
In summary, the claims made for non-metallic posts are not
supported by the logic of many laboratory studies.
Further, the use of esthetic non-metallic posts with butt
joint full coverage restorations is counter-productive and
should be avoided. Well designed stainless steel prefabricated
posts (Flexi-Post and Flexi-Flange) are more compatible with
functioning roots, producing far higher retention, minimum
stress upon insertion, and even distribution of stress under
function.
It would appear that the even distribution of stress under
function is enhanced by a post that bends very similarly to
dentin, the result of a significantly higher modulus of
elasticity, such as that of stainless steel.
11/02/1999
FEEDBACK?
How to Instrument and Obturate Superbly
How to Instrument and Obturate Canals Superbly

and Economically
Barry Musikant
Barry Musikant
ost dentists instrument canals with .02

tapered stainless steel reamers or files.
They may open the apex anywhere from a #15 to
a #40. Having instrumented with .02 reamers or
files, they then obturate the canals with .02 tapered
gutta-percha or standardized (I.S.O.) or
(standardized points). Generally, the canals and
the point are coated with cement and the pre-fitted
point is placed into the canal, followed by the
addition of extra points in a combination with
vertical and lateral condensation.
As you may know, although the fit film is
placed accurately to the apex, the final film often
shows gutta-percha over the apex. You might
logically decide that you used too much vertical
force. What you should understand is that you are
placing an almost parallel gutta-percha point into
an almost parallel preparation. An .02 taper is very
close to parallel. Is it any wonder, therefore, that a
small amount of condensation then results in
overfill?
An alternative is to shape your canals with
greater taper and place points of greater taper,
making it more difficult to drive the points over
the apex, even if you apply significant vertical
condensation. Because of this greater resistance,
you will have fewer unpleasant discrepancies
between your trial fit and final cementation.
Buchanan designed a set of files of greater taper
going from .06 mm/mm to .12 mm/mm. These
tapered files correlate almost exactly to various
tapered gutta-percha points. For example, the .06
file of greater taper correlates to a fine-medium
point. The .08 file of greater taper corresponds to a
medium point.
Both Buchanan files will bind exactly at the
apex. As good as these files are for creating proper
shapes, they should not be used from the start of
instrumentation because they would be subjected
to considerable stress
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm06howtoobturate.html[2/21/2011 10:25:20 ]
Since they are made out of Ni-Ti, they can

break without warning despite showing no signs of
wear.
Using Ni-Ti Instruments Without Fear of

Fracture
To take advantage of these Ni-Ti instruments
without fear of fracture, shape your canals first
with a step-back sequence using the .02 tapered
stainless steel reamers. The sequence consists of
the following steps:
1. Determine the distance to the apex. (We
obtain greater accuracy from an apex locator
than x-rays. Weve used a unit from Osada
for years)
2. Coat all files and reamers with RC Prep and
irrigate copiously with with 5.25 percent
NaOCL delivered with a 30 gauge needle
used with very light pressure.
3.
4.
5.
6.
7.
8.
9.
10.
A 30 gauge needle allows you to irrigate

efficiently near the apex as the shaping
progresses. The light pressure prevents the
solution from going peripically. Remember,
only a few drops are necessary apically to
thoroughly fill the canal space with fluid,
and time is necessary for the NaOCL to
digest the organic debris and kill residual
bacteria.
Instrument to the apex through a #20 reamer
using a rotational motion.
Track the canal 1/3 to 1/2 its length with a
#2 Peeso reamer, tapering the canal in the
process. Minimal force assures no ledging or
blocking.
Recheck your apical patency with the #20
reamer.
Go 1 mm short of the apex with a #25
stainless steel reamer.
Checking your patency after each reamer
is a good idea. Having used the stainless
steel reamers through #45 in a step-back
fashion, you now have created a canal shape
with a .05 taper using .02 tapered
ENDO TIP
A key point in using NiTi instruments is to

prevent heavy hand
pressure and binding. If
you use light hand
instruments! The increasing stiffness of the

thicker stainless steel reamers have not
distorted the canal shape because as the
reamers become progressively wider, they
go diminishing distances. This sequencing is
an excellent safety device.
If by chance you initially over-instrument,
you will not compoud the problem by
repeatedly injuring the peripical tissues
because the technique requires you to pull
back. At this point in the process, you are
more than halfway to achieving an .06 or .08
tapered canal space.
11. Employing a balanced-force technique, use
Buchanans .06 file of greater taper to the
apex without applying a lot of pressure. The
final shape, going from a .05 taper to a .06
taper should take less than 30 seconds.
12. Once an .06 taper is achieved, you can
automatically fit a fine-medium point, or
you can choose to shape the canal with an
.08 file of greater taper, which should take
you no more than an additional 90 seconds
followed by a trial fitting of a medium
gutta-percha point.
pressure, the binding is

minimal. You will remove
less tooth structure at
any one time, but will be
compensated for it by
increasing the number of
instrumentation cycles.
A key point in using Ni-Ti instruments is to

prevent heavy hand pressure and binding. If you
use light hand pressure, the binding is minimal.
You will remove less tooth structure at any one
time, but will be compensated for it by increasing
the number of instrumentation cycles. A higher
number of cycles combined with reduced hand
pressure prevents the Ni-Ti instrument from
reaching its elastic limit.
Distortion occurs only after reaching its elastic
limit, and Ni-Ti easily fractures when reaching
this point without any tell-tale signs. An additional
advantage is that as delicate as Ni-Ti is, it will last
almost indefinitely, if the elastic limit is not
violated.
The Bi-Directional Spiral

The placement of a well-coated tapered guttapercha point into a well-coated tapered canal
drives the cement into accessory invaginations if
they exist and ensures the safe release of excess
cement coronally.
The bi-directional spiral (BDS) is the most
effective way to safely place cement on all walls
of the preparation. The BDS creates lateral
movement of the cement while preventing it from
going over the apex.
EZ-Fill cement is used to coat the canals and

the prefitted tapered gutta percha point. It has the
following advantages:
It is non-toxic and non-inflammatory.
It is eugenol-free.
Because it is an epoxy resin, its compatible
with composite chemistry
It bonds to dentin and gutta-percha.
It is highly radiopaque.
It neither shrinks or expands.
More than 45 years of research back its use.
After coating the canal, coat the last 4-5 mm of the
tapered gutta-percha point, place it into the canal,
and sear off the excess material. A single tapered
gutta-percha point is all that is required. Coronally,
the thicker cement seal stays perfectly intact.
Displacing it with further point placement will
achieve nothing.
The time requirements for this sequence from
start to finish on a non-calcified single canal
should be less than 20 minutes (with practice).
The money invested in this technique is
minimal because the emphasis is on inexpensive
traditional stainless steel reamers and regular
tapered gutta-percha points.
We believe that this technique is truly the best
of both worlds, resulting in superbly shaped
canals, a well-fitted gutta-percha point with a
continuous epoxy resin interface that has been
driven into any invaginations that may have
existed, produced in a time-efficient and
economical manner.
Nothing else comes close!
11/02/1999
Instruments used in this procedure are available

from the following sources:
Buchanan Files
Tulsa Dental . . . (800) 662-1202
MDKD&V Logo
EZ-Fill Endodontic Cement

Bi-directional Spirals
EDS . . . (800) 223-5934
Endodontic Reamers
Tapered gutta-percha points
If you would like a

demonstration of this
technique, e-mail us or call
L. D. Caulk . . . (800) 532-2855
our offices at (212) 582-8161.
Peeso Reemers #2
NaOCI(Clorox)
Standard Items
FEEDBACK?
your comments about any of the articles in EndoMail.
Thoughts on Nickel-Titanium Instrumentation

Barry Musikant
Barry Musikant
egular readers of our newsletters will

notice an increased emphasis on simplified
endodontics. I have taken many courses on
new techniques available for instrumentation and
obturation, and have concluded that needless
complexity and expense has evolved from the
insight that there is not a single canal, but rather
a system that may include various accessory
invaginations.
To clean and obturate this system, leading
endondontists determined that all canals had to
be thoroughly debrided and obturated. Opening
the canals to a wider taper allows them to be
cleaned and irrigated more efficiently. Shaping
to a greater taper allowed the canals to be
obturated with thermoplasticized gutta-percha
without pushing the gutta-percha over the apex.
These innovations, wider taper and thermoplastic
obturation, are improvements over the traditional
.02 tapered canal shaping and obturation with
standardized points.
Improvements Brought Complication

and Expense
While these innovations are improvements,
many of the instruments and techniques used to
achieve them are complicated and expensive.
The introduction of Ni-Ti files of different
designs to achieve a wider taper requires the
implementation of a crown-down technique
because of their metallurgic characteristics.
Although Ni-Ti has super elasticity to negotiate
curved canals without distorting them, it has little
tolerance for deformation without fracturing.
To minimize instrument distortion, the crowndown technique requires the use of thicker files
first with thinner ones used sequentially in a
crown-down direction. This technique is delicate,
requiring keen tactile sense and patience. In the
process of switching from stainless steel to NiTi, the cost of the average instrument increased
from $1 to over $6! This, without any promise
ENDO TIP
Have you ever opened the

chamber of a pulp and
experienced a fetid odor? I
have. Using a mouthwash in
a syringe to irrigate the pulp
canal works to eliminate that
odor. Many times I'll leave
the rinse inside the chamber
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm07niti.html[2/21/2011 10:25:21 ]
that the Ni-Ti instruments would last even as

long as stainless steel ones. The increased use of
Ni-Ti that must be replaced frequently to achieve
the continuously tapered canal shape is common
to most of the techniques employing crowndown preparations.
Replacing lateral condensation with various
thermoplastic techniques also produced a major
increase in the cost of obturation. $6
thermoplastic points replaced $.07 gutta-percha
points. Heating systems costing thousands of
dollars replaced Bunsen burners and lateral
condensation. One method of thermoplastic
obturation requires placing a red-hot spreader
within 5 mm of the apex, releasing the heat ring,
and further advancing it another 3 mm over a
matter of seconds,
reheating the spreader, and releasing it from the
gutta-percha followed by further obturation with
a gutta-percha glue gun.
Are the improved results justification for the
increase complexity and expense? I do not
believe so.
for a few minutes. Afterwards,

I'll rinse with sodium
hypochloride. Then the odor
will dissipate. Patients who
smelled the initial odor feel
terrific, for there is no longer
an odor. Furthermore, they
feel that you, as a practitioner,
have "really" done something
for them. I hope you have as
much success with this
technique and patients'
acceptance of it as I have.
Amy Dukoff, D.M.D.
Simple and Economical Alternatives

Read the accompanying article on this site
entitled How to Instrument and Obturate Canals
Superbly and Economically for alternative
methods that are simple and economical.
We have employed them in our office for ten
months with immense success, characterized by
reduced flare-ups, excellent radiographic results
and ease of operation. The techniques described
in this article are in full conformity with the
latest research in endodontics. The sealing ability
was at least the equal of thermoplastic and lateral
condensation techniques. These techniques have
reduced cost and time.
The increase in complexity and expense to
achieve superior results has proved not to be
inevitable after all; it has been short-circuited by
a little creativity and common sense.
11/02/1999
FEEDBACK?
Endo-Mail.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm07niti.html[2/21/2011 10:25:21 ]
X-Tip Product Review
X-Tip, Where X Marks the Spot

Product Review
Barry Musikant
Barry Musikant
X-Tip Step 1
ractical Endodontics (800.215.4245) lives up to its
name by introducing the X-Tip anesthetic system. It
is a system that eliminates the weaknesses of
Stabident.
Both systems create a hole into the trabecular bone
approximately 5 mm apical to the buccal papilla. The
anesthetic solution is then injected under low pressure into
the trabacular bone mesal to the tooth that is being treated.
The problem with the Stabedent system was finding the
hole, which was made through the attached gingiva to
inject the anesthetic. X-Tip solves this problem by making X-Tip Step 2
the drill itself a hollow tube through which a 28 gauge
needle can pass. The initial drill stays in place, allowing
the anesthetic to then be placed without hunting for the
hole that was just created!
What I like most about this system is the fact that the
guide (your drill), stays in place for the entire procedure,
allowing for more anesthetic to be placed if necessary.
Because extra anesthetic can be delivered so effortlessly,
there is never a need to include adrenaline in the
X-Tip Step 3
anesthetic, which prevents tachycardias and other
unwanted events.
The safety and convenience of this tool will give every
dentist the ability to give adequate anesthesia, generally
one of the first prerequisites for successful endodontics.
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm08xtip.html[2/21/2011 10:25:21 ]
New Post Designs and Applications
Barry L. Musikant, D.M.D., F.A.C.D., Brett I. Cohen Ph.D., Allan S. Deutsch D.M.D., F.A.C.D.

Barry Musikant
Barry Musikant
Allan Deutsch
uch has been written about new post designs that

bend like the tooth structure and, through the use of
bonding agents, have very high retention values. One study
has stated that the new composite posts create no stress under
function because they bend like the tooth. Other passive
post systems are ceramic, look like tooth structure, are
bonded into place with high retention and are, consequently,
said to be superior.
From a review of literature, and from our own clinical
experience, we hope to clarify the situation.
First of all. There is no thing as a passive post. They still
distribute functional stresses to the walls of the root. They
may have the advantage of not inducing insertional stresses,
but if not designed properly still have the potential of
distributing functional stresses in a concentrated fashion. In
fact, the only passive post is the one in the box!
Another point to remember is that to date, no combination
of etchants, microabrasion, bonding agents, or cements has
proven to be as resilient or as strong as dentin. A threaded
post with even a weak cement still offers more tensile
resistance than any passive post because the thread is locked
into the dentin. The resistance that dentin offers is far greater
than any cement developed to date. More importantly, the
fatique charachteristics far exceed that of any composite
cement.
Research has made it abundantly clear that threaded posts
have the potential of creating high levels of insertional
stresses. We could not agree more! The concept of the split
flange, a characteristic of the Flexi family of posts, was
developed to mitigate the stressful effects of the thread while
maintaining its retentive advantages.
Many independent studies confirm the combination of high
retention with minimal insertional stresses and the even
distribution of functional stresses associated with the splitshank concept.
One relevant clinical question is when to use the FlexiPost versus the Flexi-Flange. First, it is important to know
that the Flexi-Flange exists. It is the third tier that was
designed to give the post greater stability when no coronal
tooth structure exists.
The flange creates a broader metal-to-dentin surface.
Under function, all posts put tensile stress on the cement
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm09newpostdesigns.html[2/21/2011 10:25:22 ]
interfaces between the shank of the post and the walls of the
root. A large flange offers vertical resistance to the posts
lateral movement, consequently preserving the cement
interface along the post shank. Added reinforcement is not
necessary when adequate coronal tooth structure exists, but is
a necessity when it doesnt.
To take advantage of the multi-tiered design, the post may
be fully seated. If the flange is not seated, it is the same as
not being there! Depending on the amount of dentin
remaining, either a Flexi-Post or a Flexi-Flange is our choice
when it has been determined that a post is necessary.
During our courses on Simplified Endodontic Techniques,
we practice instrumentation on plastic blocks. If you wish to
practice placing Flexi-Post or Flexi-Flange in these blocks,
let us know, and we will accommodate you.
11/02/1999
FEEDBACK?
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm09newpostdesigns.html[2/21/2011 10:25:22 ]
How to Judge a Safe Endodontic System
How to Judge a Safe Endodontic system
Barry Musikant
SYSTEM of endodontic instrumentation is created to

provide a shape to a canal that assures that it has been
thoroughly cleansed by both the instruments used and
the irrigating solutions applied with them. The system is
composed of a series of instruments used in a specific
sequence delivered to the canal either manually or by a
powered handpiece. Each of those instruments should ideally
have a design that optimizes its usage. The design, delivery,
and sequence (DDS) of the instruments should support one
another in the most efficient and safest way possible.
Design
CANAL SHAPES with tapers of .06 mm/mm or greater are
more likely to be cleansed than the traditional .02 mm/mm
tapered canals because greater tapers remove more pulp
tissue, increase the ability to place irrigating solutions closer
to the apex, and increase the intimate contact of the irrigating
solutions with the walls of the canal. As the taper of the canal
increases, the surface tension between the walls of the canal
and the irrigating solutions decreases, allowing greater flow
of the irrigating solution producing more effective cleansing
action.
Delivery
LEARNING TO USE these instruments in a safe manner
requires the ability to develop a light touch that prevents
excess engagement at any one time. The touch that one
must develop has no clear parameters other than it must feel
right. Poorly defined parameters mean that fewer
practitioners will get it just right.
Long-rooted teeth with tight canals and one or more curves
further complicate successful instrumentation. Most
problematic is the fact that NiTi reamers and files are prone
to fracture when subjected to levels of torque, flexure, and
fatigue that are close to the normal forces that must be
applied. Consequently, NiTi rotary instrumentation is a
technique with a very narrow window of success. If the
technique is not performed exactly right, the result may be a
fractured instrument locked into the canal space.
Sequence
THE SEQUENCE of the instruments should be compatible
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm10howtojudge.html[2/21/2011 10:25:22 ]
How to Judge a Safe Endodontic System
with their strengths. If a rotary NiTi reamer is used in a

crown-down fashion, the potential of high dentin engagement
exists. The greater the engagement, the greater the stress to
the instrument, stress that is magnified further if the
instrument is negotiated around a curve.
Proper sequencing ensures, first, that the extra work each
instrument must do falls well within its ability to do it
without fracturing and, second, that the practitioner can easily
tell when to progress from one instrument to the next. The
design of each instrument in the sequence should further
enhance its ease of use.
Results
THE RESULT of properly designed instruments used in the
correct sequence is a system that shapes canals safely,
simply, predictably, effectively, and economically. The
impact upon you personally is far less stress, greater pleasure
in performing the procedures, and more free timemeaning
either greater financial productivity or increased leisure time.
To learn more about properly designed systems that eliminate
the endodontic stress in your life, e-mail me.
FEEDBACK?
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm10howtojudge.html[2/21/2011 10:25:22 ]
The Future Is Coming
Barry L. Musikant, D.M.D., F.A.C.D.
Barry Musikant
OME OF THE DENTISTS I speak to praise the

nickel-titanium rotary crown-down technique. They
say that it eliminates the most significant problems of
traditional endodontics: there is no more hand fatigue, there
are no more distorted canals, and instrumentation sizes the
canal to a tapered gutta-percha point. The unpredictable
flimsy fills of traditional endodontics have given way to a
standardized taper that allows the dentist to place a much
bigger gutta-percha point producing dramatically improved
radiographs.
Given this picture of progress, I have at times felt like a
Cassandra when I talk about the shortcomings of this
highly praised and highly advertised technique. My
biggest concern regarding rotary NiTi instrumentation is
the increased potential for instrument fracture. More often
than not, dentists tell me that they used to fracture
instruments when they first began using the nickeltitanium rotary crown-down technique, but since they have
become more familiar with the techniques, fracture is very
infrequent and is further reduced by replacing the
instruments before they weaken to the point where fracture
is likely. That response might have ended further
discussion, but thinking about my own emotions when I
was going through the NiTi rotary phase, I ask them
whether they worry about the possibility of fracture even
though the instruments rarely do fracture. And the
response is always the same. They always worry.
This consistent response from dentists, most of them
significantly younger than I am, made me think that
perhaps there are generational differences toward stress.
Maybe the younger you are, the more comfortable you are
with stress. I dont think so. More likely, the dentists who
accept this stress do so because they see no alternative to
doing excellent endodontics and, therefore, that is the price
they must pay. I believe I would have done the same
except that I had a crying need to produce excellent results
in a simplified manner, eliminating the stress that seemed
as if it would lie ahead of me for the rest of my
professional life.
The result of my attempt to lessen that stress was the
development of the EZ-Fill bi-directional spiral, which
coats the canals thoroughly in a controlled manner, and a
Endo Tip
When the length

of a tooth
approaches the
maximal depth of
a 25-millimeter
instrument, the
interference of
tooth structure or
a metallic
restoration may
make placing the
probe of the apex
locator difficult. In
such cases, it is
easier to attain
proper
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm11futurecoming.html[2/21/2011 10:25:23 ]
sequence of eight stainless steel hand reamers and two

NiTi hand files, which allow the dentist to perform onevisit endodontics in less than an hour with results that are
indistinguishable from thermoplastic obturation techniques.
Most dentists react quite positively to these new
techniques even if they are doing rotary NiTi crowndown. The idea of eliminating the fear of fracture while
reducing overhead by at least a factor of ten will generally
gain someones attention. However, some dentists actually
take mild offense when shown an easier way, especially
when they have made a large investment in time and
money to learn the so-called modern techniques. The
contemporary term for the anxiety that they feel when they
recognize the superiority of the new techniques but reject
the idea of adopting them is cognitive disonance. Like
jealousy and envy, cognitive dissonance does little to
improve our ability to take in new information.
We are in an irritating era for endodontics. Every time
we think weve got our act together, along comes new
information that unsettles the applecart, even if it doesnt
quite upset it. Take heart. In these pages, over the next
few months, we are going to show you complete
endodontic systemssimple in design, affordable, and
efficientthat will give you the ability to do endodontics
as well as the best endodontists.
measurement
control using a
31-millimeter
instrument rather
than a 25millimeter
instrument.
Doug Kase
FEEDBACK?
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm11futurecoming.html[2/21/2011 10:25:23 ]
The EZ-Fill SafeSider Instrumentation System
The Introduction of the EZ-Fill SafeSider

Instrumentation System
Barry Musikant
PPROXIMATELY seven years ago, after attending

rotary nickel-titanium hands-on courses by Drs.
Ruddle and Buchanan, I implemented these systems
into my practice. Although many of my results improved due
to the greater tapered shapes these techniques produce, I felt
subjected to increased stress because of the higher incidence
of fractured instruments and the fear of not knowing when I
might fracture an instrument. Higher stress levels are exactly
what I did not need at that stage of my professional life, and
my desire to eliminate that stress was the prime motivation
for my searching for a sequence of instruments that would do
away with it.
As most of you probably know, this search led to the
development of Simplified Endodontic Techniques (SET).
SET transformed our practice, allowing us to become at least
twice as productive, producing radiographic results at least as
good as rotary nickel-titanium, and removing the fear of
fractured instruments.
Beyond SET
AS GOOD AS SET IS, it was still a sequence of existing
instruments not specifically designed to optimize
instrumentation. After two years of development, we are
finally able to introduce the SafeSiders, a sequence of ten
hand instruments that will allow you to instrument an average
canal in less than five minutes and a difficult, curved canal in
less than eight minutes, making one-visit endodontics a
readily achievable goal. (See Figure 1.)
The name of the game in endodontics is to get to the apex as
easily and quickly as possible without blocking or distorting
the canals. The sequence of SET maximized this process for
the instruments that existed until now.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm12safesiders.html[2/21/2011 10:25:23 ]
FIGURE 1: The EZ-Fill SafeSider Instrumentation System.
The Effect of the Flat

THE SAFESIDERS improve upon SET by having along their
entire working length an uninterrupted area of relief, called a
flat, that does not engage the dentin when the instrument is
negotiated to the apex (see Figure 2). The flat is one of those
simple design changes that has a profound effect on
instrumentation. Any canal can now be quickly instrumented
to receive a medium or medium large gutta-percha point. I
would say that the SafeSiders improve instrument efficiency
by about 25 percent.
FIGURE 2: EZ-Fill SafeSider flat on the 30/.04 NiTi instrument.
The increased taper encourages better irrigation with 5.25

percent NaOCl. The flat creates an open space for debris.
While the flutes on one side are relieved, the central core of
the instrument is not, leaving the instrument essentially as
strong as it was before. Yet the rotational force needed to
negotiate apically is significantly reduced, allowing total
instrumentation with a light touch. (Dr. Deutsch discusses
the flat in more detail in New EZ-Fill SafeSider Endodontic
Instruments.)
Less engagement means less resistance. The small
reduction in cutting ability is compensated by rotating the
instrument an extra turn, something the dentist does
automatically anyway. The net result is that the instruments
glide through the tooth, reaching the apex quickly and
efficiently. The first eight instruments are tough stainless
steel, and the last two instruments in the sequence are nickeltitanium. They are used to size the canal to accommodate the
tapered gutta-percha point that is to be placed.
Unlike rotary nickel-titanium, the relieved nickel-titanium
SafeSiders may be used many times without replacement
because the SafeSiders are not subject to high degrees of
torsional stress. They are never rotated beyond resistance. In
addition, we perform a simple manual bending test that

assures the dentist that if the instruments do not break in the
hand they will not fracture in the tooth.
In conjunction with the EZ-Fill Obturation System,
SafeSiders will give you a great sense of control and, with
time, the confidence to take on more difficult cases.
Personally, it gives me great satisfaction to introduce an
instrumentation system that meets our needs, is economical,
produces results that are at least the equivalent of rotary
nickel-titanium, and does away with all the insecurities and
expenses that those modern systems impose.
As always, we are ready to help you learn these new skills.
In the past, weve taught many of you how to use SET; we
now encourage you to take the new course with the SafeSider
instruments and see the difference. (Click here for the course
announcement.)
March-April 2001
FEEDBACK?
Fractured Instruments in Rotary NiTi Endodontics
Fractured Instruments in Rotary Nickel-Titanium

Endodontics
Barry Musikant
ITH INCREASING momentum, modern endodontics

is being defined by rotary nickel-titanium
endodontics. There is no question that these
modern techniques have solved the problems associated
with traditional endodontics, including canal distortion, hand
fatigue, weak underfills, overfills, fractured roots, damage to
the periodontal ligament, and iatrogenically blocked canals.
The shift to rotary nickel-titanium also brings with it the
potential for increased incidence of fractured instruments as
well as strip perforations in thin, curved roots with
concavities. To reduce the incidence of fracture,
manufacturers strongly recommend replacing the instruments
after only limited use. In addition, torque sensing handpieces
have been developed that autoreverse when a set amount of
torque is exceeded. Glickman and Koch state that
Making the
formerly
unacceptable
acceptable is a
definition of
lowered
standards.
nickel-titanium utilization requires special

precautions. [Nickel-titanium instruments]
should only be used to resistance and never be
forced. Limiting factors associated with NiTi
include the inability to bypass or remove ledges,
a steep learning curve, high expense, and the
universal concern for file separation.
They further state that
NiTi rotary files are no more susceptible to
breakage than stainless steel so long as all
principles of rotary instrumentation are strictly
adhered to, clinicians understand and master the
respective systems prior to clinical usage, and
proper disposal schedules are developed for
NiTi. Aberrant canal anatomy, instrument
fatigue, and improper usage patterns can
contribute to file separation. It is much more
critical in a rotary technique to fully comprehend
the canal anatomy of each canal. For example,
NiTi files should be avoided in canal systems
where two canals come together, when a canal
bifurcates or where there is an S curve. During
use, clinicians should continually observe for
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm13fractinsts.html[2/21/2011 10:25:24 ]
instrument fatigue, as overuse or abuse of files

will predispose them to failure. How a file is
used and the type of canal form it is used in are
probably just as critical as how many times a
respective file is used; for example, calcified
canals will logically stress NiTi files more than
patent straighter canals. Usage and constant
monitoring is additionally important because
these files need to operate at the proper RPM and
in a consistent manner.
NiTis Narrow Window

LICKMAN AND KOCHS list of caveats shows how
narrow the window for success is in nickel-titanium
endodontics. If canals were not curved, there would
be no need for nickel-titanium. Yet the greater the curve the
more susceptible nickel-titanium instruments are to fracture.
Manufacturers recommend frequent replacement of rotary
nickel-titanium instruments, but they do not shed light on the
interactions between the canal and the rotating NiTi file that
rapidly produce the defects in the instrument that lead to
fracture. It is an empirical rule to reduce the separation of
instruments within the canals without truly understanding the
causes of separation. Innovative methods of controlling
torque are being added to the technique because fractures still
occur despite increased and highly expensive precautions.
Another phenomenon is starting to appear: the
rationalization of the entire problem of fractured files.
Articles have recently appeared that minimize the problem.
One paper states that if an instrument fractures in the tooth,
the tooth will often heal anyway or a simple apical procedure
will solve the problem. An apicoectomy on a mandibular
second molar in close proximity to the inferior alveolar nerve
is not a simple apical procedure. Nor is any apical surgery
simple for the patient. If endodontic failure occurs because
the dentist who performed the procedure is not able to
cleanse and seal a canal with a fractured instrument in it, the
dentist may be responsible for that tooth and any restoration
supported by that tooth even though the doctor informed the
patient that the instrument had fractured in the tooth when it
happened.
Progress?
RACTURING A SEGMENT of an endodontic
instrument is no less a problem for dentists today than it
was 25 years ago. Any suggestion to the contrary potentially
misleads dentists, reducing their ability to make wise
decisions concerning the endodontic techniques they wish to
use. From a historical perspective, any attempt to mollify
concerns about fractured instruments tends to make more
acceptable the techniques that lead to fractures. Making the
formerly unacceptable acceptable is a definition of lowered
standards. Standards should not be lowered as a way of

being less critical toward a new system. Any new system
should meet and exceed consistently held standards. That is
a definition of progress.
The advantages of manual and rotary nickel-titanium
instruments must be balanced against their disadvantages.
The same principle applies to stainless steel instruments.
Deciding which type of instrument to use is not an either-or
situation, but rather an effort to incorporate the advantages of
NiTi with the advantages of stainless steel into a system that
eliminates the weaknesses of both. The result would be a
new system that would benefit from the best of both worlds:
it would cause no hand fatigue or canal distortion, and it
would be predictable, controllable, simpler, far less prone to
fracture, and significantly less expensive.
Advocates of rotary nickel-titanium techniques claim that
there has been a paradigm shift in endodontics. There has
been a paradigm shift, but it is defined by the final result, not
the methods by which that result is attained.
May-June 2001
FEEDBACK?
When Science and Empiricism Go Hand-in-Hand

N THE August 2001 issue of the Journal of Endodontics,
authors Kuhn et al. analyzed the potential reasons for the
incontestable increase in fractured instruments when
using engine-driven rotary nickel-titanium instruments. The
article fascinated me because it gave a scientific explanation
for these fractures and indirectly supported many of the
concepts we developed for the EZ-Fill SafeSider
Instrumentation System. The points they make include these:
Barry Musikant
1. Superelastic metals such as nickel-titanium flex far

more than stainless steel instruments yet in clinical use
have a much higher incidence of fracture.
2. The incidence of nickel-titanium fracture is related to
defects from:
work hardening of the alloy before machining
surface defects produced during machining
propagation of existing surface defects by cyclic
fatigue, making the metal more brittle as the
defects become larger and more numerous
The authors used x-ray diffraction, scanning electron
microscopes, and microhardness tests to observe the initial
state of the nickel-titanium instruments as well as the
degradation that took place with use. They came to the same
conclusions scientifically that we reached empirically.
Nickel-titanium instruments are most prone to fracture when
instrumenting curved canals. The greater the curve, the more
stress the nickel-titanium instrument undergoes, producing a
greater number of crystalline defects within the alloy as well
as an increased number of growing surface defects that make
the instrument more brittle and prone to fracture. Nickeltitanium alloy differs markedly from stainless steel, which
distorts and fractures due strictly to plastic deformation and
not because it becomes more brittle with use.
Score One for Empirical Reasoning

THE EMPIRICAL reasoning behind the manual SafeSider
Instrumentation Technique was to develop a system that
would create a canal space equivalent to the best shape
produced by engine-driven rotary NiTi instruments while also
replacing the vulnerable, unpredictable NiTi alloy with tough,
predictable stainless steel wherever possible.
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm15whenscience.html[2/21/2011 10:25:24 ]
To further enhance the ease, simplicity, and predictability

of the SafeSider Technique, we designed a sequence of
relieved flat-sided cutting-edge instruments that promote
rapid negotiation to the apex. Stainless steel instruments
compose the first 80 percent of the system. Only the last two
instruments in the sequence are composed of nickel-titanium,
and they, too, incorporate the SafeSider relieved flat. By
shaping 90 percent of the canal space prior to the use of
NiTi instruments, the remaining 10 percent puts little stress
on the subsequent NiTi hand instruments. The forces applied
to the NiTi instruments are further reduced by a significant
straightening of the canal prior to their use. Because they are
never rotated beyond resistance, the amount of stress the
instruments are subject to is limited. Finally, the NiTi
instruments are first test-bent in the hand approximately 90
degrees. If they do not break in the hand, they will not break
in the tooth if used in the prescribed manner. If they do break
in the hand, breakage is the ultimate confirmation that
discarding the instrument at this point was the proper thing to
do. The bending test is highly significant in light of Kuhns
paper, which states that crack propagation increases,
rendering the instruments more and more brittle.
The SafeSider Instrumentation System replaces and
compensates for an engine-driven rotary NiTi system,
delivering comparable shaping in less time and at far less
cost. The entire SafeSider System consists of ten instruments
plus the No. 2 Peeso reamer used in a completely safe
fashion. The first four instruments enlarge the canal to the
apex to a No. 20 stainless steel reamer, which is usually the
starting point for all NiTi rotary systems. After this only six
more instruments and under four minutes are usually needed
to produce a canal shape that accepts a medium or greater
gutta-percha point.
A tremendous amount of marketing money has been spent
convincing dentists to use the rotary NiTi systems. Despite
all the expensive secondary innovations to reduce the
incidence of fracture plus the support of large segments of the
endodontic community repeating the mantra that rotary NiTi
is the new paradigm, there are more caveats today in the use
of these systems than for any other systems. The Kuhn paper
clearly defines the basic weaknesses of rotary NiTi
endodontics. With full appreciation of the superior shaping
results that can be attained, the SafeSider Instrumentation
System delivers those results without yielding to rotary
NiTis disadvantages.
Stress and the Thermal Gradient

IN ANOTHER PAPER, titled The effect of thermal change
on various dowel-and-core restorative materials, published
in the July 2001 issue of the Journal of Prosthetic Dentistry,
Yang et al. demonstrated that the stress level developed in the
restoration and the surrounding dentin was closely related to
the degree of thermal gradient. The nonmetallic dowel and
cores generated greater thermal stresses than metal dowel and

cores. The combination of a resin core with a carbon-fiber
dowel generated the highest stress in the cement layer core
and metal-ceramic crown. Thermal stresses generated from
the thermal gradients of the nonmetallic dowel-and-core
materials generated additional stresses in the cement and its
interface. With increasing thermal expansion, stresses in the
restorations and coronal portion of the dentin increased more
markedly than did stress levels in the supporting bone.
As I often point out in my lectures, to me the worst
restorative combination is a carbon fiber post with a full
composite core surrounded by a ceramic crown ending in a
butt joint onto dentin. The Yang paper states that the cement
layer between the core and the crown undergoes the highest
degree of degradation, opening up the margins. Open
margins lead to secondary decay and internalized
micromovement in a vicious cycle that shortens the life of
the restoration The esthetic goals that prompt the use of a
full ceramic restorationwhich, in turn, requires a
nonmetallic postmay be more functionally met by the use
of a Captek-like restoration with a feathered metal margin
that allows the use of a fully functional metal post without
compromising esthetics.
The Flexi-Post and Flexi-Flange design have a metal
dowel and a supporting core that is generally about 75
percent metal after the core has been prepared. The small
amount of additional composite should limit the amount of
heat absorbed by the core material. In addition, if Ti-Core
with titanium is used, the metal component of the post and
core is even greater, mitigating the thermal gradient of the
composite portion of the core.
As founders of Essential Dental Systems, we obviously
support the products we developed and market. However, it
is nice to see that as the years go on the latest data from
independent researchers support concepts that we have
incorporated and, in turn, critically review concepts and
designs that we have rejected. These products were first
developed for our own use and, if they worked as we
planned, we then made them available to the profession. It is
a simple concept that still seems to work.
An Interesting Insight
THE OTHER DAY, the suction in my rooms went down and
I had to use another room. The slow speed handpiece was
different from the one I am used to, and I found using the
No. 2 Peeso in this room more difficult than in my own.
Here are the particulars: In both my rooms I use a Titan slow
speed unit. It is connected to a rheostat that allows low
rotations with good torque. A slight depression of the foot
rheostat starts the Peeso slowly rotating exactly as it should.
However, in the other room, a Viper handpiece from Kinetics
did not operate as smoothly. Depressing the rheostat slightly
did not start the handpiece slowly. The rheostat had to be
depressed more to make the handpiece start, and then it went

faster than I wanted. Once it had started, I could back off on
the speed, but this movement did not give me the same
control I have with the Titan unit. In addition, despite the
greater speed I did not have as much torque. Ideally, I want
slow speed and high torque to give me optimum control of
where to remove circumferential dentin. Bottom line: it did
not give me the same control that I have with the Titan
handpiece. Certainly, you can use the Viper and get used to
it. Perhaps, the Viper handpiece can be better adjusted.
However, I believe in making life as easy as possible, and
using the Titan makes my life easier. If this little insight
strikes a chord with you, check out the Titan. It cant hurt,
and it might help.
P.S. I used Amys room. Since then she has switched to
the Titan slow speed handpiece and also finds life a lot
easier.
FEEDBACK?
Design and Sequence Determine Endodontic Success Success
Design and Sequence Determine Endodontic Success
Barry Musikant
UCCESSFUL ENDODONTICS results in teeth that

are comfortable under function and regrow bone
where bone loss has previously occurred.
Inflammation within the periodontal ligament is usually
the reason endodontically treated teeth are
uncomfortable. Inflammation is incompatible with bone
regeneration. Inadequate debriding, overinstrumentation,
and overfilling either initiate inflammation or do not
resolve preexisting inflammation.
Fractured instruments are one cause of inadequate
debriding. If the apical portion of the canal is blocked
early on by a fractured file, irrigating and cleansing apical
to the broken instrument will be impossible unless the
dentist can remove or negotiate around the separated
segment (Figure 1). The incidence of fracture is directly
related to the instruments resistance to torsional and
flexural stress, which in turn is related to the sequence of
instruments used. The greater the amount of dentin each
instrument must cut, the greater stress that instrument
may encounter.
Crown-down rotary NiTi poten-tially subjects the
initial instruments to excessive torsional and flexural
stresses. The torsional stresses increase as the instrument
engages and cuts a greater length of canal. The flexural
stresses increase as the instrument deviates from a
straight line (Figures 2 and 3). Torsional and flexural
stresses together create a stress load that is greater than
the sum of their individual loads. NiTi offers far less
resistance to these stresses than stainless steel. NiTi is
flexible, but soft. Where stainless steel can selectively
cut into dentin in a directed fashion, NiTi can only mill
dentin away while staying centered. A centered canal
preparation is far more likely to encounter a strip
perforation on the distal aspect of a mesiobuccal root than
is a canal prepared by a No. 2 Peeso purposefully directed
away from the furcation and the distal aspect of the
mesiobuccal root.
The sharper and harder the metal, the easier the task of
cleaving dentin from the canal wall during
instrumentation. Stainless steel is approximately four to
five times harder than NiTi. NiTi can cut dentin only in
very small increments. If it engages more than the
Figure 1
FIGURE 1: Fractured
instrument blocking apical
portion of the canal.
Figure 2
FIGURE 2: Flexural stress

increases as the
instrument deviates from a
straight line; the arrow
indicates the point of
stress and potential
fracture.
file:///D|/...DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm16designandsequence.html[2/21/2011 10:25:25 ]
minimum amount of dentin at any one time, it is unable

to cleave the dentin from the canal walls. Rather, the
dentin engages the flutes of the file or reamer and sucks
the instrument into the tooth without cleaving off the
dentin, subjecting the instrument to excessive torsional
and flexural stresses.
This potential stress problem is aggravated by the
crown-down sequence of instrumentation. Crown-down
implies going from thicker to thinner instruments as the
canal is negotiated apically. How far apically to go with
the initial instruments is not well-defined. If a .12
tapered rotary NiTi instrument .20 mm at the tip initially
negotiates 6 mm into the canal, the diameter of this
instrument at the orifice is 0.92 mm (6 x .12 + .20). This
width can only be gained gradually and carefully by using
a light touch and a rapid up-and-down motion of the
instrument, making certain never to engage too much
dentin at any one time.
A system that uses a sequence that does not define a
clear-cut method of instrumentation, further limited by its
lack of strength and cutting efficiency, is one that cannot
predictably shape the great variety of canal curvatures,
lengths, and widths that will be encountered. Inadequate
instrumentation that results from separated instruments
would logically increase the incidence of inflammation in
the periodontal ligament, leading to success rate lower
than that for teeth shaped to the same taper without
instrument separation.
Although the traditional step-back sequence of
instrumentation required modifications to produce a wider
tapered canal preparation, step-back defines the amount
of dentin to be removed at any one time much more
specifically than crown-down does. For example, if the
canal is already opened to the apex to a No. 20 reamer or
file, the width of the apical 12 mm of the canal are as
shown in Figure 4.
If the canal is sequentially widened from No. 25
through No. 40 using a 1 mm step-back technique, the
maximum amount of dentin removed from instrument to
instrument is .03 mm/mm, as shown in Figures 5 through
8, below. This is less than 1/10 th the incremental dentin
removed with the initial crown-down rotary NiTi
instruments (see Figure 9, below). Furthermore, the
instruments doing the cutting are tough, inexpensive
stainless steel, highly resistant to fracture. The step-back
also minimizes hand fatigue and canal distortion because
the instruments go a shorter distance as they become
thicker and stiffer.
Optimization of the modified step-back technique is
encapsulated in the EZ-Fill SafeSider Instrumentation
System, a series of predominantly stainless steel
instruments that are designed with a patented noninterrupted continuous flat along the entire cutting
Figure 3
FIGURE 3: Flexural stress

will be increased if the
instrument must negotiate
past an overhang; arrow A
indicates overhang
preventing continuous
straight line access; arrow
B indicates point of
greatest curvature on
outside wall of canal.
Figure 4
FIGURE 4: Showing a
canal opened to the apex
to a No. 20 reamer or file;
arrow indicates the
thickest, most engaged
part of NiTi, most prone to
fracture.
length. The flat further facilitates rapid negotiation to the

apex in the following ways:
The instrument does not engage the dentin along
the flat. Less engagement means less resistance,
which allows for a lighter touch while negotiating
more rapid access to the apex.
Two vertical blades are created that sweep the
dentin from the flutes into the open space.
The instrument is more flexible, allowing it to
negotiate curves more efficiently.
Instruments last longer because they are used with
less force and in conjunction with the No. 2 Peeso
reamer.
The last two instruments in the sequence are NiTi and
are used manually. They too have the flats and are used
in such a way that they are subject to minimal torsional
and flexural stress. The EZ-Fill SafeSider System
provides a hand test to determine whether or not the NiTi
instruments are strong enough to be used in the tooth
without fracturing. If they do not fracture in the hand
when bent approximately 90 degrees, they will not break
in the tooth if used in the prescribed manner. The two
NiTi instruments quickly provide an .08 taper that is
consistent with complete debridement and thorough
irrigation, standard requirements for endodontic success.
The SafeSiders provide a design and a sequence that
together give the dentist the ability to perform complete
shaping to at least an .08 taper, fit a medium gutta-percha
point, and, with the use of the bi-directional spiral and
EZ-Fill Epoxy-resin cement, create a total threedimensional obturation that is at least the equivalent of far
more expensive and complicated techniques.
Every aspect of the EZ-Fill SafeSider Instrumentation
and Obturation System falls well within the safe capacity
of each instrument to perform its task. Consequently,
excellent results are easily, speedily, economically, and
predictably achieved.
Figure 5
Figure 6
Figure 7
Figure 8
FIGURES 58: Maximum dentin removed from instrument to instrument in 1 mm step-back technique.
Figure 9
FIGURE 9: Showing amount of dentin removed by initial crowndown rotary NiTi instruments.
FEEDBACK?
"No Mans Land": Endodontics Last Frontier
No Mans Land: Endodontics Last Frontier
Barry Musikant
OR THOSE OF YOU who have followed the discussion

of the EZ-Fill SafeSider instrumentation techniques,
it is obvious that straight canals are a lot easier to shape than
curved ones. In fact, the greater the curve, the harder the
shaping process. If you think about it, and probably even if
you dont, the reasons are also obvious.
The straighter the canal, the greater the depth that the No. 2
Peeso can gain before it meets resistance. If a canal
measures 21 mm to the incisal edge and is perfectly straight,
at some point in the instrumentation the No. 2 Peeso, can
attain the depth of 19 mm, its complete extension from the
slow-speed handpiece. The only portion not shaped by the
No. 2 Peeso would be the most apical 2 millimeters.
On the other hand, if a 21 mm canal is highly curved, as in
a molar, the Peeso will go a shorter distance down the root.
The pulp chamber might take up 11 mm of the length,
leaving 10 mm for the canal. Of that length, the Peeso may
only be able to go down 4 mm, leaving a distance of 6 mm to
the apex.
In both the straight and curved canals, a .05mm/mm taper
would be prepared with a 1 mm stepback from instruments
sized 25 through 40 in the most apical 4 mm of the canal.
In the straight canal, the No. 2 Peeso would be able to go
so far apically that it would prepare the canal space into the
stepback area. In the highly curved canal, a space would
exist between the most coronal extension of the stepback (4
mm from the apex) and the most apical extension of the No.
2 Peeso reamer, a length of 2 mm. (The full canal length is
21 mm minus the 11 mm of pulp chamber access minus the 4
mm the Peeso was able to go apically minus the 4 mm
coronal extension from the stepback; 21 - 11 - 4 - 4 = 2 mm.)
I call this space no mans land.
For whatever length no mans land has, its taper is 2
mm/mm, starting at .40 mm. If the length is 2 mm, the
coronal extension of this space is .44 mm in width. (.40 mm
+ [2 x .02 mm] = .44 mm).
The final shaping instruments in the SafeSider technique
include 30/.04 and a 25/.08 manual reamers. The longer no
mans land is, the more these greater tapered NiTi
instruments must cut. This is not a problem, but it is
something the dentist should be aware of.
Fortunately, canals that are so curved that they prevent the
The concept of
no mans land
gives the dentist
a clear
understanding of
the potential of
the No. 2 Peeso
reamer.
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm17nomansland.html[2/21/2011 10:25:25 ]
"No Mans Land": Endodontics Last Frontier
No. 2 Peeso from approaching the coronal end of the

stepback are rare. When they do occur, the remaining NiTi
instruments must do more work, but the technique and
sequencing is designed to minimize the stress developed
within these instruments and produce the final taper quickly,
efficiently, and predictably. (Remember: you should always
test-bend the instruments before using them in the canal.)
The concept of no mans land gives the dentist a clear
understanding of the potential of the No. 2 Peeso reamer.
While this instrument cannot be forced around a curve, the
No. 2 Peeso reamer should extend as apically as possible in a
straight line at right angles to the occlusal surface of the
tooth. With a light touch, the No. 2 Peeso will find its own
depth for each canal without any fear of perforation or
ledging. Combining the No. 2 Peeso reamer with the
SafeSider sequencing allows the dentist to shape all canals to
at least an .08 mm/mm taper, generally in five minutes per
canal or less.
As usual, if any dentist wants help in attaining these skills,
just call me at (212) 582-8161 and Ill set up an evening to
teach you. I never teach more than two dentists on any given
night, so I do get booked up at times. The course takes about
an hour and a half, after which you wont believe how
straightforward and simple the technique is. There is no
charge for this course. I have been doing it as an exercise in
good will for the last six years and personally enjoy it. I
believe you will too.
ENDO TIP
Perforation of a molar does not

mean that the tooth is a lost cause.
You can use MTA to seal the

perforation and get a good
prognosis. MTA is biocompatible and allows for
bone and tissue healing against it. It sets nicely in a
moist environment.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
By mixing the material a little on the wet side, you

can manipulate it a little easier and help it to set
quicker.
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm17nomansland.html[2/21/2011 10:25:25 ]
SafeSiders Produce Superior Post-Hole Preparations
Barry Musikant
E HAVE OFFERED several articles on the benefits

of the EZ-Fill SafeSider instruments for safely
and quickly shaping canals that have a taper similar
to that of engine driven nickel-titanium systems without the
accompanying fear of fracturing instruments. In addition, the
EZ-Fill SafeSider Instrumentation System allows the
practitioner to create a coronal space that is more compatible
to post placement, particularly in molars. In past articles we
described how the SafeSiders do this. In this article we
describe how superior post placement is another result of the
EZ-Fill SafeSider technique.
Nickel-titanium instruments are approximately 75 percent
to 80 percent softer than stainless steel and far less resistant
to torsional stresses. Consequently, when entering a curved
canal, it does not straighten it (Figure 1). Rather, it centers
itself within the canal and widens the inner wall (toward the
furcation) and outer wall (away from the furcation) evenly
(Figure 2).
Figure 1
FIGURE 1: A C-shaped
canal that has yet to be
widened.
Figure 2
FIGURE 2: A C-shaped canal that has

been widened, demonstrating the
removal of tooth structure from the
inner wall.
The result is a curved canal that is uniformly wider. In

single-rooted teeth this feature might be considered
advantageous. However, in a molar protecting the tooth
structure between the inner wall and the furcation is very
important in order to avoid strip perforations particularly in
MB roots of maxillary and mandibular molars. NiTi can do
no differently because it lacks the hardness and torsional

strength to allow it to selectively cut dentin away from the
furca to straighten the coronal portion of the canal. When a
post is to be placed, drills are finally used that will straighten
the coronal path of the canal to give the post straight-line
access and greater depth. Because tooth structure has been
needlessly removed on the furcal side of the canal, the newly
prepared straight-line coronal access has resulted in a canal
space that may be significantly wider than it needed to be
(Figure 3). If a cast post is to be placed, it will have a wider
taper that makes it that much more of a potentially destructive
wedge (Figure 4).
Figure 3
Figure 4
FIGURE 3: A picture of the canal

FIGURE 4: A wide tapered
space after tooth structure has been
cast post with a wide
removed from the outer wall, producing coronal cement interface.
a coronal canal space with a wide
taper.
If a parallel prefabricated post is placed, a lack of coronal fit

will result in a large cement interface that has lower retention
and is more prone to breakdown (Figure 5). If the
practitioner chooses not to straighten the coronal canal path,
the length of the post will be shorter, concentrating more
functional stresses over a smaller area and the post will not
be in line with the long axis of the tooth, resulting in more
functional stresses being distributed laterally within the root
containing the post.
The EZ-Fill SafeSider, on the other hand, create straightline access early in the instrumentation process. Coronally,
dentin is selectively removed from the outer wall, turning Cshaped canals into J-shaped canals (Figure 6).
Figure 5
FIGURE 5: A parallel
prefabricated post with a
wide coronal cement
interface.
Figure 6
FIGURE 6: The C-shaped canal

opened up early on with a No. 2
Peeso to attain straight-line access,
showing where the dentin is selectively
removed.
Not only is a J-shaped canal far easier to instrument, because

you are dealing with one curve and not two, but the canal
shape needs little modification to accept a conservative cast
or prefabricated parallel post. The cast post will have a
thinner taper, making it less of a wedge (Figure 7). The
parallel prefabricated post should fit fairly accurately within
the prepared canal space along its entire length, assuring
greater retention and a longer-lasting cement interface
(Figure 8). Straight-line access assures that the dentist can
create adequate length as well as post placement in line with
the long axis of the root.
Figure 7
FIGURE 7: A thinner tapered cast

post in the canal with a thin
coronal cement interface.
Figure 8
FIGURE 8: A parallel
prefabricated post with a thin
coronal cement interface.
This discussion is an example of taking a concept that was

first enunciated by engine-driven NiTi proponents, namely
that greater tapered shapes are superior to those produced by
conventional endodontic techniques, and achieving those

results in a far simpler, more efficient, and more economical
way.
As usual, we welcome discussion on any points that you
may agree or disagree with and we will be happy to publish
the insights gained from those discussions. I personally
prefer discussion by phone at (212) 582-8161, but if e-mail is
to your liking, by all means use it.
ENDO TIP
Would you like to learn an easy,
thorough, and economical technique
for obturating canals?
Take our free hands-on endo course.
Click here for details.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
Knowing the Research Makes All the Difference
Barry Musikant
ECENTLY, a local endodontist distributed a newsletter

A body of
quoting research from an article by Pommel et al stating
research has
that obturation with a single gutta-percha point produces the
determined that
greatest amount of leakage. From their conclusions he
extrapolated the further conclusion that the EZ-Fill

the use of an
Obturation System (Essential Dental Systems, Inc. S.
epoxy-resin
Hackensack, NJ) would perform badly because it too is a
single-point obturation system. The quoted authors conducted cement . . . is at
least as
their research using a zinc-oxide-eugenol cement as the
interface. They noted that zinc oxide, unlike the epoxy resin
effective as
used in EZ-Fill, hydrolizes in water. The authors conjectured
every other
that zinc oxide would be prone to cement washout over time
method of
because the setting reaction is reversible in the presence of
obturation.
water, resulting in a degradation of the material and leaching
of hydrolized eugenol and unreacted zinc oxide. They
concluded that the large volume of sealer used for the singlecone technique is more prone to shrinkage than the small
volume used for compaction techniques. However, epoxy
resins setting reaction is not reversible in the presence of
water, and because it is a polymer it is far tougher than the
particulate zinc-eugenol cement. The endodontist would not
have come to the erroneous conclusion he reached if he had
been aware of the differences in cement interfaces between
zinc oxide eugenol and epoxy resins.
Furthermore, several studies comparing single-cone
techniques using epoxy-resin cements have attained different
results. Wu, Ozok and Wesselink compared the sealercoated canal perimeter at 3 mm and 6 mm from the apex and
found significantly better seals after the single-cone
obturation (with no condensation) than after vertical or lateral
condensation. Antonopoulous, comparing lateral
condensation with lateral condensation, found similar sealing
abilities. Spangberg tested single-cone, lateral-condensation,
vertical-condensation Thermafil and Ultrafil and found them
all statistically the same, with the single-cone technique
having the least deviation in results. In a study published this
year, Hata et al compared the apical sealing ability of System
B, lateral condensation, and the EZ-Fill obturation technique,
using a one-way analysis of variance, and found no
significant difference among the groups. However, the
authors stated that the root canals obturated with the EZ-Fill
technique showed the least dye penetration. Baumann et al
file:///D|/.../DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm20knowingresearch.html[2/21/2011 10:25:27 ]
compared the leakage of five different single-cone techniques

with lateral condensation and concluded that some singlecone techniques with thermoplastic gutta percha and sealer or
cold gutta percha and a new sealer application tool (EZ-Fill)
can be an alternative to lateral and vertical
condensation. Cohen et al compared the leakage of singlepoint fills using epoxy resins to lateral condensation and
Thermafil and found them all statistically equal, with the
single-point fill having the least leakage in absolute terms.
In a study that addresses the long-term sealing ability of an
epoxy-resin cement interface, Kontakotis, Wu, and
Wesselink compared the performance of five sealers before
and after storage in water for two years. They concluded that
Roth and Pulp Canal Sealer, both zinc-oxide-eugenol
cements, allowed more leakage in thick layers than thin,
whereas no significant difference was found between the thin
and thick layers for the epoxy-resin cement. Cohen et al
confirmed the weakness of zinc-oxide-eugenol cements
compared with epoxy-resin cements. The shear bond
strength of the zinc-oxide-based cement was literally zero,
while that of the EZ-Fill epoxy-resin was 323.9 psi. No
more-adhesive endodontic cement exists.
Furthermore, Cohen determined that the free eugenol found
in all zinc-oxide cements prevents the polymerization of
composites and their bonding agents by scavenging the free
radicals that initiate the polymerization process10. From a
clinical point of view, using the EZ-Fill Obturation
System, Deutsch et al reported a success rate of 94.1 percent
over two-and-a-half years.
A body of research has determined that the use of an
epoxy-resin cement as an interface of varying thicknesses
over at least two years is at least as effective as every other
method of obturation. From a mechanical point of view, one
may believe that a single-point fill cannot obturate accessory
canals. Yet, obturating with EZ-Fill often shows lateral
canals filled. Unlike thermoplastic obturation, in which the
canals are filled with gutta percha, the EZ-Fill technique
predictably fills these canals with epoxy-resin cement. The
filling of these canals is clearly observed because the epoxyresin cement is radiopaque. The canals have been debrided
both mechanically and chemically with NaOCl and are
sufficiently open to allow the extrusion of material into these
spaces.
There is no innate superiority of gutta percha over epoxyresin. In fact, Lee has demonstrated that thermoplastic gutta
percha contracts as it cools from a minimum of 45 minutes to
10 hours, shrinking approximately 4 percent in the process.
Epoxy-resin, on the other hand, goes into the canal at room
temperature and expands approximately 1.75 percent as it
warms from room to body temperature. Not only does
shrinkage continue far longer than the 10 seconds popularly
believed, but very little cement can even be used during
thermoplastic obturation. Because the coronal escape route is
closed off when obturating thermoplastically, any excess
cement in the canal would be forced over the apex under

significant pressure. The single-point technique allows the
safe coronal extrusion of excess cement and, consequently,
cement can be used liberally both in the canal and on the
point itself. Hall demonstrated that at best 62.5 percent of
curved canal spaces are coated with cement with the
traditional applicators, obviously less when thermoplastic
techniques are used. Therefore, combining a thermoplastic
technique with an inadequate cement interface produces a
result far removed from the three-dimensional claims made
for it.
To understand the EZ-Fill obturation system, you must
appreciate the mechanics behind the bi-directional spiral.
The coronal spirals drive the cement apically while the three
apical spirals drive the cement coronally. These two cement
flows collide and are driven laterally. The spiral is used with
an up-and-down hand motion, driving the cement against the
canal walls and any accessory canals that may reside there,
along its entire length. The cement is driven further laterally
when the coated tapered gutta-percha point is placed into the
canal. The EZ-Fill SafeSider instrumentation system rapidly
shapes the canal to a minimum of an .08 mm/mm taper,
which corresponds to a medium gutta-percha point. The
greater the taper of the gutta percha, the more the cement
interface is driven laterally, which is why so many lateral
canals are filled with this instrumentation and obturation
system.
Some other points to be considered: Floren et al noted that
System B represented a narrow window of success because it
is possible to cause thermal damage to the ligament if the
temperature rise exceeds 10 degrees C, something that is
more likely in canals with thin roots. Saw et al demonstrated
that thermoplastic techniques not only caused a temperature
rise in the tooth and ligament, but that this rise created
dentinal stress and could lead to premature fracture. Jurcak et
al reported that Touch N Heat produced increases in
temperature from 8 to 67 degrees C and that this was a
concern. E. M. Hardie reported on similar concerns for the
same reasons.
To further appreciate the utility of the EZ-Fill system,
consider the following research: Zidan et al state that it
appears that leakage is independent of the method of
obturation when an adhesive sealer is used. This can be
attributed to the ability of the adhesive sealer to wet the walls
of the canal, bond to the dentin, and seal the residual volume
between gutta percha and the canal wall. In fact, the
literature shows that an epoxy-resin has strong adhesion to
dentin and the gutta-percha point without the need of a
dentinal bonding agent. Opening the dentinal tubules of the
canal with EDTA significantly increases the bond strength of
the epoxy-resin cement to the dentinal walls. Gettleman et al
compared the adhesion of three cementsAH-26, Sultan,
and Sealapexto dentin with the smear layer intact and the
smear layer removed. AH-26 has the highest adhesion to
dentin when the smear layer is removed.

Limkangwalmongkol et al compared the sealing abilities of
four root-canal cements, including Apexit, Sealapex, TubliSeal and AH-26. AH-26 demonstrated a significantly better
apical seal than the other sealers. The authors note that from
the findings of other studies AH-26 appears to have many
advantages over other sealers. It mixes easily, flows well,
has ample working time, good radiopacity, comparable
solubility, good adhesion and good biocompatibility. It has
also been shown to adhere to dentin that has been maintained
in a moist state. Of the materials tested in this study, AH-26
had the best working characteristics. Wu et al, in comparing
the leakage of four sealers stored in water for one year,
determined that AH26, Ketac-Endo, and Tubli-Seal showed a
reduction in leakage over time and gave significantly less
leakage than Sealapex. The authors also noted that AH26
gave a long-lasting seal when used as the sole material,
showing its possible multiple applications.
Those dentists who try the EZ-Fill Instrumentation and
Obturation Systems will quickly find that they have the
ability to produce the highest quality results more easily,
quickly, simply, and far less expensively. I hope that this
detailed response to wayward conclusions sets things
straight. The research and our seven years of clinical results
speak for themselves. In the past you may have felt that you
had to invest in complex, complicated, and expensive
endodontic systems, but you can bring about a major
reduction in your level of stress and financial costs if you
adopt the EZ-Fill SafeSider Instrumentation and Obturation
systems.
References
1. Pommel L, Camps J. In Vitro Apical Leakage of
System B Compared with Other Filling Techniques. J
Endodon 2001;27:449-51. [BACK]
2. Wu M-K, Ozok R, Wesselink P R. Sealer distribution
in root canals obturated by three techniques.
International Endodontic J 2000;33:340-345. [BACK]
3. Antonopoulos K G, Attin T and Helwig E. Evaluation
of the apical seal of root canal fillings with different
methods. J Endodon 1998;24;655 [BACK]
4. Dalat D M, Spangberg LSW. Comparison of apical
leakage in root canals obturated with various guttapercha techniques using a dye vacuum tracing method.
J Endodon 1994; 20:315-9. [BACK]
5. Hata G, Imura N, Matsuda T, Kato A, Souza F J, Toda
T. Apical sealing ability of the EZ-Fill obturation
technique. J Endodon 2002; 28:260. [BACK]
6. Baumann M A, Loy R, Behrens O. Dye penetration of
five different single cone techniques compared to
lateral condensation. Abstract IADR/AADR/CADR
80th General Session March 2002 [BACK]
7. Cohen B I, Pagnillo MK, Musikant B L and Deutsch A
S. The evaluation of apical leakage for three

endodontic fill systems. Gen Dent.1998; Nov-Dec:
618-23. [BACK]
8. Kontakiotis E G, Wu M-K, Wesselink P R. Effect of
sealer thickness on long surface of the tooth during the
thermo-mechanical compaction technique of root canal
obturation. International Endodontic J. 1986; 19:73-77.
[BACK]
9. Cohen B, Volovich S, Musikant B and Deutsch A.

Shear bond strength for four endodontic sealers.
Endodontic Practice; 3:9-14. [BACK]
10. Cohen BI, Volovich Y, Musikant B L and Deutsch A
S. The Effects of Eugenol and Epoxy-Resin on the
Strength of a Hybrid Composite Resin. J Endodon;
2:79-82. [BACK]
11. Deutsch A S, Cohen B I, Musikant B L, Kase D. A
study of one-visit treatment using EZ-Fill root canal
sealer. Endodontic Practice 2001 4:29-36. [BACK]
12. Lee C Q, Chang Y, Cobb C M, Robinson S, Hellmuth
E M. Dimensional Stability of Thermosensitive GuttaPercha. J Endodon; 23:579-582. [BACK]
13. Hall M C, Clement D J, Dove S B, Walker lll W A. A
Comparison of Sealer Placement Techniques in Curved
Canals. J Endodon 1996; 22: 638-642. [BACK]
14. Floren J W, Weller R N, Pashley D H, Kimbrough W
F. Changes in Root Surface Temperatures with In Vitro
Use of the System B HeatSource. J Endodon 1999;
25:593-595. [BACK]
15. Saw L-P, Messer H H. Root Strains Associated with
Different Obturation Techniques. J Endodon 1995;
21:314-320. [BACK]
16. Jurcak J J, Weller R N, Kulild J C, Donley D L. In
Vitro Intracanal Temperatures Produced during Warm
Lateral Condensation of Gutta-percha. J Endodon
1992; 18:1-3. [BACK]
17. Hardie E M. Heat transmission to the outer surface of
the tooth during the thermo-mechanical compaction
technique of root canal obturation. International
Endodontic J. 1986; 19:73-77. [BACK]
18. Zidan O, Al-Khatib Z, Gomez-Marin O. Obturation of
root canals using the single cone gutta-percha
technique and dentinal bonding agents. Internatinal
Endodontic J 1987; 20:128-132. [BACK]
19. Gettleman B H, Messer H H, ElDeeb M E. Adhesion
of Sealer Cements to Dentin with and without the
Smear Layer. J Endodon 1991; 17:15-20. [BACK]
20. Limkangwalmongkol S, Burtscher P, Abbott P V,
Sandler A B, Bishop B M. A Comparative Study of the
Apical Leakage of Four Root Canal Sealers and
Laterally Condensed Gutta-percha. J Endodon 1991;
17:495-499. [BACK]
21. Wu M-K, Wesselink P R, Boersma J. A 1-year followup study on leakage of four root canal sealers at
different thicknesses. International Endodontic J 1995;
28:185-189. [BACK]
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
Changing Endodontic Perceptions
Barry Musikant
AVING LECTURED in the Carolinas and Kentucky

recently, I thought I would give you my impressions
of the state of endodontics from the viewpoint of
many of the practitioners I met. Many dentists still perform
traditional endodontics for three reasons: they understand that
rotary NiTi instruments sometimes separate in the canals,
especially when they are curved; NiTi systems are very
expensive; and the dentists truly are not displeased with the
results that they have been getting. Another group, perhaps
larger than the first, has switched from traditional endodontic
techniques and instruments to some form of rotary NiTi.
Many of these dentists were at first very enthusiastic about
the new systems because they gave them far better results
without hand fatigue and canal distortion. Those who have
used these systems for a couple of years readily admit that
they have separated some files. However, in general their
results are so improved that despite the occasional separated
instrument they continue to use these systems. Ultimately,
they believe that they have no choice because they do not
want to return to the poorer results produced by traditional
techniques.
I asked one attendee who uses rotary NiTi what he does
about curved canals and he said he sends patients with curved
canals to a specialist. I noted that given the chance of
instrument separation while shaping curved canals that was
probably a wise choice. This dentist is really saying that he
recognizes the limitations of the system and is in turn
limiting himself from gaining further expertise. I think that a
system should not put barriers in the way of growing.
Certainly the rotary NiTi system should not present such a
barrier, since rotary NiTi was originally designed to shape the
curved canals that time and experience had proven risky.
The EZ-Fill SafeSider instrumentation system and EZFill obturation system are alternatives that produce the
superior results of rotary NiTi without the fear of instrument
separation and take no more time to complete the process.
The SafeSiders are designed to treat all teeth, from the
simplest to the most complicated. Shaping a canal will take
on average two to seven minutes from the time of
measurement depending upon the canal curvature and how
far apically the No. 2 Peeso can go. The axially relieved
SafeSiders coupled with the No. 2 Peeso reamer negotiate to
The EZ-Fill
SafeSider
instrumentation
system and EZFill obturation
system produce
the superior
results of rotary
NiTi without the
fear of
instrument
separation.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm21changing.html[2/21/2011 10:25:28 ]
the apex more quickly because they engage less dentin, are
more flexible, take a curve with greater ease, remove debris
from the flutes, and require less hand pressure.
The beauty of the EZ-Fill SafeSider system is that only
two NiTi instruments, used manually with a reciprocating
hand motion, are required to produce an .08 mm/mm taper,
the space needed to fit a medium gutta-percha point.
Moreover, the two NiTi instruments are used only after 95
percent of the canal space has been shaped with tough
inexpensive stainless steel instruments. The coronal 1/2 to 2/3
of the canal space has been shaped to straight-line access,
limiting any negotiated curves to the apical 1/3.
The fact that the two NiTi SafeSider instruments are used
manually in a reciprocating motion allows them to be bendtested before they are placed into the tooth. If they do not
break when bent 90 degrees in the hand, they will not break
in the tooth if used in the prescribed way. The bend test gives
the dentist a rational way to decide whether to discard
expensive NiTi instruments rather than replacing them
automatically after one or two uses. Quite simply, if they
break in the hand you know for sure that they must be
replaced.
The EZ-Fill SafeSider instruments represent a manual
system that, nevertheless, shapes 85 percent of the canal with
the rotary No. 2 Peeso reamer or the No. 2 and 3 Gates
Gliddens, leaving the apical 1/3 to be efficiently shaped with
the simple sequence of relieved EZ-Fill SafeSider reamers or
files.
Endo Tip
I am always pleased to conduct a nocost hands-on session for anyone

who wants to learn how to use the
SafeSiders for efficient and excellent
results. Click here for information
about our next in-house hands-on course, or
contact me at (212) 582-8161 if the scheduled date
is not convenient for you.
Barry Musikant
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm21changing.html[2/21/2011 10:25:28 ]
Long-Term Fluoride-Release Restorative Materials
Barry L. Musikant, D.M.D., F.A.C.D.; Brett I. Cohen, Ph.D.; Allan S. Deutsch, D.M.D., F.A.C.D.
Barry Musikant
OMPOSITE RESINS have replaced many of the

Because many
materials that were formerly used in dentistry.
people now
Posterior and anterior composites and resin cements
drink bottled
used with the appropriate bonding agents are now substitutes
for amalgam, glass ionomers, and zinc phosphate. An
water, which
important element associated with long-term success of these
does not
newer materials is the release of fluoride. Fluoride is
contain
dynamically incorporated into the hydroxyapatite matrix
fluoride, . . .
forming the more acid- resistant fluorapatite and thereby
rendering the tooth structure less susceptible to subsequent
using long-term
decay. Fluoride has also been shown to reduce the cariogenic
fluoridepotential of bacteria by inhibiting their metabolism.1
releasing
Cohen, et al., recently reported in Oral Health a ten-year
restorative
fluoride release of four reinforced composite resins; theirs is
the only study found in the literature for this duration. The
materials in
composite resins included in the study are Ti-Core and Tiareas of
Core Natural (Essential Dental Systems, South Hackensack,
restoration that
New Jersey), two core materials that are approximately 80
percent filled and have incorporated titanium and lanthanides abut dentin is
respectively to produce compressive strength equivalent to
essential.
2
that of dentin.
The other two composite resins were Flexi-Flow and FlexiFlow Natural (Essential Dental Systems), cements that are 60
percent filled to allow for greater flow and also incorporate
titanium and lanthanide respectively. The four composite
resins have continued to demonstrate release of fluoride over
a ten-year period. The higher filled Ti-Core samples released
fluoride in a burst effect over the first two years and then
settled down to a lower level of continuous release. The
Flexi-Flow composite resins, on the other hand, released
fluoride at a low level from the beginning. The different
release patterns make sense because the more densely filled
Ti-Core resins leave less room for the efficient incorporation
of fluoride while the less densely filled Flexi-Flows have
room to incorporate the fluoride more efficiently,
consequently releasing it over time in smaller quantities.
(See the graphs.)
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm22fluoride.html[2/21/2011 10:25:28 ]
Graph 1
Graph 2
Although the mechanics of fluoride release are interesting,

the important fact is that fluoride release does not weaken the
Ti-Core and Flexi-Flow polymer structures over time. In
contrast, glass ionomers and resin-modified glass ionomers
weaken as the fluoride is released over time. In real-world
dentistry, the fluoride release should occur only when the
polymer is exposed to moisture; such exposure occurs at the
composite-dentin interface, because dentin is 30 percent
water. The amount of fluoride released in these situations is
far less than the amount released when the composite resins
are completely immersed in water for test purposes.
Ti-Core core material and Flexi-Flow cement will release
their fluoride only at the composite-dentin interface if there is
no marginal leakage under the crown. If leakage does occur,
more fluoride will be released at the very time when it is
most needed. Since we do not expect leakage to occur on the
first day of post-and-crown placement, the effective release
of fluoride should last far longer than the ten-year release
period reported in this study, which subjected the composite
resins to an immersion bath. Because the incorporation of
the fluoride into dentin is dynamic, meaning that it is a
reversible reaction, the fluoride must be released
continuously to prevent the eventual loss of the fluoride from
tooth structure and the conversion of the fluorapatite matrix

back to the hydroxyapatite matrixand, of course, to
maintain its inhibitory effect on bacterial metabolism. Hence,
the significance of this long-term fluoride release study.
Fewer people are exposed to fluoride because many people
now drink bottled water, which does not contain fluoride,
rather than public water, which does. Despite the beneficial
effects of the low-level mass exposure to fluoride in many
public water systems, a number of people avoid municipal
water supplies for fear of exposing themselves to lead and
arsenic. Given this reality, using long-term fluoride-releasing
restorative materials in areas of restoration that abut dentin is
essential.
References:
1. Nouri M-Reza, Titley KC. A Review of the
Anitbacterial Effect of Fluoride. Oral Health
2003;93(1):8-11.
2. Cohen, BI, Musikant BL, Deutsch S. Ten Year
Fluoride Release from Four Reinforced Composite
Resins. Oral Health 2002;92(9):44-52.
February-March 2003
FEEDBACK?
DentalTown.com Is a True Home on the Web
Barry Musikant
THOUGHT THAT it would be a good idea to tell you

about my experiences at DentalTown.com, the website of
the magazine DentalTown, the brainchild of Dr. Howard
Farran. DentalTown.com is the most comprehensive and
easy-to-use dental website I have ever seen. It covers just
about every subject of interest and doesnt cost a penny.
Joining and becoming an active participant are both easy.
When I joined, two years ago, DentalTown.com had about
9,000 members. Currently, it has more than 20,000
members. There must be a reason why so many people are
joining.
DentalTown.coms most outstanding feature is an array of
message boards on which you can interact with other
dentists. If you wish, you can start a new subject to learn the
views of others. I believe that the grassroots nature of these
message boards is the basis of this sites success. A true
community is being formed in cyberspace for the benefit of
all. As the slogan of the site puts it, With DentalTown.com
. . . no dentist will ever have to practice solo again. The
cyberspace dental community starts and ends with the
participants, so it is no better or worse than the integrity of
the dentists who participate. I have found it well worth my
time.
In addition to message boards, DentalTown.com includes
an extensive area of the site for case presentations in any
discipline that is likely to interest you. If you have a scanner,
you can upload cases in a matter of a few minutes and then
have other dentists discuss the particulars of your
presentation.
DentalTown held the first meeting for participating dentists
this past February in Las Vegas. I was among the more than
800 dentists who attended the three-day meeting. Although
most of us had never met any of the other participants, we
did not feel like strangers because of all the previous contacts
we had had through the various message boards.
Many of the dentists active in DentalTown.com are
involved with other organizations and interests. Many
include in their messages a link to an active website of their
own. Just by clicking the link, you can go to the participants site, permitting you to travel freely not only within
the DentalTown website, but laterally to many other sites
with useful information of their own. For example, recently I
The cyberspace
dental
community
starts and ends
with the
participants, so
it is no better or
worse than the
integrity of the
dentists who
participate. I
have found it
well worth my
time.
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm23dentaltown.html[2/21/2011 10:25:29 ]
was reading a post on DentalTown.com from an endodontist

who is involved with Roots, a web site devoted to
endodontics. I clicked the link that he had included and was
there in a moment.
For a guy like me, DentalTown.com has become
addictive. At this stage of my career I love to teach, and the
constantly growing membership in DentalTown.com gives
me a larger and larger audience that I can talk to. The
advantages of SafeSiders and EZ-Fill obturation are not
always immediately obvious to dentists. Most of them have
been swayed by a combination of ineffective endodontic
training in dental school and the intensive mass marketing of
rotary NiTi systems. Two years ago, when I first started
corresponding on DentalTown.com about the alternatives to
rotary NiTi, thermoplastic obturation, and vertical
condensation, I was met either with significant skepticism or
worsewith non-responsiveness. But repetition and the
honing of these alternative presentations have increased the
awareness and the acceptance of the SafeSiders and EZ-Fill.
Short of spending a fortune on mass marketing (we cannot
compete with Dentsply) I cannot think of a better way to get
these new ideas across than a genuine grass-roots movement,
such as the DentalTown.com message boards, where the
acceptance of new equipment and techniques will be only as
good as the validity of the arguments we make for them.
Dentists sometimes tell me in DentalTown.com forums that
they are looking forward to lectures that I am going to give in
their areas, further increasing the sense of community. The
relationship with a large number of dentists through
DentalTown.com is ongoing and growing. The challenge of
answering questions accurately and honestly makes any
participant grow professionally.
So, I would suggest that whether you are a casual reader of
posts or an active dentist with information that you want to
disseminate you should become involved in
DentalTown.com.
April-May 2003
Click here for information about

our next in-house hands-on
course.
FEEDBACK?
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm23dentaltown.html[2/21/2011 10:25:29 ]
The Challenge of Changing Viewpoints and Attitudes

SafeSider Reamer Instrumentation and EZ-Fill Obturation
Barry Musikant
THOUGHT THAT it would be worthwhile to discuss the

The SafeSider
goals that we have set for ourselves and for the courses
reamer
we teach in endodontic techniques. We want to help all
instrumentation
of you do far better endodontics with less stress and
significantly lower costs. We developed the SafeSider
and EZ-Fill
reamer instrumentation and EZ-Fill obturation systems as
obturation
the tools to accomplish these goals. We want to show as
techniques
many open-minded dentists as we possibly can (and as many
virtually
not-so-many not-so-open-minded dentists) that the SafeSider
instrumentation and EZ-Fill techniques will change their
eliminate
lives by virtually eliminating instrument separation and
instrument
reducing their overhead by about 90 percent without
separation and
compromising the final results.
reduce
Many of you have taken the courses in which we teach
these simplified yet uncompromising methods. If you have
overhead by
taken one of our courses more than a year ago, I
about 90
enthusiastically suggest that you take one again. We have
percent without
streamlined our teaching techniques and the sequences we
use to produce excellence even more efficiently.
compromising
Demonstration and practice are now on natural teeth rather
the results.
than plastic blocks.
If you have not taken our courses, consider doing so. It is
not too strong a statement to say that the learning experience
has the potential to change your life. I say this with growing
conviction, based on comments from dentists who have taken
the courses. I am very active on the Dentaltown.com forum,
the largest forum for dentists on the Internet. There I offer
dentists all over the world the opportunity to take hands-on
courses with me. Many have taken me up on the offer and
have then described their experiences for the membership.
Their comments regarding the learning experience and their
subsequent use of the two systems we teach have been so
uniformly positive that we know we are accomplishing
something that is unquestionably constructive.
Please understand that undertaking and continuing the task
of teaching SafeSider reamer instrumentation and EZ-Fill
obturation techniques truly require the desire to fight the
good fight. In part, we are working to overcome the negative
results of misleading instruction in dental schools. For years,
dental students were subjected to an inadequate and
ineffective method of performing endodontics. They were
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm24challenge.html[2/21/2011 10:25:30 ]
taught that files were more efficient than reamers when, in

fact, K-files are one of the least efficient ways to shape
canals. They were taught to fear and avoid the use of Peeso
or Gates Glidden reamers in canal preparations when, in fact,
the smaller sizes can be used safely and simply.
We are also working to overcome the misinformation
promulgated by major dental companies. They have
promoted rotary NiTi as the answer to all the deficiencies of
traditional endodontics. Granted, traditional endodontics was
so limited in its potential to produce adequate endodontic
therapy that in contrast almost any other system looked good.
Rotary NiTi instruments eliminate hand fatigue and canal
distortion while producing shapes of greater taper that
promise far better debridement and obturation. As it turns
out, the advantages of these instruments come at the cost of
certain disadvantages. One disadvantage is obvious. These
instruments cost about 20 times as much as traditional
endodontic instruments. The second disadvantage is far more
discouraging. Rotary NiTi instruments do not have the
strength and resilience of stainless steel and will break
unpredictably, either from excess torque caused by apical
binding or from cyclic fatigue brought on by rotation around
a significant curve.
The weakness of rotary NiTi instruments has been the
impetus behind a whole second wave of innovation that has
added to the cost of a system that is already 20 times more
expensive than traditional techniques. Such expensive tools
as autoreversing torque-sensing handpieces, reduction
handpieces, and electric handpieces as well as the
recommendation that NiTi instruments be thrown away after
one use have added immensely to the costs.
Yet, many of those who have mastered the rotary NiTi
techniques rationalize higher expenses and occasional
instrument separation by noting that they generally produce
far better results more quickly than they ever did using
traditional techniques. It is human nature not to abandon
something that you believe has improved your life, and
considering the state of traditional endodontics, rotary NiTi
can certainly make that claim. People are even more likely to
resist making a change when they believe that there is really
no alternative that can further improve their present situation.
So, this is the great challenge thats worth the good fight:
To show that the SafeSider reamer instrumentation and EZFill obturation techniques virtually eliminate instrument
separation and reduce overhead by about 90 percent without
compromising the results. These results are attained in a
simplified, time-efficient manner that improves the
productivity of the dentists who use the techniques.
Possibly, the most basic question someone could ask is, If
the SafeSider reamers and the EZ-Fill obturation techniques
are as good as you say, why isnt everyone using them?
The converse of that question would be, Since not everyone
knows about them, why are those who do know so
enthusiastic about using them? The reality of the

marketplace is that getting the message out takes time and
money. The more money invested, the less time required.
This is the route that the big rotary NiTi companies have
taken. If one cannot invest millions in marketing, superior
ideas and innovations must give a new product or technique
the chance of having an impact in the dental community.
Thanks to Dentaltown.com and its founders, Howard
Farran and his wife Judith, we have had an opportunity to
level the playing field with the big boys somewhat and
present these innovative new approaches to a large number of
dentists. Better yet, weve been able to get their feedback for
the betterment of the entire profession. In fact, this peerreview feedback is readily available to anyone who joins
Dentaltown.com (at no cost) and goes to its endodontic file
section.

course.
FEEDBACK?
The Stability of Metal Posts

JUST ATTENDED a lecture by Dr. Ed McLaren in
which he discussed the use of ceramic crowns and when
to use them. The factors that determine what is used as
the overlying crown include:
Barry Musikant
What tooth structure is underneath the crown? If there

is significant dentin then there is no problem in just
bonding the overlying porcelain crown to that dentin.
What is the potential for flexure of the underlying
core? The greater the potential for flexure is, the less
likely is a porcelain restoration to last.
What type of stress is applied, and how much?
Can the internal interface of cement be protected
during function?
From a
functional point
of view, fiberreinforced
posts work best
where they are
not needed in
the first place.
If you look at this short list for determining whether to use

a purely porcelain-constructed crown it appears that the most
important factor is the potential for flexure of the underlying
core. This factor alone will determine how the stresses are
tolerated and the long-term success of the cement interface.
Flexure takes on increased significance when you are
considering the restoration of an endodontically treated tooth
where the coronal tooth structure, if any exists, has been
weakened by the access opening, diminishing the strength
and rigidity of the coronal tooth structure. To the extent that
the coronal tooth structure has become compromised, the
need to restore rigidity (reducing flexibility) becomes
increasingly critical.
Over the past several years, non-metallic fiber-reinforced
composite posts have come into vogue. The primary claim
made for them is that they have a modulus of elasticity
similar to that of dentin, implying that they will bend like
dentin under function. If this were true, they would not have
too much flexibility, just the right amount of flexibility.
However, the concept that materials having the same modulus
of elasticity bend the same is a false one for the placement of
posts.
Having the same modulus of elasticity implies that two
materials (dentin and the composite post) will bend the same
only if they have the same cross-sectional area. However, a
post is generally 10 to 15 times thinner than the root it is in
and will, consequently, bend 10 to 15 times more than the
root because it has the same modulus of elasticity. A quality
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm25stability.html[2/21/2011 10:25:31 ]
that the manufacturers imply is a plus turns out to be a

tremendous negative.
From a functional point of view, the best that can be said
about non-metallic fiber-reinforced posts is that if they are
placed in a tooth with sufficient coronal dentin, it will be a
case of the tooths supporting the post, not the posts
supporting the tooth. Or to say it another way, fiberreinforced posts work best where they are not needed in the
first place.
A secondary advantage of these non-metallic fiberreinforced composite posts is their color. They can be made
of a tooth-like color that allows the placement of a porcelain
crown without any dark shadow being cast from underneath.
Yet, if they are used in these situations, the problem of
excess flexibility becomes an issue for the long-term success
of the porcelain restoration, whichthough it looks
esthetically pleasingmay not have enough stability. As
McLaren stated, if the criteria for porcelain crowns are not
present he will place a metallic post and restore with
porcelain-fused-to-metal restorations, such as Captek. In fact,
he showed a number of cases restored with porcelain-fusedto-metal restorations, and the esthetic result could not have
been more pleasing.
It should be stated that McLaren was not emphasizing
endodontically treated teeth. Yet, he still found many
situations where pure porcelain restorations were not good
choices. Endodontically treated teeth have much less margin
for error because there is that much less tooth structure and
greater underlying flexibility. From my own experience, I
would say that the minimum requirement for placement of a
non-metallic fiber-reinforced post, followed by the placement
of a porcelain restoration, is enough tooth structure to supply
a minimum of an internal bevel 3 mm long to which the
ceramic restoration can be bonded. However, if this much
tooth structure exists, is it really necessary to place a post at
all? Thus, we arrive again at the conclusion that nonmetallic posts work best where they are not needed in the
first place. Less dentin than this means that a porcelainfused-to-metal crown must be placed. This in turn means that
a stronger metal post should be used because esthetic
considerations are of little or no significance.
Another claim that is made for non-metallic fiberreinforced posts is that they are able to absorb high impact
without fracturing the tooth. This is said to be a direct result
of their flexibility. One must understand that this data comes
from experimental destructive compression tests done in a
lab. If enough force is applied to a metal post, there will be a
higher incidence of root fracture than if the same force is
applied to a non-metallic fiber-reinforced post. However, the
force that is applied experimentally is in excess of what the
human jaws can generate. In fact, the only time in real life
that this would have significance is when a tooth suffers the
large sudden impact of a force from a blow. To use this as a
criterion for placement while ignoring the routine functional
stresses that can cause a non-metallic fiber-reinforced post

and the overlying restoration to fail is completely missing the
point. Excessive flexibility leads to open margins, secondary
decay, and eventual failure of the restoration. The stability
offered by metal posts prevents crown displacement, reducing
the chances of open margins and their consequences.
I would add one more point. For the highest rate of success
on endodontically restored teeth, not only should a metal post
such as the Flexi-Post or Flexi-Flange be used, but a
porcelain-fused-to-metal restoration incorporating an
external bevel of 23 mm would maximize stability for the
long haul. Or, as my partner Allan Deutsch says, theres
nothing like wearing a belt and suspenders to make sure that
your pants dont fall down.

course.
FEEDBACK?
Education as a Means of Practice-Building
Barry Musikant
HIS ARTICLE is really directed more to endodontists

When you teach
than to the general practioner. When I was a good deal
an effective
younger and just starting out, I wanted to meet dentists so
simplified
that I could build my endodontics practice. My father was a
well-known dentist in Manhattan, many of his friends were
approach in
dentists, and as a result I had been surrounded by dentists
contrast to all
since early childhood. So, when I had to meet dentists to
the other
build a practice it was not an uncomfortable situation for me
techniques out
to be in.
I knocked on doors and introduced myself, and I also
there, the
became an instructor at one of the local dental schools. In
practiceaddition, my partner Allan Deutsch and I started throwing
building
singles parties for dentists, dental assistants, hygienists, and
potential is
anyone else remotely associated with dental offices. This
was easy to do when I was single. I dont recommend this
amazing.
approach if you are married. We also gave many lectures at
localities throughout the greater New York area.
The standard we always attempted to reach was something
that set us apart from the others. That was why we opened
up seven days a week and twelve hours a day, because no
one else was doing it. The same motivation was behind the
the singles parties. When we lectured originally, it wasnt on
endodontics, but rather on post and core buildups, because no
one else at the time was doing it.
Today, we teach dentists how to perform efficient,
inexpensive, and predictable endodontics by learning the
SafeSider instrumentation and the EZ-Fill obturation
techniques. When you teach an effective simplified approach
in contrast to all the other techniques out there, the practicebuilding potential is amazing. It dwarfs whatever we had
done over the preceding 25 years.
Many times I speak to an endodontist and say that one of
the things you probably do is to call up new dentists and ask
them out for dinner. In effect, you are trying to charm them
into sending you referrals. I understand that. I did plenty of
that over the years. Now maybe Im being cynical, but most
dentists really dont want to go out for dinner. I think most
of them want to get home when the workday is done, and
when they agree to go out with an endodontist (or any other
specialist) its because they are being a nice guy (or gal).
So here we are teaching dentists how to do much better
endo simply and effectively without spending a lot of money
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm26education.html[2/21/2011 10:25:31 ]
and, in fact, virtually eliminating the chances of fractured

instruments. We tell other endodontists, our potential
competitors, how and why it works for us. And the results
are amazing. Most endodontists believe that if they really
teach an effective method of endodontics it will result in less
work for themselves, so they dont want the general
practioner to learn these simpler, more effective systems. We
tell them that, in reality, they are only half right. If they teach
these systems, many of their referrers will send fewer patients
because they can do more on their own; however, what these
endodontists fail to see is that teaching the Safesider and EZFill techniques will result in their meeting many new dentists
whom they would have never met otherwise.
By the way, most of the individual hands-on courses we
give last two to three hours. That means that both the dentist
and the endodontist get home earlier than if they had gone
out to eat. In addition, you have not polluted yourself with
alcohol and fat-drenched steaks, adding to your long-term
good health.
The endodontists who teach the techniques that allow the
gps to make more income in a simplified fashion will get
less work per dentist, but they will have many more dentists
who send work. As for being charming, I tell them that if
they teach a dentist to make $125,000 more a year, there are
few things that are more charming. It certainly beats sending
a case of wine or a dozen steaks from Omaha, not that we
are telling those specialists to stop sending the wine and the
steak.
Teaching the SafeSider instrumentation and EZ-Fill
obturation techniques is particularly timely, considering the
fact that rotary NiTi has two things that are going on
concurrently. Many recent graduates are coming out of
dental school having been exposed to rotary NiTi techniques,
and a low but persistent incidence of instrument separation
keeps occurring. While the major manufacturers say that
instrument separation is a result of the practioners
techniques, the research clearly shows that instrument failure
is directly connected to NiTis poor resistance to torsional
and fatigue stresses. Studies have shown fracture rates
between 2 and 9 percent, a level that translates into great
inefficiency when attempting to remove embedded segments
of broken instruments.
Once the dentists see and understand the SafeSider
alternative, they begin to appreciate the formerly
inconceivable notion that rotary NiTi is truly an irrelevant
departure from safe predictable endodontics, and its
abandonment results in superior results and less anxiety.
Spring 2004

course.
FEEDBACK?
SafeSiders and the Mindsets They Encounter
Barry Musikant
ENTALTOWN.COM has been a vital vehicle for

SafeSiders growth. A wonderfully interactive dental
site with close to 35,000 members who participate in a slew
of varied message boards, the site is intuitive and easy to
master. I recommend that everyone join. You will be a
better dentist for it. That, however, while absolutely true, is
not the thrust of this article.
As the main advocate of this relatively new system, the
SafeSiders, I have encountered a variety of reactions from
the dental community. Most reactions have been positive,
coming as they do from dentists who want to learn the
technique to solve problems that they are having with some
form of rotary NiTi or with their traditional techniques.
SafeSiders have received so many positive testimonials that
we could practically fill a small book with them.
While I am grateful for those positive reactions, they are
not the reactions that amaze me. Instead, I am amazed by the
reactions of a handful of dentists, practically all of them
rotary NiTi users, who somehow feel that an aggressive
discussion of the SafeSider alternative is a violation of the
status of rotary NiTi as the endodontic paradigm. These
dentists assert the superiority of rotary NiTi by listing the
assumed shortcomings of the SafeSiders, whichaccording
to theminclude the following:
SafeSiders
have received
so many
positive
testimonials
that we could
practically fill a
small book with
them.
The SafeSider system is a manual system and must,

therefore, create far more hand fatigue than rotary NiTi
and take much longer time to shape the canals.
Canals cannot be shaped to a greater taper with
SafeSiders.
Gutta-percha points will not fit as well in canals
shaped with rotary.
The assertions made by these dentists are inaccurate whether
they come from endodontists (the strongest advocates of
rotary NiTi) or general practitioners, who often quote the
opinions of the endodontists they associate with.
In truth, in the SafeSiders technique, 85 percent of the
canal space is shaped with the number 2 Peeso reamer and
the number 2 Gates Glidden in a crown-down fashion similar
to, but a lot safer than, the crown-down technique used with
rotary NiTi. The procedure is safer because it ensures that if
the Peeso or the Gates breaks, the break will be in the coronal
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm27mindsets.html[2/21/2011 10:25:32 ]
section of the shank and therefore the broken piece can be

removed easily in seconds. Another reason for the safety of
the technique is the fact that as the Peeso straightens the
coronal curve it removes tooth structure from the outer wall
of the canal, the wall away from the furcation. Compare this
pattern of removal with that of the orifice openers of rotary
NiTi instruments, which remove equal amounts of tooth
structure from the inner and outer walls, and you quickly
realize that the rotary NiTi instruments are more likely to
cause strip perforations on the furcal side of the root. The
widest diameter of a number 2 Peeso is 0.9 mm versus
diameters as high as 1.6 mm for the rotary NiTi orifice
openers.
The SafeSiders create a .08 mm/mm taper with 95 percent
of the shaping first done with tough, fracture-resistant
stainless steel before the far more vulnerable NiTi is used.
The remaining 5 percent is shaped manually, using NiTi
SafeSider reamers with a reciprocating motion that prevents
fracture. A simple manually applied bend test is used to
confirm that the reamer can be used in the canal without
fracturing before it is placed into the canal. The SafeSiders
produce an .08 mm/mm taper, while the best that rotary
systems create for the most part is an .04 to .06 mm/mm
taper. NiTi instruments are limited to smaller tapers not
because reduced tapers are superior, but because the dentist
cannot create an .08 mm/mm taper using rotary NiTi without
increasing the risk of separating an instrument around a
curved canal. It is becoming increasingly obvious that the
limitations of rotary NiTi have a direct impact on the results
that can be obtained.
Like rotary NiTi, the SafeSiders work quite efficiently in
straight or mildly curved canals, producing a fully shaped
canal in minutes. As the canals become more curved, nickel
titaniums weakness under torsional stresses and its low
resistance to cyclic fatigue impose a whole set of safety rules
on rotary NiTi instruments. Because the SafeSiders are
predominantly stainless steel based, they are not nearly as
subject to these stresses and have far less likelihood of
fracturing in similar situations.
The physical characteristics of these two metals means that
in straightforward cases both systems will produce excellent
results in minutes, but as the curves become greater and
sharper the NiTi must be used with far more caution, and
consequently take far more time, than the SafeSiders in
similar situations. Given the .08 mm/mm taper produced by
the SafeSiders, a medium gutta-percha point (preferably from
Dentsply Maillefer) fits perfectly, and when combined with
the EZ-Fill epoxy resin creates an excellent seal. If the canal
is very elliptical, there is no problem placing a second or
even a third well coated accessory point.
Supporters of rotary NiTi often contend that the cause for
concern about fractures really does not exist. They use data
from their own offices to demonstrate a minuscule fracture
rate of less than 1 instrument in 1000 used. While this is
impressive, it does not come close to agreeing with the far

more pessimistic feedback we constantly receive from
dentists who are signing up to take the SafeSiders courses.
The marketplace also belies these dentists appraisals of the
safety of rotary NiTi. For example, the following products
and procedures have been introduced in recent years to avoid
or overcome fractured instruments:
a spate of new systems, each promising a design that is
more resistant to fracture
auto-reversing handpieces that reverse at the first signs
of excessive torque
electric handpieces that allow precise control of the
rotation speed
the concept of single usage
increasing limitations on the types of cases that can be
done with rotary NiTi as well as constant
reinforcement of the meticulous technique that must be
employed to prevent these fractures, as reported in a
number of published articles
methods of removing fractured instruments once
fracture has occurred
and finally, the contention in a number of articles that
fractures generally are not that bad, that they rarely
result in apical problems, and that when they do a
simple apico wll suffice
This last point, in my mind, is a prime example of denial and
a major impetus to turn the clock back by rationalizing events
that should be occurring less frequently, not more frequently.
The endodontic publications also belie the upbeat
evaluations from rotary NiTi supporters. Not a month goes
by without an article in one or more publications concerning
the causes of rotary NiTi instrument separation and what is
required to prevent it, so far to no avail. Publications would
not give this much attention to a problem if it were virtually
non-existent, as some endodontists claim.
What it all boils down to is an example of the prejudice of
those who have become quite good at rotary NiTi and dont
find the need or the desire to learn a new alternative,
especially one that by comparison is so simple that it may
detract from the effort and expense they have already made
to master the complexities of rotary NiTi. I say prejudice
because I have met very few advocates of rotary NiTi who
have really learned the SafeSiders technique. Most say that it
is a manual system and dismiss it as old technology without
ever having tried it.
My persistence in making all of the above points has also
taken on a personal tone. Some, when they dont like the
message, attack the messenger, but such an attack does not
make the message any less valid. Simply put, rotary NiTi
has had all the time in the world to refine itself and show
solid progress in preventing instrument separation. However,
over the last 15 years or so, as more dentists have employed
these systems, the fracture rate has continued. The most

basic question should be whether you want to continue with
these systems or consider systems that are predominantly
based on stainless steel and virtually eliminate instrument
separation while reducing the overall costs by at least 90
percent.
Summer 2004
FREE DOWNLOAD!
The Best Ways to Perform

EZ-Fill SafeSider
Endodontics
by
Barry Lee Musikant, D.M.D., F.A.C.D.
CLICK TO DOWNLOAD
This document is in Portable Document

Format (PDF). You can download it and
print it. You will need Adobes free
Acrobat Viewer (available here) to view
and print this file.
FEEDBACK?
Post and Core Decisions Based on Fact, Not Fiction
Barry Musikant
IKE EVERY OTHER DENTIST, I read the latest

articles in the dental trade journals and can certainly be
influenced by them . . . with a few major exceptions.
When I see products that are in direct competition with the
things we have developed for Essential Dental Systems, such
as the Flexi-Post and Flexi-Flange, SafeSiders, and the EZFill obturation system, I think extra-critically to determine in
my own mind whether what they claim is mostly hype or is
based on solid data that defines their products as a step
forward.
One area of product development that has caught my
attention is the introduction of new bonded fiber-reinforced
composite posts. Claims have been made in one article or
another that posts of this type actually strengthen teeth, that
they seal the tooth better than root canal cement and gutta
percha, and that they hold up at least as well as metal posts
while dramatically reducing the incidence of root fracture
associated with metal posts.
If even one of these claims were true, these new products
would represent major competition for the split-shanked
metal post. Certainly, those claiming superiority for fiberreinforced composite posts cannot do it on the basis of
retention. The Flexi-Post and Flexi-Flange have retention
values in the range of 300 pounds, while the maximum
retention of a passive postwhether metal or fiberreinforced compositedoes not exceed 90 pounds, which is
equal to the maximum cohesive strength of the strongest
cements that exist today.
A case could be made that fiber-reinforced posts will
distribute less functional stress to the root than metal posts do
because they are more flexible than metal posts of the same
diameter. This is true, but in the literature it has been amply
documented that the forces that the human musculature can
generate are not sufficient to cause a passively seated metal
post to fracture the tooth if there is a minimum of 1 mm of
lateral tooth structure surrounding the post at its most apical
placement. It has also been documented that the Flexi-Post
and Flexi-Flange generate no more insertional stresses upon
cementation despite their high retention than a passively
placed post does. At the same time, the Flexi-Post and FlexiFlange have the additional benefit of distributing functional
stresses more evenly around the entire shaft of the post than
The real test of

a post is how
well it will do
when little or
no coronal
dentin exists.
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm28postandcore.html[2/21/2011 10:25:33 ]
is the case for a passive parallel metal post, where the

functional stresses are concentrated apically.
Recently one paper has definitively stated that a composite
post in combination with a methacrylate resin cement will
strengthen teeth if the cement is bonded to the dentinal walls
via a primer. Yet the primer, which is drawn up into the
dentinal tubules, has a hydrophilic nature and has been
documented to continue to absorb water. This process leads
to nano leakage and the weakening of the original bond.
Although some authors have hyhpothesized that what is
needed is a bond that is hyrodphilic prior to curing and
hydrophobic after it cures, it also has been stated that these
shifting qualities are beyond the present capabilities of the
bonding agents and cements. As a result, any increase in
strength is transient at best because the hydrophilic primer
embedded into the dentinal tubules continues to attract the
water molecules that accelerate the degradation of this bond.
The results are a decrease in initial strength and the start of
nanoleakage, which is a foot in the door in the process
leading to microleakage. Furthermore, significant
degradation of the bond of the post to the interface between
cement and primer results from thermocycling, a process that
is unavoidable in the mouth.
In contrast, this degradation process does not occur when
the threads of a metal post are embedded and cemented into
the dentinal walls. At a minimum, independent research
disputes the company-sponsored research claims of superior
characteristics for the products they sell. However, once they
have their research in print, companies will continue to make
claims that are far from being universally accepted because
they believe that those claims will sell the product.
It is important for dentists to know what is real and to have
the ability to differentiate it from what is claimed. Yes, one
could read all the conflicting research and come to his or her
own conclusions, but if we are honest we have to admit that
this is not a likely scenario in most cases, where time is our
most valuable asset. A shortcut approach, even though it is
self-serving, is to read the viewpoints of those who, as I do,
have competitive products and want to make sure that the
alternative interpretations gain public attention. At worst, a
protracted dialogue goes on, with each side defending its own
position. Ultimately the winners are those who follow the
dialogue. Lincoln had it right: You can fool all the people
some of the time and some of the people all the time, but you
cannot fool all the people all the time.
So what can be said about fiber-reinforced composite
posts? There is no question that they work when sufficient
dentin exists, but so does every postor, for that matter, no
post at all. The only purpose of a post is to create a more
stable and substantial core upon which to seat, so the real test
of a post is how well it will do when little or no coronal
dentin exists. In these situations the core must support the
crown without the added stability of extra dentin. Without
coronal dentin, the post must have high retention, because its
anchoring is limited to the internal retention of the shank of

the post within the root canal. If the post is passively held in
by the strongest cement, it will have a maximum retention of
90 pounds. If it is held into the dentin with threads, like those
of a Flexi-Post or Flexi-Flange, the post will have over 300
pounds of retention, mimicking the retention that a natural
crown has to a natural root with far greater accuracy than a
passive post, no matter what material it is made of.
Many dentists have chosen to use fiber-reinforced
composite posts because these posts dont discolor the core,
which in turn may affect the shade of the overlying ceramic
crown. If a post is necessary, then insufficient dentin is
present, which implies that the crown should have a ferrule,
which means that the final restoration should be porcelain
fused to metal. If this is the case, a full porcelain jacket that
is incapable of creating a fine chamfered finish line is the
wrong restoration. A porcelain to metal restoration allows
the placement of the stronger, more retentive, metal post
while supporting the core with a ferrule, a design feature that
has been shown to be the most important aspect of a final
restoration where minimal dentin exists. And the esthetics of
the post are not an issue because the porcelain fused to metal
restoration is not translucent.
The worst situation would be to place a shoulder
preparation around a core that is entirely or nearly entirely
composed of a flexible fiber-reinforced composite core
surrounded by a composite core material. A restortion of this
design is most likely to open gaps under repeated functional
loads of compression and tension. Gaps lead to leakage,
which leads to secondary decay.
The most that can be said for fiber-reinforced composite
posts is that in the event of a traumatic blow a flexible post
will absorb more stress than the stiffer metal posts and in so
doing will reduce the chances that the traumatic force will
produce a vertical fracture. While reducing the incidence of
root fracture is a plus, employing a flexible post to prevent
these rare events while increasing the chances of gap
formation and secondary decay under normal function does
not make for long-term success.
Rare events should never be the criteria that determine the
mode of treatment. Ideal treatment should reflect the
elimination or minimizing of those events that are most likely
to occur. Unless we realize this, we may make treatment
decisions based on an overemphasis of unlikely events while
missing the common-sense approach that will most likely
succeed for the largest number of patients.
This approachworking to eliminate or minimize the
most likely eventsapplies to many aspects of dentistry,
including endodontics in particular, which we will go into in
further detail in future issues of Endo-Mail.
Fall 2004
In canals where you need to

place a curve or 45-degree bend
at the end of the instrument to
negotiate the apical
dilacerations, line up the mark or
notch on the rubber instrument
stop with the bend of the
instrument. This will ensure that
the bend is facing in the right
direction in relation to the apical
curve every time the instrument
is inserted into the canal.
Doug Kase
FEEDBACK?
The Hands-On Dental Education Center (HODEC)

At Last!
Barry Musikant
N OCTOBER 8 AND 9, 2004, we acted as hosts for

the first use of our new hands-on dental education
center (HODEC); Kit Weathers and Mike Goldstein
conducted a two-day course on rotary endodontics and
associated subjects. HODEC is located in South Hackensack,
New Jersey, and can accommodate as many as 40
participants in hands-on technique sessions.
This facility has been a dream of ours for some time. We
Kit Weathers lecturing at
know that actually using new instruments and experiencing
HODEC
new techniques has a far greater impact than just listening to
someone talk about them. Unlike the workshops that we give
one-on-one at our endodontic practice in Manhattan, we will
have to charge for the courses conducted at HODEC.
However, instruments and materials that we recommend
during the full-day and two-day workshops will be included
in the fee for all the courses. Those instruments would cost
well over half the course fee if they were purchased
separately. We know of no other continuing education
courses that make this offer.
Barry Musikant explains
We are providing this extensive armamentarium as a takethe
advantages of the EZhome package to show in a dramatic way that dentists can get
Fill obturation system
a topnotch educational experience and all the tools they will
need without having to make further payments for the
instruments to perform the techniques they just learned. We
want the knowledge and the instruments to be in your hands
as soon as you complete these educational experiences.
The techniques that you will learn will challenge any
preconceived notions you may hold regarding the need for
expensive rotary NiTi. We will show you how to prepare
canals to an .08 mm/mm taper within minutes while virtually
eliminating any chance of instrument separation. If you are
presently using rotary NiTi, your ongoing costs will be
reduced by at least 90 percent. If you are using traditional
time-consuming techniques, your productivity will at least
double, and you will achieve superior results in the process.
You will understand the simple concept of relieved reamers
and why they negotiate through tight curved canals far more
easily than any other endodontic instrument. You will learn
why thermoplastic obturation techniques add needless
complexity and expense and why they will give more
consistent results at a fraction of the cost and in a fraction of
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm29hodec.html[2/21/2011 10:25:33 ]
the time. In short, many of the concepts that have been

promoted by massive marketing and recent dental school
programs will be shown to be illogical, ill-conceived, and
counterproductive. The overarching thrust of this two-day
course is to address all these issues and the discussions that
may ensue to clear up our thinking and demonstrate that
rational thinking is far more important to excellent
endodontics than some of the unproductive complex and
expensive approaches that have been promulgated in recent
years.
The first two-day course will start in January 2005. Those
taking this course will receive 17 CE credits. It will be a
comprehensive endodontic educational experience including:
1. Diagnosis and case selection
2. Achieving safe and proper access with a simple new
device that virtually prevents all perforations
3. Using releaved reamers in reciprocating handpieces
that allow quick and easy shaping of even tightly
curved canals to an .08 mm/mm taper within a few
minutes per canal while virtually eliminating
instrument separation
4. Obturation of the prepared canals in a procedure that
incorporates the use of a bidirectional spiral to load the
canals and coat the points with an epoxy-resin cement
that binds chemically and physically to both the gutta
percha and the dentin
5. Using digital imagery to confirm the accurate and
thorough placement of the cement and gutta-percha
points from both mesio-distal and bucco-lingual
angulations
6. Placing a highly retentive post to insure a stable core
for the long-term success of the final crown
While the emphasis will be hands-on, with at least half of
each day being devoted to benchtop workshops, we will also
present a solid case for these techniques as the very best and
most practical ways to perform these phases of endodontics.
We are prepared to discuss all other methods of
instrumentation and obturation that the participants may be
interested in and to demonstrate clearly why the methods that
you will learn in this course are superior.
In addition to the above disciplines, participants will be
able to acquaint themselves with the endodontic microscope,
apex locators, and ultrasonic and sonic units for the purpose
of debriding and removing instruments broken while using
other techniques.
The two-day courses will include breakfasts and luncheons
at the lecture site and an optional dinner on the first night of
the two-day program for those who would like to relax
informally with the group.
In the future, we will also hold specialty courses
emphasizing the microscope and its ability to aid in the
removal of broken posts and instruments. You will learn the
technical care and maintenance of the microscope as well as

proper positioning to see every tooth in the mouth.
For information on the growing list of these courses please
CLICK HERE or call 888-5HANDS-ON.
This is just the beginning of what we believe will be both
a common-sense and revolutionary approach to endodontics
with both the dental profession and the general public sharing
the benefits.
Barry Musikant lecturing in the new Hands-On Dental Education

Center
Winter 2004
Take an online tour of the

Hands-On Dental Education
Center (HODEC)!
CLICK HERE
FEEDBACK?
The Maturing of the SafeSiders and Ourselves
Barry Musikant
BIT OF A DICHOTOMY exists when it comes to the The Endo-Express

with SafeSiders
excellence in results produced by rotary NiTi
approach is
instruments. As Bill Watson, a well-known
thoroughly
endodontist from Kansas, has pointed out, there are often
compatible with
collateral spaces that can harbor tissue. Finding these canals
all endodontic
requires placing bends on instruments and probing the walls
situations from
of the canals. Yet placing bends in this way is difficult at
the simplest to
best with rotary NiTi instruments, which do not take bends
the most
well and weaken substantially when they are bent, making
complex.
routine usage of rotary NiTi instruments after bending a
potential problem. Unfortunately, NiTis flexibility is
directly related to its fragility, magnifying its dichotomous
nature. NiTis flexibility is most needed in the shaping of
curved canals, but that is where NiTi instruments are most
vulnerable to functional separation.
The problem of weakening upon bending is solved with the
SafeSiders approach. These instruments, which are all
stainless steel until the last two in the sequence, may be
prebent to more efficiently explore for collateral spaces.
Once the spaces have been found with the reamer, the
probing instrument can then be attached to a reciprocating
handpiece, which will enlarge the space, debriding it in the
process without any concern for separation of the instrument
or distortion of the probed space because the motion is
limited to 90 degrees.
So I look at the SafeSiders from the viewpoint that they are
designed for maximum manual exploration if so desired, yet
retain the adaptability to be engine-driven for ease of use.
This duality of usage gives the dentist the ability to
comprehend the internal anatomy with excellent tactile
perception yet not have to pay for that fine tactile perception
with eventual hand fatigue when it comes to debriding these
collateral spaces through sequential canal enlargement.
In short, no other system that I know of gives the dentist
instruments that are designed to have the least resistance to
apical negotiation, bring debris coronally, be routinely
prebent for fine probing and then attached to an engine that
eliminates hand fatigue without producing distortions, excess
torsional stress, or cyclic fatigue. The Endo-Express with
SafeSiders approach is thoroughly compatible with all
endodontic situations from the simplest to the most complex.
The dentist does not have to know the degree of difficulty he
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm30maturing.html[2/21/2011 10:25:34 ]
or she is going to face before starting the case, which if you

think about it, makes things much simpler in its own right.
The SafeSiders produce a tapered canal preparation equal
to or better than that produced by rotary NiTi instruments,
but are far superior in finding those accessory canals that
would be missed by a rotary system that stays centered in the
main canal. A far better case can be made that the SafeSiders
have a greater potential for thorough debridement than rotary
NiTi because of NiTis strict limitation in probing sharp
curves and the difficulty of then trying to shape them with a
rotary system. The design of the rotary systems simply does
not allow for this type of action. The fact that this limitation
can be compensated for with the use of other systems does
not minimize the inadequacies of the rotary NiTi approach to
instrumentation.
The ability to consistently produce excellent endodontic
results in all the various anatomic challenges that confront us
produces confidence in the operator whether that operator is a
G.P. or a specialist. Consistently good results increase
confidence in ones own abilities as well as the system
through which those abilities work. Because I teach the
SafeSiders technique to so many people, I am constantly reevaluating just what this system is all about. Over a period
of four years of use and the last year of use with the
instruments coupled to the reciprocating handpiece, I have
found no shortcomings attached to this system. Some
dentists voiced initial fears of the No. 2 Peeso that is
incorporated into the system. Yet, when I show them the
proper use of the No. 2 Peeso, the two fears they have (strip
perforation into the furca and ledging) are no longer a
concern. In fact, I learned early on in the teaching process
that many of the fears that dentists have originate in their
dental education at a point in time where they had no choice
but to accept academic dogma because they were not in a
position to test the inhibitions imposed by their teachers.
Dogma left untested can solidify into hard held beliefs.
That is part of the challenge when teaching dentists with
diverse educational backgrounds. Teaching is our new
mantra, whether we do it with the free hands-on workshops
we offer in our dental office in Manhattan or the more formal
intensive two-day courses we give at the Hands-On Dental
Education Center (HODEC) in New Jersey. We find that
dentists are hungry for effective methods of producing
excellent endodontic results that are simpler, less stressful,
and dramatically less expensive. The feedback on our
educational courses has been so positive that we are in the
process of expanding our commitment to hands-on
education. We believe that ultimately our own success is
directly dependent upon our commitment to the dental
community and the degree of effort we put into constantly
refining that commitment.
Its taken us more than 30 years to truly believe that we
have something of significant substance to offer our
colleagues. Active practice is an essential if we are to
continue to innovate both in products and our teaching.

When asked a question during our lectures, I always want to
be able to relate what I did clinically the day before. When
we tout endodontic reality, that reality must be backed up by
daily practical experience. Without it, any dental lecturer
would quickly become hollow, if not to the audience then to
himself.
January-March 2005
FEEDBACK?
Posts and Cores: Myths and Realities

I THOUGHT THAT it would be timely to once again
compare the design of the Flexi-Post and FlexiFlange to the new concepts of post buildups, namely
the use of fiber-reinforced composite posts.
The supposed advantages of fiber-reinforced composite
posts include:
Barry Musikant
1. They have a modulus of elasticity similar to that of

dentin, implying that the post will bend similarly to the
tooth in which it is embedded.
2. They have high retention because they are bonded into
the teeth.
3. They bend enough to absorb parafunctional forces
without acting as a conduit for excessive stresses that
lead to root fracture.
4. They eliminate the high insertional stresses associated
with threaded metal posts because they are of passive
design.
5. They impose no esthetic challenges because they have
the color of teeth.
6. They strengthen the teeth.
Before challenging these supposed advantages, we should
understand the parameters of post placement. Until the
recent claims that bonded composite posts strengthen teeth, it
was a well accepted fact that posts do not strengthen teeth,
that they are used only to support the retention of a core that
does not have sufficient coronal dentin to support occlusal
function. Removing coronal dentin to support a post makes
no sense because removing dentin weakens core support more
than introducing a post supports it.
As endodontists, we no longer subscribe to the philosophy
that every endodontically treated tooth automatically must
have a post. Today we will not hesitate to place or
recommend the placement of a post if an inadequate amount
of coronal dentin exists to support the core that in turn
supports the overlying restoration.
With that in mind, lets examine some of the listed
advantages of fiber-reinforced composite posts.
1. They have a modulus of elasticity similar to that

of dentin, implying that the post will bend
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm31postsandcores.html[2/21/2011 10:25:35 ]
similarly to the tooth in which it is embedded.

This claim made its way into post advertisements early on.
The thrust of these advertisements is the illogical conclusion
that posts made of materials with a modulus of elasticity
similar to that of dentin will bend the same as dentin. In fact,
materials with a modulus of elasticity similar to that of dentin
will only bend the same if (and it is a crucial if) they have the
same or similar cross-sectional area. When one realizes that
a redwood tree and a redwood toothpick both have the same
modulus of elasticity it becomes clear that the modulus of
elasticity alone does not define deformation under function.
In the case of teeth, a post with the same modulus of
elasticity as the tooth is likely to have a cross-sectional area
approximately 1/10 to 1/15 that of the tooth it is embedded
into, making the post 10 to 15 times more deformable under
function than the surrounding tooth. The differences in
cross-sectional area of the tooth and post define the degree of
deformation, unavoidably leading to increased compressive
and tensile stresses within the core material simply because
the core material is supported by the more highly deformable
post.
The effects of a deformable post on the core material are
another issue that has not been accurately addressed.
Advertisements claim that the post and core bond to one
another, creating a monobloc that is stronger than either
component alone. That might be true if the two materials
were enmeshed in each others structures to such an intimate
extent that a new composite material was created, such as
occurs in airplane propellers. However, in the case of posts
and cores the fiber-reinforced post stands as a separate entity
and is then grossly overlaid with a composite material in
which either no fibers are included or the fibers are randomly
aligned, giving it minimal resistance to functional forces.
The resistance to deformation and the resistance to cyclic
fatigue degradation is defined by the strongest link in the
chain, the fiber-reinforced post, which we have already
demonstrated is 10 to 15 times more deformable than the root
it is in. Adding a weaker composite overlay does nothing to
strengthen the posts resistance to deformation. The end
result of the core buildup is stress to the core material as it
undergoes repeated cycles of compression and tension
because of the supporting posts low resistance to
deformation. To reinforce the above point, consider a post
that is as flexible as a human hair supporting a core against
lateral movement without any coronal dentin existing. The
only resistance encountered is the minimal support of the
post, a hair in this case, and the frictional resistance of the
bonded composite to the relatively flat surface of dentin. In
this example, it should be clear that the composite adds
nothing to the strength of the post.
The saving grace in this dismal scenario comes from the
outer margins of the final restoration. As long as these
circumferential margins stay intact, the weakness of the post-
and-core construct will not be tested, allowing any type of

underlying support or no underlying support at all to
succeed. If and when the outer margins of the restoration
degrade, as they often do over time, then all the functional
forces will be directed internally and the weaknesses of the
construct will take their toll.
2. They have high retention because they are

bonded into the teeth.
Advertisements make claims that bonded posts have
unusually high retention, rendering the retention of threaded
posts irrelevant. The factor that made threaded posts
irrelevant was not the still-present need for high retention,
but rather the inability to disassociate high retention from
high insertional stresses. High retention is not acceptable
even though it is needed if it must come with high insertional
stresses because these stresses too often lead to root fracture.
The maximum retention that a bonded passive post can attain
is 90 pounds, far less than the 340 pounds attained with a
threaded Flexi-Post and Flexi-Flange. Most importantly,
both the Flexi-Post and Flexi-Flange attain their high
retention values without introducing high insertional stresses,
which are at a level comparable to those of passive posts.
The split-shank design of these posts creates high retention
by making the grooves for the threads in a sequential manner
as it is screwed into the root. The posts themselves are, in
effect, graduated taps that allow the dentist to enjoy the
benefits of high retention, low insertional stresses, and an
even distribution of functional stresses.
3. They bend enough to absorb parafunctional

forces without acting as a conduit for excessive
stresses that lead to root fracture.
The one marginal advantage a fiber-reinforced post would
have over a Flexi-Post or Flexi-Flange is the greater
deformation displayed by the former when a sharp blow
would be applied to the post-restored tooth. Under these
unique circumstances, the increased bending would lead to a
lower chance of root fracture than in a tooth with a metal
post. However, short of these circumstances, namely during
all the normal functions that dentition undergo, the rigidity of
a metal post bending in unison with a root is far more likely
to keep margins intact while supporting the external
restoration.
To design for traumatic blows while not meeting the needs
for routine function is a poor choice of options in our
opinion.
4. They eliminate the high insertional stresses

associated with threaded metal posts because they
are of passive design.
Over the years, the split-shank design of the Flexi-Post and
Flexi-Flange has shown that a metal post can be threaded
into a tooth producing high retention and minimal stress at

the same time. This fact alone makes the claimed advantages
of a fiber-reinforced post non-existent.
5. They impose no esthetic challenges because they

have the color of teeth.
The problem of discoloration is pretty much nullified with
opaquing bonding agents. I typically will opaque out the
color of metal by coating the post, as it exits the root, with C
& B Metabond opaquing agent. This same cement can be
used even within the root to minimize any color that might
show through the length of the root and the overlying
gingival. Because this problem is eliminated so efficiently,
esthetic considerations impose no limitation on the use of
these split-shank metal posts.
6. They strengthen the teeth.

This is a claim that is more apparent than real when first
considered. To clarify logical thinking, consider a metal pipe
that is strong enough to resist 300 pounds of force before
bending. Now place a material within the pipe that alone
resists 200 pounds of force before bending. Does it now
require 500 pounds of applied force to bend the pipe filled
with the 200-pound resistant material? On the contrary, the
bending is still ultimately resisted by the pipe alone, which
will bend after 300 pounds of force is applied even though
the pipe is now filled with a 200 pound resistant core.
In the same way, a post that bends far more easily than the
tooth it is embedded into will not increase the resistance to
bending of the tooth. The concept has a nice sound, but it is
not backed up by fact.
OVER THE YEARS, from the use of reamers rather than
files and now relieved reamers and their incorporation of a
reciprocating handpiece rather than a rotary driving force, to
the scientifically proven advantages of a split-shank design
of threaded metal posts, we have attempted to demonstrate
the connection between sound design and practical
mechanics producing more successful techniques and
restorative components. We hope this discussion is timely
and helps dentists to think more critically when exposed to
advertising claims that, in our estimation, do not reflect
clinical reality.
April-June 2005
FEEDBACK?

Post and Core Myths and Misconceptions
Barry Musikant
Figure 1
ALLACIOUS CONCEPTS encouraging the use of fiber-reinforced
posts are not supported by a growing number of research articles and
clinical experience. Unless the weaknesses of these concepts are well
understood, they have the potential to propagate as valid approaches. The
purpose of this article is to shed light on these misconceptions.
Posts in teeth serve only one purpose: to supply extra support for a core
when sufficient tooth structure does not exist to do it alone. Posts placed
into teeth with sufficient dentin to support a core serve no purpose and are,
at best, redundant. In fact, removing dentin in order to place a post may
actually weaken the root. The placement of a post may give support to the
core, but it does not strengthen the root.
Having the same modulus of elasticity as a root in no way assures that
the post will bend to the same degree as the tooth in which it is embedded.
Materials having the same modulus of elasticity will bend the same only
if they have the same cross-sectional area. A post with the same modulus
of elasticity as tooth, yet 1/15 the diameter of the tooth in which it is
placed, will bend about 15 times more than the surrounding root, creating
stresses in the supporting cement, the surrounding core buildup, and the
FIGURE 1: Split-shank
post itself. In short, a post with greater flexibility than the tooth
parallel-thread posts.
compromises the longevity of the overlying crown. Fiber posts are
significantly more flexible than the roots in which they are embedded (16).
The concept that the core and post join together and create a monobloc
stronger than either two of these components is a false notion. This is
easily realized by making a post-and-core combination in which the post
is no thicker than the diameter of a thread of hair. In this case, the post
bends in the air and offers no support to the core. If such a post were
placed in a root without the support of circumferential dentin, there would
be virtually no resistance to lateral forces. In this absurd example, it
becomes clear that the resistance to lateral movement is defined by the
weakest element in the construct, namely the hair-thin post. As the posts
become stronger, the resistance to lateral displacement increases. This
resistance is always limited by the flexibility of the post, which is not
enhanced by bonding to a stronger core material.
In order for a post to bend like tooth in spite of its thinner crosssectional area, the modulus of elasticity must be much higher than that of
the surrounding root. In fact, because the post is about 1/15 the diameter
of the root, the modulus of elasticity should be about 15 times higher than
the tooths. Stainless steel and titanium fall into this category and will
therefore bend much more similarly to the bending of the tooth in which
they are embedded.
Another false concept implies that bonding will increase the retention of
a post beyond the cohesive strength of the cement holding the tooth in
place. SEMs are often shown with fibrils of cement infiltrating the
dentinal tubules by the millions as proof of the greatly increased retention.
While this type of adhesion increases retention more than that of a nonadhesive cement, these millions of penetrating fibrils provide no additional
strength to the bond beyond the strength of the cement. To date, this
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm32postandcore.html[2/21/2011 10:25:36 ]
strength has never exceeded 90 pounds of tensile resistance (7-8).

Research has demonstrated not only that retention is limited to the
cohesive strength of the cement, but also that when subjected to thermal
cycling fiber-reinforced composite posts degrade over time significantly
more than metal posts do (9).
Many studies conclude that metal posts offer more support for
restoration than fiber-reinforced composite posts do. Metal posts are more
resistant to bending and are far more resistant to thermal cycling. Those
who support fiber-reinforced metal posts have attempted to turn a
weakness into a strength by saying that fiber-reinforced posts are less
likely to cause root fracture if subjected to excessive forces. The research
has again clearly demonstrated that while this is true, it takes forces
beyond human capacity to produce these fractures when metal posts are
placed (10). On the other hand, the forces necessary to displace cores
supported by fiber-reinforced composite posts fall clearly within the
capabilities of human function. The best rationale for the use of fiberreinforced posts would be to place them in order to avoid the increased
chances of fracture when a tooth is subjected to a traumatic blow. This
would, however, leave the restored tooth open to gap formation from
normal function, an everyday occurrence.
Once the strong case for the preference of metal posts over fiberreinforced composites is established, an equally strong case can be made
for the design of a split-shank parallel-thread post. (See Figure 1.)
The split-shank design is the only threaded post design that produces the
degree of retention that only threads embedded in dentin can provide while
simultaneously minimizing the insertional stresses to those of a passive
post (11). In effect, the split-shank design is a graduated tap that deepens
the threads in a sequential fashion, never cutting more than .02 mm of
dentin at any one time (Figure 2).
Figure 2
FIGURE 2: The split-shank design is a graduated tap that deepens the threads
in a sequential fashion, never cutting more than .02 mm of dentin at any one
time.
By limiting the removal of dentin, the stresses associated with that

removal are also limited. The result is a post with retention of about 340
pounds, about four times higher than that of the most retentive passive
post, but with stress levels no higher than that of a passive post.
The retention of a natural crown to that of a natural root is at least 220
pounds, a result extrapolated from the research of Shimon Friedman. He
demonstrated that it took at least 220 pounds to split a tooth in half along
its long axis. Two hundred twenty pounds represents the weakest vector
of strength for a tooth. As such, it is reasonable to expect that a natural
tooth would have at least that much retention to a natural crown. The 90
pounds that the best passive post provides is inadequate to duplicate
natures design. The split-shank design, on the other hand, is far more
comparable to natures design. Not only does it supply 340 pounds of
retention, it does so without generating high insertional stresses. Just as
important, a parallel threaded post also distributes its functional stresses

evenly around each of the threads. A passive parallel post distributes a
good portion of the functional stresses in the apical region because the
non-threaded parallel design offers no other area of resistance to these
forces. Like all stresses, they are handled better when distributed evenly
over a large area than they are when concentrated into a small area, as is
the case with the passive parallel post design.
From a restorative point of view, it is only the lack of coronal tooth
structure that defines the need for a post. Therefore, once a post is
required, external support by the crown is also required. The best way for
the crown to supply this support is through the incorporation of a
circumferential ferrule ending on the dentinal surfaces. The longer this
ferrule, the greater the support the crown offers. To place a butt joint
restoration on a tooth where most, if not all, of the axial wall is composed
of a post supported by a composite core is to dramatically increase the
functional stresses that will be directed against the axial wall. Knowing
that this post-and-core buildup is subject to degradation, it is important to
create a ferrule onto solid tooth structure that redirects most of these
functional forces away from the axial wall and toward the external root
surface.
Summary
Establishing the greatest stability and longevity for restorations requires
building a highly retentive and stable substructure. In turn, this requires
the placement of a parallel threaded metal post. The split-shank design
provides high retention with minimal stress, as well as even distribution of
functional stresses. The crown should incorporate a ferrule and end on a
long beveled dentin margin for maximum support.
References
1. King PA, Setchell DJ, Rees JS. Clinical evaluation of a carbon fibre
reinforced carbon endodontic post J Oral Rehabil. 2003 Aug;
30(8):785-9.
2. Drummond JL, Bapna MS. Static and cyclic loading of fiberreinforced dental resin. Dent. Mater. 2003 May;19(3): 226-31.
3. Drummond JL In vitro evaluation of endodontic posts. Am J. Dent.
2000 May;13 (Spec No): 5B-8B.
4. Sidoli GE, King PA, Setchell DJ. An in vitro evaluation of a
carbon-based post and core system. J Prosthet Dent. 1997
Jul;78(1):5-9.
5. Torbjorner A, Karlsson S, Syverud M, Hentsen-Pettersen A.
Carbon fiber reinforced root canal posts. Mechanical and Cytotoxic
properties. Eur J Oral Sci. 1996 Oct-Dec;104(5-6):605-11.
6. Yang HS, Lang LA, Guckes AD, Felton DA. The effect of thermal
change on various dowel-and-core restorative materials. J Prosthet
Dent. 2001 Jul;86(1):74-80.
7. Saunders, RD, Lorey RE, Powers JM, Sloan KM. A comparison of
five post-cement systems for tensile retentive capacity. J Den Res
1988;67: IADR Abstract 304.
8. Stockton LW, Williams PT. Retention and shear bond strength of
two post systems. Oper Dent 1999;24:210-216.
9. Yang HS, Lang LA, Guckes AD, Felton DA. The effect of thermal
change on various dowel-and-core restorative materials. J Prosthet
Dent 2001;86:74-80.
10. Wong EJ, Ruse ND, Greenfeld RS, Coil JM. Initial failure of
post/core systems under compressive-shear loads. J De Res (IADR
abstract #2269) 1999;78:389.
11. Ross RS, Nicholls JI, Harrington GW. A comparison of strains

generated during placement of five endodontic posts. J Endodon
1991;17:450-456.
July-September 2005
FEEDBACK?
Please feel free to visit the Endo Forum and add your comments about any
of the articles in Endo-Mail.
A Deeper Understanding of Endodontic Mechanics
Barry L. Musikant, D.M.D., F.A.S.D.A.
Barry Musikant
N TERMS OF what is generally considered the state of

the art of endodontic shaping, NiTi instruments used in a
reduction-gear rotary engine are presently at the head of
the class. Their use has certainly improved the results
compared to what was routinely attained with the traditional
use of stainless steel files. Not only are the shapes more
conducive to a better fill, but the shapes are gained without
hand fatigue, a major plus when one compares the effort that
went into shaping curved canals with hand files.
Rotary NiTi produced a quantum leap in quality while
reducing the effort needed to attain that quality. One could
say that the advocates of rotary NiTi actually popularized a
standard for superior endodontics that, heretofore, was only
attainable by a few highly skilled endodontists taking an
excessively long time to produce.
Rotary NiTi works because NiTi instruments have much
greater flexibility than stainless steel files. It also works
because the configuration of the NiTi files is really not that
of files at all, but the configuration of reamers. The flutes on
a NiTi file have the more vertical orientation one sees on kreamers. This makes sense because the more horizontal flutes
on a k-file are very inefficient when used with a rotary
motion. Horizontal flutes tend to groove the dentin rather
than remove it while also inefficiently planing the walls. It is
still a mystery that all the rotary NiTi files have the
configuration of reamers while the hand instruments used to
establish the critical glidepath have the configuration of files.
If the former is such a plus, which it is, why not use hand
reamers initially?
A secondary problem arises because of the efficient design
of the NiTi files (which are really reamers). Attached to a
rotary engine, these files have the ability to aggressively
engage the length of the canal system. However, apical
engagement potentially leads to torsional stress, a factor that
NiTi is highly vulnerable to. Those who develop rotary NiTi
techniques are well aware of this weakness and have
established crown-down techniques that minimize the
development of torsional stress. NiTi is also vulnerable to
cyclic fatigue, defined as repetitive cycles of compression
and tension to the shank of the NiTi instrument as it rotates
around a curve. Excessive cyclic fatigue leads to separated
instruments even if torsional stress is completely eliminated,
This discussion
attempts to bring
some deeper
understanding to
the
interconnection
between the
design of
instruments, the
metals they are
made of, and the
forms of delivery
that are used to
make them
function.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm33deeper.html[2/21/2011 10:25:37 ]
which it never is.

Minimizing cyclic fatigue for any given NiTi instrument is
only possible by their frequent replacement with new
instruments. Over the past two decades, the factors that lead
to increased separation of NiTi include a direct relationship
to the degree of curvature encountered, the abruptness of the
curve, the thickness and taper of the NiTi instrument, and the
speed of rotation.
Eliminating the sources of rotary NiTi separation has
become the paramount goal of the advocates and
manufacturers of these systems. This goal is so dominant that
it now supersedes the biologic needs of the teeth being
instrumented. Where 20 years ago it was recommended to
shape canals to a minimum of 35 and a taper of .08 or higher,
as Dr. Schilder originally recommended to meet the biologic
needs for cleansing the canal, today a mesio-buccal canal will
most likely be shaped to a 20 or 25 with either an .04 or .06
taper, not because the shaping is adequate, but because
shaping to a smaller apical diameter with a lesser tapered
instrument produces a lower incidence of separated
instruments. Tables exist that clearly show the average width
of canals 1 mm, 2 mm, and 5 mm from the apex in the canals
of all teeth. The mesio-distal width of a mesio-buccal canal
of a first molar is over .40 mm. at the 1 mm level making a
20 or 25 preparation inadequate. Preparations to this level
may look good on x-ray when they are obturated with a
radiopaque material, but the walls surrounding that fill have
not been properly cleansed according to the data established
for the original dimensions of the canal before
instrumentation. In short, fills of this sort are reminiscent of
silver point fills two generations back. In their day, they
looked good on x-ray, but they often did not do the job.
Rotary NiTi is not only flexible to a far greater degree
than stainless steel, but also has shape memory. It seeks to
regain its straight-line configuration even after taking an
appreciable curve. It is highly resistant to plastic deformation
and when finally deformed NiTi instruments are far more
prone to separation when exposed to torsional stress and
cyclic fatigue. While flexibility is an excellent quality in an
endodontic instrument, shape memory is not. Shape memory
in instruments of increasing thickness and diameter forces
these instruments to work more and more selectively on the
outer walls of teeth, increasing the chances of canal distortion
in the apical third and elliptical shaping at the apex. The
distorting effects of shape memory along the walls of the
canal along with the fear of separation due to torsional stress
and cyclic fatigue have defined the more limited use of rotary
NiTi in curved canals as the effects of their properties have
become better understood.
As we see, rotating NiTi exaggerates the weaknesses of
this metal. If a 45-degree horizontal reciprocating motion
were substituted for rotation, torsional stress and cyclic
fatigue would be virtually eliminated. However, shape
memory would still be a problem.
On the other hand, the use of the reciprocating engine

offers us the chance to reexamine the increased use of
stainless steel. Unlike NiTi, stainless steel does not have
significant shape memory. In other words, it can be pre-bent
to more readily adapt to the canal being shaped. If a pre-bent
stainless steel instrument were to be placed into a rotary
handpiece, the increased stiffness of the stainless steel would
tend to distort the apical preparation. However, when placed
into a 45-degree reciprocating handpiece, the pre-bent
instruments scribe an arc of 1/8 of a full rotation, not enough
to produce apical distortion because the motion does not
extend beyond the canal curvature that the instrument will
shape and widen. Therefore, the stiffness, a negative quality
of the stainless steel instruments, is compensated for by the
use of the reciprocating handpiece and their having been prebent.
Reciprocation is far closer to the balanced force technique
of canal instrumentation that has been recommended as a
way of keeping the instruments centered within the canal. In
fact, it is safer than the balanced force technique because the
back stroke with the reciprocating handpiece mills the dentin
away rather than cleaving it, mechanics that induce far less
stress in the instruments. The reciprocating engine substitutes
a far larger number of reciprocating cycles with low
amplitude rather than having very few cycles with very high
amplitude that occur with balanced force. The end result is
the same, only accomplished much more safely with the
reciprocating handpiece.
We hope we have established the fact that stainless steel
when used with the reciprocating handpiece has far more
versatility than rotary NiTi. The only challenge left is to
design a reamer that has the most advantageous architecture
to be efficient and safe. We already know that a reamer
engages the dentin far less than a file and the vertically
oriented flute design of a reamer is more efficient than the
horizontally oriented flutes on a file when the motion is
either rotation or reciprocation which is nothing more than a
series of short rotations. The reamer can be designed to have
even less engagement by placing a flat along the entire length
of the shank, which reduces the engagement by an additional
third. The incorporation of a flat creates two columns of
chisels with one cutting in the clockwise direction and the
other in the counterclockwise direction, making the
instrument ideally designed for the reciprocating handpiece.
The overall lack of resistance creates superb tactile
perception either when used manually or in the reciprocating
handpiece. And please be aware that these instruments, called
the SafeSiders, are designed to be used either manually or
in the reciprocating handpiece.
The reduced engagement along the entire length of the
instruments shank affords the ability to have a cutting tip
that will pierce tissue rather than impacting it apically. Apical
resistance will let the dentist know if a sharp bend is being
contacted, and the ability to pre-bend them, negotiate to the
apex with the pre-bent instrument, and then attach to the

reciprocating handpiece to produce effective apical shaping
simply, safely, and efficiently, gives the dentist a tool that
had not existed up until this time.
Because they are relieved, they are also more flexible than
non-relieved reamers. They are also more flexible because the
reamer design means that they have fewer flutes, which
means they are less work-hardened and even less prone than
stainless steel files to distort and fracture.
This discussion has attempted to bring some deeper
understanding to the interconnection between the design of
instruments, the metals they are made of, and the forms of
delivery that are used to make them function. It is our opinion
that the SafeSiders approach used with the EndoExpress
reciprocating handpiece is the most effectively designed
system, bringing both efficiency and safety to the highest
levels yet attainable.
Cavit washes out easily. Protect the
Cavit with a covering of Ti-Core
Auto E. No mixing, it dispenses
directly into the access opening
through its micro tip. Light cure for 20
seconds and no more worries about
iatrogenic infections because the
Cavit washed out.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
Beyond Rotary NiTi: Eliminating Stress and Anxiety
Barry L. Musikant, D.M.D., F.A.S.D.A.
Barry Musikant
THOUGHT that it would be good to let our readers know

the number of courses that are available to learn the
endodontic techniques we advocate and why these
courses are unlike any other endodontic course they are likely
to take.
The most comprehensive courses we give are two-day
affairs that cover in detail all the information necessary to
successfully gain access to the pulp chamber, thoroughly
clean and obturate the canal system, seal it off coronally, and
build up a core where necessary. The attendees have a very
good chance of absorbing all this information because the
didactic is combined with more than ten hours of hands-on
experience. One of the most positive reinforcing tools we use
is clinical repetition over two days. The opportunity to
sleep on what was learned from the first day and then
practice the second day is an effective method of inculcating
new knowledge both academically and clinically. The
dentists have the opportunity to use the surgical microscope,
apex locators, and sonic irrigatation techniques as well.
Unlike most courses that emphasize rotary NiTi, in which
the learning curve can be defined as learning when not to use
them, we teach alternative techniques that produce at a
minimum equivalent results while virtually eliminating
instrument separation. The SafeSiders instrumentation
technique used with the Endo-Express reciprocating
handpiece eliminates torsional stress and cyclic fatigue, the
two most important factors in rotary NiTi instrument
separation.
For those unable to take a two-day course, we offer a fullday course that includes at least five hours of hands-on. This
course includes most of what is offered in the two-day course
except that the attendees do not get as much practice.
While the two-day and one-day courses are tuition-based,
we also give a number of free 2-3 hour workshops held in
our dental office in Manhattan.
We are happy to give these free courses because they
inevitably lead to use of the SafeSiders and generate a high
degree of good will for our endodontic practice.
Teaching these courses is a unique experience for Dr.
Deutsch and me because we invented and continue to refine
the SafeSiders system first for ourselves. When you have
been an endodontist for as long as Allan and I, you know
We believe that
anyone who
familiarizes
himself or
herself with the
use of the
SafeSiders in
the EndoExpress
reciprocating
handpiece will
quickly see that
rotary NiTi
instruments are
not only not
necessary, but,
in fact,
irrelevant.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/blm34beyond.html[2/21/2011 10:25:37 ]
exactly what you are trying to accomplish when you develop

a new system. The SafeSiders are designed not only to
eliminate all the problems of traditional techniques, but also
to eliminate the problems of rotary NiTi that surfaced as they
were solving the problems of traditional techniques.
Rotary NiTi at its best minimized the problems of
overfills, weak apical fills, hand fatigue, canal distortion,
fractured roots, and blocked canals. The SafeSiders in the
reciprocating handpiece eliminate these problems at least as
effectively as rotary NiTi. In addition, they eliminate the
problems of separation and excessive expense that are a
byproduct of rotary NiTi. In effect, the SafeSiders represent a
third generation of endodontic instrumentation that brings
relief from the shortcomings of the first two generations.
The SafeSiders approach to endodontics can easily induce
a state of cognitive dissonance in those who use rotary NiTi.
The rotary NiTi user realizes that those instruments can break
if not used correctly, if used too often, if a glide path is not
first established, if sharply curved cases are negotiated, or if
curved canals are opened beyond a fairly small apical
preparation and taper beyond an 04 or 06. Rotary NiTi users
have accepted all these limitations because the results when
successful are far better than was routinely achieved with
traditional techniques. The tradeoff of NiTis limitations for
NiTis results was acceptable and logical until the SafeSiders
were introduced. The introduction of the SafeSiders provides
an alternative method of canal preparation. Included within
the system is the establishment of a glide path accomplished
far more easily with the relieved SafeSider reamers than the
unrelieved files recommended as the glide path creators with
rotary NiTi techniques.
The SafeSiders technique incorporates the safe use of the
No. 2 Peeso reamer to straighten the coronal curve, which
makes all subsequent instruments less challenging,
particularly in those cases with significant apical curves. This
alternative technique also incorporates the use of the No. 2
Gates Glidden reamers to prepare the canals to a diameter of
.65 mm to within 3 mm of the apex. NiTi instruments are not
used with the SafeSiders technique until 95 percent of the
canal has been shaped and the coronal curve has been
straightened. The two NiTi instruments used have been
hand-tested to assure their not fracturing during use and then
are only employed in the 30 degree reciprocating handpiece
which virtually eliminates the torsional stress and cyclic
fatigue associated with separations in rotary NiTi techniques.
Because the SafeSiders instruments cost about one-third
that of rotary NiTi and can be used at least six times, the cost
per instrument use is approximately 90 percent less than that
of rotary NiTi. In fact, the danger resulting from over-using a
SafeSiders instrument in the reciprocating handpiece is one
of dullness, not separation. So, while the SafeSiders
instruments should be discarded after using them on
approximately 6?8 teeth, the downside of dullness represents
a far smaller concern than that of the potential of separation.
In short, we believe that anyone who familiarizes himself

or herself with the use of the SafeSiders in the Endo-Express
reciprocating handpiece will quickly see that rotary NiTi
instruments are not only not necessary, but, in fact, irrelevant.
This statement is so bold that the only way to prove it is for
dentists to try the instruments and make their own
assessments. It is for these reasons that both tuition-based and
free courses are offered. To doubt these claims is more than
understandable, especially when your endodontic techniques
have been improved so much with the incorporation of rotary
NiTi. Yet the third generation of endodontic instrumentation
represented by the SafeSiders is designed to overcome all the
disadvantages of the first two generations and we welcome
anyone to critically appraise their use after trying them.
It is important to change your gloves
intermittently during an endodontic
procedure, particularly in a non-vital
purulent case. If you do so, the
possibility of cross-contamination
from your gloves finger tip to a
sterilized instrument or gutta-percha
cone will certainly be greatly reduced
if not eliminated.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
Doug Kase
Alternatives to Management of a Horizontal Root Fracture
Claudia Hoffman, D.D.S.
Alternatives to Management of a Horizontal Root

Fracture
Claudia Hoffman
20-YEAR-OLD FEMALE presented with the chief

complaint that I fell off my bike two months ago
and my tooth hurt for a while and has been loose
ever since. This was the patients first visit to the dentist
since the accident. She had no significant medical history,
no known allergies to medications, and was taking no
medications daily.
The patient had a history of regular dental visits every
year. The types of past dental therapy included root-canal
therapy, restorations, extractions, fixed prostodontics,
sealants, and implants. The patient had a history of
trauma to the right anterior region four years earlier, and
#7 had been lost and replaced with an implant.
The extra-oral exam was within normal limits. The
intra-oral exam was also within normal limits; there were
no lesions, edema, or abnormalities noted. All probing
depths were 3 mm or less, and oral hygiene was excellent.
The dental exam revealed that #10 had no response to
cold or hot stimuli and was tender to percussion. Also,
#10 was tender to palpation on the buccal gingiva at the
mid-root level. There was class 2 mobility on #10.
Multiple periapical radiographs of #10 were taken for
evaluation. The horizontal root fracture in the middle
third of #10 was evident (see Figure 1).
Radiographically, the horizontal fracture appeared like a
football-shaped radiolucency. There was no periapical
pathology at the apex of #10. The space between the
fractured segments appeared minimal. A widened PDL
was apparent surrounding the fracture site, but the PDL
remained intact. There was no significant bone loss in the
anterior region.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch01alternatives.html[2/21/2011 10:25:38 ]
Figure 1
FIGURE 1: Showing the horizontal root fracture in the

middle third of #10.
The angulation of the cone in radiographic detection of

a horizontal root fracture is critical. In order to
successfully diagnosis a horizontal root fracture the cone
must be between 20 degrees and +10 degrees. Therefore,
if you suspect a horizontal root fracture, it is a good idea
to take multiple radiographs (see Figure 2).
Figure 2
FIGURE 2: Radiographs taken at various angles to a fracture (top row) produce images that reveal the fracture to
varying degreesor not at all.
Treatment
To facilitate pulpal and periodontal ligament healing, the
coronal and apical segments were repositioned in as close
proximity as possible, and a rigid splint of composite was
placed on the buccal surface of #9 through #11. This was
verified radiographically. The rigid splint should be
placed for two to four months. If a long period has
elapsed between the injury and treatment, it is unlikely
that the two segments can be returned to their original

position, therefore compromising the long-term prognosis
of the tooth.
The tooth was isolated without anesthesia, and access
was made. Upon entry into #10 no heme was noted. The
patient was comfortable until the #10 file was placed
beyond 15 mm. A radiograph was taken, and it showed
that the file was at the fracture site. It was apparent at this
point that the coronal segment was necrotic and the apical
segment had maintained its vitality. Extirpation of the
coronal pulp short of the fracture line was performed,
using only sterile saline to maintain the vitality of the
pulp tissue in the apical segment. Calcium Hydroxide was
placed in the coronal segment to induce a hard tissue
closure between the fractured segments. The patient was
advised to avoid masticating in that area and to try to
maintain a soft diet.
When the patient returned on a six-week recall, she
was asymptomatic. The splint was replaced and the
calcium hydroxide was changed. A periapical radiograph
showed no sign of periapical radiolucency.
The patient returned for a twelve-week recall and was
asymptomatic. Again, the rigid splint and calcium
hydroxide were changed.
The patient returned for a four-month recall. Tooth #10
was healing uneventfully, and no pathology was apparent
at its apex. After splint removal, it was noted that #10 was
now class 1 mobility. Upon entry into #10, the canal
appeared clean and dry. The coronal segment was rinsed
and re-instrumented to the fracture line. A hard tissue
barrier was evident at the fracture site. The coronal
segment was obturated with calcium-hydroxide-based
cement (see Figure 3). The tooth was closed with
composite, and the patient was placed on a six-month
recall. At the six-month recall, the patient was
comfortable and no pathology had developed.
Figure 3
FIGURE 3: Showing the obturation of the coronal

segment.
Complicationssuch as pulp necrosis and root-canal

obliterationmay arise, and every case is different.
Clinical considerations to be evaluated for each case are
age, degree of dislocation, mobility, level of fracture,
type of fixation, and patient motivation. The success rate
for treatment varies but has been reported to be
approximately 74 percent. This case illustrates one
alternative to treating and managing a horizontal root
fracture. There are other options for treatment (see Figure
4).
Figure 4
FIGURE 4: Illustrating alternative treatments.
References
Andreasen JO, Andreasen FM, Bayer T. Prognosis
of root-fractured permanent incisors-prediction of
healing modalities. Endod Dent Traumatol 1989;
5:11-22.
Andreasen JO, Hjorting-Hansen E: Intra-alveolar
root fractures:radiographic and histologic study of
50 cases. J of Oral Surgery 25:414, 1967.
FEEDBACK?
questions.
Solving the Mystery of Cracked Teeth
Claudia Hoffman
CRACKED TOOTH is often a mysterious case that

can be frustrating for the practioner and patient. A
cracked tooth can present with a bizarre and
inconclusive set of signs and symptoms. The diagnosis in
these cases may be the most difficult phase of treatment.
Often the cracks are not identified until a restoration has been
removed or a periodontal defect is identified.
The following are the typical signs and symptoms that will
aid you in diagnosing a cracked tooth:
As with any
other case, a
thorough
history is
important.
Patients feel inconsistent pain on mastication,

particularly when releasing on biting.
Patients tend to have trouble articulating their chief
complaint and often have endured a long history of
discomfort.
The teeth may have had some treatment in the past that
did not relieve the symptoms.
Teeth may have pain on temperature extremes, mostly
cold.
Often there is no pain on percussion.
If the pulp is involved, there may be signs and
symptoms of irreversible pulpitis or periradicular
pathosis.
A patient may present with one or all of the above signs
and symptoms. As with any other case, a thorough history is
important. The patient can provide the practioner with
valuable information, such as a history of trauma in the area,
a history of clenching or bruxism, or an oral habit, such as
chewing on hard objects.
During oral examination, the teeth should be dried
carefully to help visualize any cracks. Multiple radiographs
should be taken from different angles including a bite wing;
this thorough imaging helps increase the chances of
identifying the crack. Periodontal probing will identify a
crack that has affected the periodontium and created a
periodontal defect. Endodontically treated teeth may present
with symptoms in the periodontium only because there is no
vital tissue remaining.
Transillumination, from a fiberoptic light, for example, can
be a valuable diagnostic tool in identifying a cracked tooth.
The light beam should be placed perpendicular to the tooth.
Sound tooth structure will transmit light throughout the
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch02mystery.html[2/21/2011 10:25:39 ]
crown. In addition, staining dye can be placed into tooth

structure to locate a potential cracked tooth.
The treatment of cracked teeth will depend on the severity,
location, and extent of the crack or fracture. A craze line,
which is very common and often confused with a fracture,
will transmit fiberoptic light and is considered normal with
no treatment necessary beyond aesthetic concerns. Fractured
cusps or cracked teeth should have full coverage to stabilize
and protect the tooth. If the pulp is involved, temporizing the
tooth as soon as the fracture is identified may be necessary to
protect the tooth before endodontic treatment. If the tooth is
split, the split usually is mesiodistal, crossing both marginal
ridges and separating the tooth into two segments. In all
cases of cracked teeth, the patient should be informed that the
prognosis is guarded, and there are no guarantees.
Reference: American Association of Endodontics Colleagues
For Excellence. Fall/Winter 1997.
February-March 2004
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch02mystery.html[2/21/2011 10:25:39 ]
Diagnosing a Radiolucent Lesion in the Posterior Mandible
Diagnosing a Radiolucent Lesion in the Posterior

Mandible
Claudia Hoffman
S ALL DENTISTS KNOW, accurate diagnosis is

crucial and can be challenging. A 46-year-old African
American female presented to me with the chief
complaint, I went for my regular check-up, and my dentist
told me I need a root canal. The patient had an
unremarkable medical history, and she had seen her dentist
annually for the past 20 years.
Upon clinical presentation, no nodes, masses, or swelling
were apparent. The patient had good oral hygiene with a
dental history of endodontics, restorative, fixed, and
extractions.
The patient was referred for evaluation of tooth #19.
Radiographically, #19 had a large 2 cm well-delineated
periapical radiolucency at the apex of the distal root. The
tooth had been restored many years earlier with a MOD
amalgam. (See Figure 1.)
The clinical exam revealed an asymptomatic molar that
tested vital with a normal response to cold stimuli. Number
19 was negative to percussion and palpation. There was a
mild buccal expansion at the apex of #19. The tooth exhibited
no mobility and pockets less than 3 mm. The fact that the
tooth tested vital was unusual, but there was the possibility
that only the distal root had been necrotic and that the mesial
roots may have remained vital.
The patient was referred to an oral and maxillofacial
surgeon for consultation regarding the lesion on #19. The
oral surgeon evaluated #19 and reported that the lesion of the
distal root was likely a granuloma with a small amount of
buccal expansion with over-lying mucosa intact. The oral
surgeon recommended root canal therapy and re-evaluation in
three to six months; if the lesion increased or did not respond
to treatment, #19 would receive an incisional biopsy,
exploration, or both.
The differential diagnosis for this radiolucent lesion in the
posterior mandible is:
Figure 1
FIGURE 1: Radiograph of
#19, showing a large welldelineated periapical
radiolucency at the apex of
the distal root.
Figure 2

tooth at the time of the
four-month recall.
Periapical granuloma: involves a nonvital

tooth
Periapical cyst: nonvital tooth
Periapical cemento-osseous dysplasia (early
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch03radiolucentlesion.html[2/21/2011 10:25:39 ]
Diagnosing a Radiolucent Lesion in the Posterior Mandible
stages): mostly in African American females;

usually apical to mandibular anteriors; teeth are
vital
Odontogenic keratocyst: unilocular
radiolucency
Ameloblastoma: especially in the posterior
mandible; often associated with an impacted
tooth (multilocular radiolucency)
Traumatic bone cyst: mandibular lesion that
scallops up between roots of teeth; usually in
younger patients
The root canal therapy was performed as indicated, and
upon access into the canals vital tissue was evident in the
distal and mesial canals. The tooth was completed, and the
patient remained asymptomatic. The patient was then
referred back to the oral and maxillofacial surgeon for reevaluation, and the pre-operative treatment was to biopsy the
lesion and possibly to perform an apicoectomy on the distal
root. The results of the biopsy would determine future
proceedings.
After the biopsy, the surgical report came back showing a
diagnosis of viable bone and connective tissue consistent
with a traumatic (simple) bone cyst in the area around #19.
This is a benign, empty, or fluid-containing cavity within
bone devoid of an epithelial lining, a pseudocyst. The lesion
is more common than the literature indicates, and the etiology
is uncertain. The typical presentation is a well-delineated
radiolucent defect that can range from 1 to 10 cm, with
domelike projections that scallop upward between roots. The
treatment is surgical exploration and curettage, the prognosis
is excellent, and reoccurrence is rare. Figure 2 shows the
tooth at the time of the four-month recall, illustrating that the
majority of the lesion has filled in.
Summer 2004
FEEDBACK?
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch03radiolucentlesion.html[2/21/2011 10:25:39 ]
A One-Year Roundup
A One-Year Roundup
Claudia Hoffman
T HAS BEEN approximately one year since I joined

Barry, Allan, Doug, Amy, and Young in this practice. It
is appropriate to say that I have been very lucky to work
with such a talented and professional group of doctors, and I
feel very fortunate.
As with anything else in life, with experience comes
knowledge. Therefore, I thought that I would share with all of
you some of the things that I have learned and changed since
I started.
Reamers are much more effective than K-Files.

I had always used K-Files before I started with this
practice. K-Files are tightly twisted square stainless steel
wire instruments that encounter four points of contact in the
canal. Reamers are loosely twisted trianglular wires that make
three points of contact. Therefore, I understood the rational
for reamers, but I had to experience the difference clinically
to fully appreciate it. I started with reamers and switched
back to files because I was comfortable with the quarter-turn
and pull motion that I had used in my training. After a few
weeks with files again, I was experiencing more handfatigue, more working time with each case, and more
distortion of the canals. I truly realized how much more
difficult it was to use files than reamers. The SafeSiders
reamers offer an easier alternative; the reamer has a flat
surface, decreasing the resistance to dentin in the canal. I can
now say that, having experienced and utilized both
techniques, I prefer SafeSiders to K-Files.
Rotary NiTi has drawbacks and is not the ultimate

answer!
This is very hard for me to admit, because I joined this
practice as a fan of rotary NiTi instrumentation. I have done
many wonderful cases using rotary NiTi, and it was difficult
to try another technique. I have only separated one rotary
NiTi file in my whole career, but the fear of instrument
fracture is always there when using rotary NiTi. I was always
careful not to push with the rotary NiTi instruments and
therefore rarely took them all the way to the apex. I was
doing most of my work with stainless steel hand files. After I
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch04oneyearroundup.html[2/21/2011 10:25:40 ]
A One-Year Roundup
started using Dr. Musikants technique with the SafeSiders

incorporating the Peeso and the Gates, I saw results similar to
those from rotary NiTi with less expense and much less
anxiety. (You can refer to our website, www.endomail.com,
for a full explanation of the SafeSiders technique.) As with
anything else the Peeso and Gates Glidden have a learning
curve before they feel totally comfortable. I have found that
these instruments can do the same shaping as a rotary NiTi in
the canals, and if these instruments break, they break at the
top of the shank and the broken piece can be removed easily.
I have less stress and anxiety and my cases are coming out
just as nicely.
Septocaine is a great adjunct to traditional

anesthesia.
Septocaine is articaine hydrochloride 4 percent with
epinephrine 1:100,000. We all encounter hot teeth, and these
situations can be challenging for the doctor and the patient. I
have always used 2 percent Lidocaine in most cases for
mandibular blocks and infiltration. In some situations where
obtaining anesthesia is difficult, I now use Septocaine to
infiltrate and in a PDL injection around the hot tooth. I avoid
Septocaine usage in patients with any significant medical
history or allergy to sulfa drugs. I also do not use Septocaine
in Mandibular blocks, due to reports of increased chance of
paresthesia, although the chances are still very minimal. I
find that using Septocaine in an infiltration and PDL injection
will obtain anesthesia in a hot tooth.
Correct diagnosis is the most important aspect in

any case.
The medical and dental history is crucial. I always start in
another quadrant than where I believe the problem lies. It is
very easy to focus in on one tooth that the patient suggests,
but it is important to examine the whole dentition. Although
making multiple radiographs can be time-consuming, they
are very helpful. I always take a periapical and bitewing
radiograph of the tooth in question. If the correct diagnosis is
not obvious or reproducible, schedule another appointment
for the patient. Time may make the diagnosis easier and more
accurate. Prescribing antibiotics and pain-killers temporarily
is better than performing a questionable procedure on a
tooth.
Know when to stop and do not always try to be a

hero.
Knowing when to say enough is a hard thing for all of us.
We all want to be heroes and help save every tooth. Telling
a patient that a tooth cannot be saved is a difficult thing. The
patients expectations and the treatment plan have to be
A One-Year Roundup
compatible. I have learned that being a hero in every case is

not an option.
These are things I have picked up or changed over the past
year, and I hope the process continues; in twenty years I
should be doing things differently from the way Im doing
them today.
Fall 2004
FEEDBACK?
Internal Bleaching Techniques and Cervical Resorption
Internal Bleaching Techniques and Cervical

Resorption
Claudia Hoffman
Figure 1
OOTH DISCOLORATION is a challenge that many
dentists face, and internal bleaching is a practical
treatment option. Internal bleaching is used to lighten a
discolored tooth that has had root canal therapy. It involves
placing a chemical oxidizing agent within the coronal portion
of a tooth to remove discoloration. The etiology of tooth
discoloration can be intrinsic, extrinsic, or both; it can
FIGURE 1: Illustrating
involve dentin, enamel, or pulp; it may be brought on by diet,
cervical resorption, number
age, or habits; it may be local or systemic; and in some cases
11, etiology internal
it may be iatrogenic. Discoloration can be caused by
bleaching.
endodontic filling materials or medications that the patient is
taking. Discoloration associated with pulpal involvement can
be caused by intrapulpal hemorrhage (in which case it is pink
or brown), necrotic pulpal tissue, secondary dentin formation
(in which case it is yellowish), and internal resorption (in
which case it is a pink spot).
Most bleaching agents are oxidizers that act on organic
structures of the hard tissues and degrade them into smaller
molecules that are lighter in color, such as C02, 02 and H20.
Indications for internal bleaching are discoloration of
pulpal origin, dentin stains, and stains not amenable to extracoronal bleaching. Contraindications to internal bleaching are
superficial enamel stains, defective enamel formation, severe
dentin loss, presence of caries, and discolored composites.
There are two techniques for internal bleaching: the
chairside technique and the walking bleach technique. The
chairside technique uses Superoxyl in 30 to 35 percent
concentration, H202, and heat. This technique is highly
effective, but the oxiding agent is strong and can burn. There
is a six-to-eight percent chance of cervical resorption,
increasing to 18 to 25 percent when the technique is used in
conjunction with heat. The walking bleach technique uses
a mixture of sodium perborate and water and may be utilized
if the chairside results are inadequate or if you prefer to avoid
the possibility of a higher chance of cervical root resorption.
The sodium perborate when fresh is 95 percent perborate
giving off 9.9 percent of available oxygen. This material is
more easily controlled and safer than Superoxyl; therefore, it
is the material of choice.
The radiograph in Figure 1 shows a tooth that had root
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch05internalbleaching.html[2/21/2011 10:25:40 ]
Internal Bleaching Techniques and Cervical Resorption
canal treatment and internal bleaching ten years earlier. The

patient presented to our office with sensitivity in the gingiva
in the area around the tooth. The patient presented with a
complete history clearly indicating that he had received
internal bleaching via the chairside technique.
Internal resorption usually occurs at six months after
internal bleaching, and after two years the tooth is usually not
restorable, so recall accordingly.
Winter 2004
Use 17 percent EDTA in the
canal to open up the
dentinal tubules before
using 2 percent
Chlorhexidine to disinfect
them.
FEEDBACK?
questions.
Allan Deutsch
file:///D|/...H/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch05internalbleaching.html[2/21/2011 10:25:40 ]
Endodontic Pain or Acute Maxillary Sinusitis?
Claudia Hoffman
ATIENTS often present to our office with pain, under

A sinus condition
the assumptioncorrectly or incorrectlythat their
is a very common
discomfort is associated with a sinus infection. As
cause of nonendodontists, we are supposed to be experts in diagnosing
dental tooth pain;
and relieving oral pain. Because of the complex anatomy in
therefore, it can
the head and neck region, conditions in this part of the body
result in
often cause referred pain that turns up in and around a tooth.
unnecessary
One anatomical structure that can be challenging to the
dental treatment.
dentist is the maxillary sinus. The average dimension of the
maxillary sinus is 40 x 26 x 28 mm (15 ml; Bailey 1998). The
maxillary sinus is usually in the premolar to molar region and
in rare cases may extend to the canine. The innervation is the
maxillary division of the trigeminal nerve, the infraorbital
nerve, and the anterior palatine nerve. The maxillary sinus is
in close proximity to the maxillary teeth.
A sinus condition is a very common cause of non-dental
tooth pain; therefore, it can result in unnecessary dental
treatment. Acute maxillary sinusitis (AMS) is a bacterial
infection that needs to be correctly diagnosed. Patients with a
sinus infection usually present with a chief complaint that
involves dull aching pain that they are not able to pinpoint.
The pain is usually lessened when the patient is standing up
and worsens when the patient is lying down, so it may
present as worse at night. Proper diagnosis starts with a
complete medical and dental history. Non-invasive tests
such as radiographs, percussion, palpation, and thermal
testingshould be performed. Does the patient have chronic
allergies, a cold, or a history of sinus infections? Always ask
patients if they have flown on an airplane recently. A true
sinus infection usually increases in pain if the patient bends
over and places the head below the knees. In addition, extraoral palpation over the sinus area will usually cause
discomfort.
If the diagnosis is AMS, the dentist should prescribe
analgesics, antihistamines, antibiotics, and nasal sprays. If it
is truly a sinus infection, the patient should feel significantly
better in twenty-four hours. If the pain recurs, the patient
should be referred to an ear, nose, and throat physician.
January - March 2005
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch06endodonticpain.html[2/21/2011 10:25:41 ]
FEEDBACK?
Endo-Mail.
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch06endodonticpain.html[2/21/2011 10:25:41 ]
Retreatment of Failed Surgical Endodontic Therapy
Claudia Hoffman
34-YEAR-OLD MALE presented to our office with

the chief complaint My tooth hurts off and on. His
dental history revealed that endodontic therapy had
been performed on tooth #6 two years earlier, due to a
carious lesion. The tooth was still symptomatic after the first
root canal therapy had been completed. Surgical endodontic
therapy was performed due to the persisting problem. The
symptoms had never completely subsided.
The intra-oral and extra-oral clinical exams were within
normal limits. Tooth #6 was sensitive to percussion and
palpation. The tooth had no mobility or periodontal
pocketing. Tooth #6 had endodontic therapy, which appeared
adequate radiographically, and an amalgam retroseal. In
addition, #6 had a screw post and the tooth had been restored
with a composite that appeared to be leaking. There was no
fracture evident radiographically or clinically.
The treatment related to #6 was failing, and possible
etiology was a microfracture or endodontic therapy failure
due to orthograde root filling contamination, questionable
apical seal, or microleakage from the coronal seal.
Factors involved with a failure in endodontic surgery can
include inadequate root end management, leakage, poor
orthograde treatment, incomplete removal of cyst lining, and
failure to recognize root fracture.
The patient was given possible treatment plans: retreatment
and observation, retreatment and apicoectomy, or extraction.
The patient was advised that the prognosis for the tooth was
guarded unless extraction was the chosen option. After
careful consideration, the patient decided to try retreatemnt
and observation.
The post and gutta percha were removed under rubber dam
isolation. The amalgam retro-seal was visualized under the
microscope and the root was checked for fractures. The canal
was irrigated with sodium hypochloride and chlorohexidine.
After careful instrumentation to the retroseal, calci-um
hydroxide was downpacked into the canal.
The patient returned after ten days and was still
symptomatic. The tooth was instrumented and irrigated again
and packed with calcium hydroxide. After another ten days,
the patient was contacted and stated that all the symptoms
had disappeared. The treatment plan at this time is to
obturate the canal and temporize the tooth for three to six
The patient was

given possible
treatment plans:
retreatment and
observation,
retreatment and
apicoectomy, or
extraction.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch07retreatment.html[2/21/2011 10:25:41 ]
months under observation.

April - June 2005
FEEDBACK?
Endo-Mail.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch07retreatment.html[2/21/2011 10:25:41 ]
C-Shaped Canals Are Challenging
Claudia Hoffman
EETH WITH C-shaped canals can be challenging and deceiving

to dentists. C- shaped canals are usually found in mandibular
second molars, and they represent 8 percent of second mandibular
molars in the general population (Weine, 1998). There is an increased
incidence in the Asian population, with 31.5 percent of second
mandibular molars having C-shaped canals.
The C-shaped root configuration is represented by fusion of mesial and
distal roots. There are three categories of C-shaped canals (Melton et al,
1991). Type I is a continuous C-shaped canal. Type II is a semicolonshaped canal, with dentin separating one distinct canal from a buccal or
lingual C-shaped canal. Type III is two or more separate canals.
There are many clinical considerations when treating teeth with Cshaped canals. There is a higher incidence of lateral canals, fins, and
apical deltas. Therefore, debridement and shaping will be more
challenging. The use of ultrasonics with irrigation will help with debris
removal. C-shaped canals can change configuration or morphology at
different levels along the length of the root. The dentin thickness
between the external root surface and the internal root canal wall is less
than in other teeth, so be careful not to strip the walls during shaping or
post placement.
C-shaped canals can present challenges to the dentist in debridement,
obturation, and restoration. Root canal therapy on these teeth generally
has a lower rate of success, and patients should be advised of this before
treatment begins.
I
II
III
FIGURE 1: The three types of C-shaped canal.
July - September 2005

FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch08cshaped.html[2/21/2011 10:25:41 ]
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch08cshaped.html[2/21/2011 10:25:41 ]
The Truth About MB2s
Claudia Hoffman
PATIENT presented to our office with the chief Figure 1

complaint, I had a root canal started on tooth #
14 eight months ago, and it was just completed a
month ago. I have been in agony ever since it was
started. The medical history revealed the patient
suffers from trigeminal neuralgia on the left side. The
clinical evaluation revealed a normal intra-oral and
extra-oral examination, and there were no apparent
swellings or lesions. Tooth # 14 was very sensitive to
FIGURE 1: an MB2 was located
percussion and palpation, and the patient had pain on
mesially lingually to the mesial
biting. The tooth tested negative to hot and cold
buccal canal.
sensitivity. Teeth # 13 and # 15 tested vital and
asymptomatic.
Radiographic evaluation of tooth # 14 showed a
completed root canal therapy that appeared acceptable.
Each of the apices had a puff of cement extruded past
the radiographic apex. A puff of cement can be
inevitable if the tooth is necrotic with no intact
periodontal ligament upon obturation. All three visible
apices had periapical radiolucencies evident, but
without a pre-operative radiograph it is impossible to
know if the PARs are healing lesions or new lesions.
The diagnosis was a failed root canal therapy, and
the etiology could be related to a crack, incomplete
cleaning and bacteria removal, coronal leakage, or an
accessory canal not treated.
The patient was anesthetized and # 14 was isolated
under a rubber dam. Upon access, the palatal, mesial
buccal, and distal buccal canals were located and
examined. The canals were obturated with gutta percha
and appeared to be sealed coronally. Upon examination
under the microscope, there were no cracks or fractures
evident and the tooth appeared intact. Upon further
examination, an MB2 was located mesially lingually to
the mesial buccal canal. (See Figure 1.) Instrumentation
was initiated on the MB2, and immediately the patient
experienced discomfort. There was no vital tissue
remaining in the MB2, but the patient was experiencing
discomfort upon cleaning and shaping. The MB2 was a
separate orifice and apex from the MB. I decided to
clean and shape the MB2 to a 25/08 file and not retreat
the other three canals at this time. Since the root canal
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch09mb2s.html[2/21/2011 10:25:42 ]
looked adequate, I wanted to start with the MB2 and if

the symptoms were relieved I would deduce the
etiology of the pain was the accessory canal. Calcium
hydroxide was packed into the MB2 for one week. The
patient called the office three days later and stated that
the pain was tapering off.
Maxillary First Molar Anatomy

The maxillary first molar can be a very challenging
tooth to treat, and has a very high endodontic failure
rate. The maxillary first molar has three individual
roots, ligual/palatal, the mesialbuccal, and the
distalbuccal. These three root orifices usually form a
tripod. The palatal canal is the biggest and easiest to
locate. The canal can be flat and ribbon-like; therefore,
careful debridement is necessary. The distalbuccal is
usually straight, conical, and has only one canal. The
mesialbuccal root of the first maxillary molar can be
challenging due to the high incidence of MB2s.
Weines 1969 classic paper showed a 50 percent
incidence of MB2 canals. Pineda reported in 1973 that
42 percent of these roots manifested two canals and
two apical foramina. Kulid and Peterss paper in 1990
concluded that 95.2 percent of mesialbuccal roots had a
second canal when the root was sectioned. The reported
incidence of MB2s varies, but one thing is clear: MB2s
are common; assume there are two canals until proven
otherwise.
Locating MB2 Canals

The orifice for the MB2 usually lies lingual to the
mesialbuccal canal toward the palatal canal. The first
thing a clinician should do is open the access from a
triangle-shaped to a rhomboid-shaped preparation. The
MB2 can be located mesial to the mesialbuccal canal. I
got wonderful advice from a teacher who told me to
sweep mesially from the mesial buccal canal toward
the lingual. Fiber-optic illumination can aide in
locating another canal. Magnification is a large factor
in the success of locating an MB2. An ultrasonic tip
can be used to sweep lingually from the mesialbuccal
canal, and this may open up the developmental
groove.
Once a canal has been located, start with small
instruments first; it is very easy to block yourself out
from these canals. Oftentimes the MB2 orifice is
angled, so the instrument will only enter at a
mesial/lingual angle in the beginning. Do not try to
straighten the orifice too early, because you do not
want to ledge or block yourself out. Very often the
mesialbuccal canal and MB2 exit through the same
foramina.
Second mesialbuccal canals can be very challenging

and frustrating for practioners, and I hope this helps!
September - October 2005
FEEDBACK?
Endo-Mail.
Possible Misconceptions Regarding Diagnosis

ISCONCEPTION 1: A patient with irreversible
pulpitis has a painful response to hot and cold.
Claudia Hoffman
Irreversible pulpitis is often characterized by a painful,

lingering response to cold. Irreversible pulpitis can be acute,
subacute, or chronic; therefore, it can be partially or totally
infected. The degree of inflammation in the pulp of a tooth
with irreversible pulpitis is so diseased that root canal therapy
is the treatment of choice. The signs and symptoms can vary,
based on the extent and inflammation in the pulp; usually the
patient feels spontaneous, intermittent, or continuous pain.
The pain may be brought on by sudden temperature changes
(usually cold), and elicit prolonged episodes of pain. This
pain may be relieved by the application of heat or cold.
Reversible pulpitis does not involve spontaneous pain;
therefore, it is reactive only when stimulated, and the
response does not linger after stimulus is removed.
Radiographs are not diagnostic in irreversible pulpitis
because the inflammation is confined to the pulp. The
radiographs can help with finding the etiology of the disease,
such as deep caries or restorations. In late stages of
irreversible pulpitis there may be a thickened PDL evident on
the radiograph.
The EPT is not diagnostic in symptomatic cases of
irreversible pulpitis because the pulp is inflamed and still
responds to electrical stimulus.
Irreversible pulpitis is the most likely to have referred
pain.
It is important to
continually disinfect
the surface of your
finger ruler. Placing
an instrument from
an infected canal
on the surface to
check or change
the measurement
control can lead to
crosscontamination of
new instruments
and gutta-percha
cones.
Doug Kase
MISCONCEPTION 2: When there is no area of

rarefaction on the radiograph the teeth are OK.
Areas of rarefaction are evident on a radiograph only when
the destruction has eroded the cortical plate. Therefore, a
tooth can be nonvital and have bone destruction around the
apices but not be evident from radiographic examination.
This becomes evident when you obturate a nonvital tooth
and there is a significant cement puff on the final film. This
is a tooth that had apical bone destruction with no intact
PDL, but the condition did not appear on the radiograph
because the bone destruction had not broken through the
cortical plate.
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch10misconceptions.html[2/21/2011 10:25:42 ]
MISCONCEPTION 3: Leaving a tooth open is a good

option if the tooth has drained and the patient is in pain.
It is common to open an infected tooth and have purulent
drainage. In most cases, after cleaning and shaping the canals
the drainage will stop. The tooth should be allowed to drain
under the rubber dam for up to 20 minutes. If the drainage
stops, closing the tooth after treatment is the best procedure,
because teeth left open are often involved in mid-treatment
flare-ups (Seltzer, 1997).
In rare occasions when the tooth will not stop draining, a
patient can be placed on antibiotics and a sponge or cotton
pellet should be placed in the access. The tooth should be
closed the next day. Teeth that are left open show higher
levels of secretory IgA than teeth not left open, and this can
lead to an increase in periapical cyst formation (Torres,
1994).
The possibility of mid-treatment flare-ups and cyst
formation illustrate the desirability of closing all teeth under
the rubber dam after treatment whenever possible.
MISCONCEPTION 4: A patient who has a fistulous tract
should be placed on antibiotics.
If a patient presents with a fistula, the first step is to trace
the fistula and obtain a radiograph. After correct diagnosis is
confirmed, and root canal therapy is initiated, when possible
the tooth should be cleaned and shaped and packed with
calcium hydroxide. The patient should be rescheduled for
evaluation and completion of treatment in approximately ten
days. It is best not to give the patient antibiotics after the first
visit because as practitioners we would like to see the fistula
resolve through the removal of the etiology of bacteria. If the
fistula resolves with no antibiotic coverage, we know we
have successfully removed the etiology of the infection.
Antibiotic coverage can cause the fistula to disappear
although the bacteria in the canal have not been removed, and
can give a false sense of healing.
FEEDBACK?
Endo-Mail.
Temporary Fillings and Coronal Leakage
Claudia Hoffman
AFTER the non-surgical root canal therapy is

A poor seal on
completed, a strong temporary cement must be placed
top of an
in the pulp space to prevent leakage and contamination. As
endodontically
dentists, we have a variety of cements and filling materials
treated tooth can
available and we must choose a cement that provides a
allow bacteria
satisfactory seal. A poor seal on top of an endodontically
and fluid products
treated tooth can allow bacteria and fluid products from the
from the oral
oral cavity to re-contaminate the pulp space. The cement
cavity to remust have strength to withstand masticatory forces and
contaminate the
preserve a good seal at the same time.
pulp space.
The most common materials used as temporary fillings are
IRM reinforced zinc oxide cement; Cavit, a mix of zinc
oxide, calcium sulfate, glycol, polyvinyl acetate, polyvinyl
chloride, and triethanolamine; and TERM, a filled composite
resin. Of these three options, Cavit and TERM provide a
better seal than IRM at any thickness. IRM has been shown
to have more extensive marginal leakage of fluid than Cavit
does. Although IRM has a bacterial barrier due to the
eugenol, that does not prevent other fluids from leaking in. If
Cavit is used, it must be placed at a thickness of at least 4
mm. If a stronger filling is needed, you can place glass
ionomer on top of the Cavit (Pathways of the Pulp, 8th Ed.).
So the question arises, when should we retreat a previously
endodontically treated tooth if we suspect contamination?
Swanson and Madison (1987) demonstrated that it took only
three days for coronal leakage of a tracer dye to reach the
apex. Khayat and Torbinejad (1993) demonstrated
recontamination of obturated root canal systems by bacteria
placed in natural saliva within 30 days. Based on these and
other studies, you should retreat leaking non-surgical root
canal therapy cases if left open for longer than three weeks.
January-March 2006
FEEDBACK?
We welcome your
responses and
questions.
Please feel free to
visit the Endo Forum
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch11temporary.html[2/21/2011 10:25:43 ]
and add your

comments about any
of the articles in
Endo-Mail.
The canal does not have to be 100 percent

dry to use EZ-Fill epoxy root canal sealer.
The epoxy sealer will set even under water!
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/ch11temporary.html[2/21/2011 10:25:43 ]
Leaders in Continuing Education
Dentistry Today

Dentistry Today
Dentistry Today
N THEIR DECEMBER 2003 issue, Dentistry Today has

acknowledged both Dr. Allan S. Deutsch and Dr. Barry
Lee Musikant as Leaders in Continuing Education.
Their dynamic speaking style and their ability to direct
dentists to the very heart of stress-free techniques set them
apart from highly marketed trends that falsely give the
appearance of being a standard. Their thirty-plus years of
practice experience have crafted them into the top authorities
in endodontics. It is often said that they introduce a logic and
common sense that is undeniable.
The lecture schedules of Dr. Musikant and Dr. Deutsch
have taken them to more than 200 domestic and international
locations. The content of their lectures ranges from practicebuilding to clinical issues to best practices in endodontic
treatment. As partners in the largest endodontic practice in
Manhattan, New York, they conduct hands-on workshops
with EDS products, as well as other products frequently used
in dentistry, to teach the innovative techniques that they have
developed. Each has co-authored more than 150 articles in
dentistry that have appeared in numerous dental journals in
the United States and Canada as well as major international
journals. A complete list of the articles can be found on the
Essential Dental Systems website.
Dr. Deutsch and Dr. Musikant are members of the
American Dental Association, the American Association of
Endodontists, the Academy of General Dentistry, the Dental
Society of New York, the First District Dental Society, the
Academy of Oral Medicine, Alpha Omega Dental Fraternity,
the American Society of Lasers, and Advanced Technologies
in Dentistry.
Essential Dental Seminars offers a variety of courses that
teach techniques for instrumentation, obturation, and
restoration. All Essential Dental Seminars are ADA and AGD
approved and recognized. Please contact EDS for upcoming
seminar dates and times by phone at 201-487-9090. If you
are interested in co-sponsoring an event, please contact
Dawn Landini at 201-487-9090 x104.
February-March 2004
Remember: when excavating for
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dentistrytoday.html[2/21/2011 10:25:43 ]
the secondary MB canal (MB2

canal) in an upper molar, angle
the excavation towards the MB1
as you deepen the excavation
apically to avoid perforation. The
root anatomy of the palatal
aspect of the MB root can taper
quickly towards the buccal.
Doug Kase
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dentistrytoday.html[2/21/2011 10:25:43 ]
Numbness and Alteration of Sensitivity after RCT
Dr. Gertsberg

Always study preS TECHNOLOGY ADVANCES in dentistry, new
operative x-rays
materials and techniques are becoming available to
with concern
produce better-quality dentistry. Graduation from
about mental
NYU Dental School changed my way of thinking about
foramen.
various dental procedures. My main problematic procedure
remained root-canal therapy, a technique that produced
numerous complications, such as PAP (periapical pathology),
broken instruments, and numbness. I had taken many courses
and spent a lot of time and money to learn new techniques in
endodontics. Nothing worked well for me.
Then a friend of mine, Dr. Natapov, recommended that I
attend Dr. Musikants course. This two-hour meeting
changed my life. I am very appreciative of Dr. Musikant for
his simple and generous technique. It enabled me to run my
practice stress-free and turned my most-feared procedure into
my most-loved.
Now, I would like to report about one of the most stressful
complications from RCT, which I experienced in very few
cases. This was numbness and alteration of sensitivity after
completion of RCT.
Usually, it is very rare that complications arise from
mandibular blocks or mental foramen anesthesia, but in my
cases, it resulted from RCT itself.
A 43-year-old Caucasian female came to my office for a
second opinion with complaints of alteration of sensitivity in
the LLQ and her lower lip following RCT on #21. The
patient stated that the anesthesia did not go away completely
and the next day it had worsened. One x-ray showed a canal
of #21 overfilled by approximately 0.5 mm. Mental foramen
located approximately 1 mm from the apex, and periapical
pathology, possibly a cyst, produced lowered tactile
sensitivity in the whole area plus a completely numb area of
5 mm on the lower lip. The patient was referred to an oral
surgeon. During her consultation, they discussed redoing
RCT on #21. The surgeon explained to the patient that the
treatment would offer a chance to remedy her situation, but if
it didnt work, she would need to do something else. In other
words, the patient was informed about the possible results of
the treatment. Using the technique of Dr. Musikant, old gutta
percha was removed and the canal was instrumented,
irrigated, and refilled with EZ-Fill cement and new gutta
percha to 0.5 mm prior apex. The patient reported feeling
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/drg01numbness.html[2/21/2011 10:25:44 ]
better the next day, and in the following three days said that
she had gone back to normal. At the six-month checkup, xrays showed that PAP had disappeared.
I had two similar cases with teeth #20 and #28 in which
the RCT was performed by me. The situation in those cases
was stressful, not only because of complications, but because
RCT was performed on the teeth so that they could serve as
an abutment for future bridges. In those three cases, I used
Dr. Musikants techniques, which made it possible for me to
resolve easily problems that might otherwise have led to
malpractice cases.
Always study pre-operative x-rays with concern about
mental foramen. Its better to underfill the canals of lower
premolars than to overfill them. It seems that filling the canal
to radiographic lengths, as required by most insurance
companies, is equal to overfilling.
Dr. Gertsberg originally hails from the USSR and has made
his home and professional practice in Brooklyn.
January - March 2005
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
When using an apex

locator, it is important to
check that a circuit exists.
That means check all
contact points. By simply
touching the lip ground to
the instrument probe
(particularly on the Endex)
a full sweep of the meter
indicates good contact
and no breaks in the
circuit. Failure to get this
result can come from a
faulty or broken wire or a
buildup of residue from
continued contact of
drying fluids contained in
cold sterilization wipes.
Now you want to make
sure that a circuit exists
between canal and lip
ground. Make sure you
wet the lip ground. As the
mucosa that the ground is
in contact with dries due to
mouth breathing or airflow
from the saliva ejector, the
conduction in the circuit

will change and hence
affect your measurement
control. What was once at
the apex will now be long.
A dry canal may also do
the same thing. So keep
things wet.
Doug Kase
Don't Bite Off More Than You Can Chew
Doug Kase, D.D.S.

Tales from the Chamber:
Dont Bite Off More Than You Can Chew

Doug Kase
Doug Kase
he purpose of step-back instrumentation during the

SET procedure, using both .02 tapered stainless steel as
well as NiTi instruments, is to establish the corresponding
resistance form of either a fine-medium or medium guttapercha point with a minimal amount of dentin engagement.
The philosophy underlying this technique is to incorporate
more instruments and for each instrument to do less work
when widening a canal. in comparison with techniques that
use fewer instruments with each file doing more work, this
system
reduces chair time
reduces operator stress
decreases the incidence of fractured instruments
The possibility of fractured instruments increases if, as some
manufacturers and clinicians advocate, we put the demand on
our Ni-Ti files to do more work than they should be doing.
This possibility increases even further when increased
demand is coupled with high-energy rotary delivery.
The following case is one that can evoke butterflies in all
our stomachs.
After instrumentation of a central incisor, a .08 file of
greater taper was fractured near the apex. The operator felt
that the canal was wide enough to skip the .06 GT file and
jumped right to the .08 file. The result was the fracture
illustrated in Figure 1, below.
The operator used the surgical microscope to visualize the
file. Using a fine ultrasonic Spartan diamond tip, he made a
trough around the coronal aspect of the file.
Then, using a white hollow trephine bur from a Masserann
Kit by Micro Mega, he created a tunnel to the top of the GT
file. Since the trephine bur cuts counterclockwise, as does
the GT file, he reversed the rotation to clockwise and exerted
apical pressure to grip the remaining piece of GT file (Figure
2) and rotate it clockwise, coronally out of the canal (Figure
3).
An alternative method for removal is to aspirate a small
amount of cyano-acrolate cement (Crazy Glue) into the
lumen of a 20 to 23 gauge needle. Insert the needle to the
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk01dontbite.html[2/21/2011 10:25:44 ]
Don't Bite Off More Than You Can Chew
exposed instrument and engage the coronal aspect of the file.

After the instantaneous set, try to rotate the instrument out of
the canal.
Figure 1
Figure 3
Figure 2
FIGURE 1: Fractured
instrument in the canal.
FIGURE 2: Gripping the remaining piece of GT file

with a hollow trephine bur.
FIGURE 3: Rotating the file clockwise

out of the canal.
FEEDBACK?
My Apex Runneth Over
Doug Kase, D.D.S.

My Apex Runneth Over

Doug Kase
Doug Kase
n event you may have encountered at one time or

another in your endodontic past or may yet encounter
in your endodontic future is an overfill during
obturation of the canal either with gutta-percha or sealer.
Employing techniques that utilize lateral and or apical
pressure with or without thermoplastics increase the
possibility of an overfill.
Over-extended gutta-percha or extruded sealer of various
types such as ZOE-based sealers can act as chronic irritants,
preventing the healing of periapical pathology or even
causing apical breakdown that did not have pathology to
begin with. Thus, it is important to choose the correct system
of obturation that is consistent with a low probability of
overfill.
A single-cone technique utilizing AH-26 or its derivatives,
such as EZ-Fill cement, will minimize your exposure to an
overfill. Placing a single gutta-percha cone to a premeasured length without apical pressure as in the Simplified
Endodontic Technique (S.E.T.), will eliminate gutta-percha
overfills and decrease the probability of apical sealer
extrusion. Since AH-26 and its derivative EZ-Fill cement
are biocompatible, the minimum amount of cement that may
be extruded is well tolerated.
As illustrated by the series of radiographs at the right,
which show a maxillary molar obturated with EZ-Fill and a
single-cone technique, the body will resorb sealer extrusion.
The one-month and six-month recall films further indicate
that the healing process is unimpeded.
03/20/2000
Figure 1
FIGURE 1
Figure 2
FIGURE 2
Figure 3
FIGURE 3
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk02myapex.html[2/21/2011 10:25:45 ]
Cracked Tooth Syndrome
Doug Kase, D.D.S.


Doug Kase
Doug Kase
t is a sure bet that at one time or another you have wanted

to tell a patient in your practice, Youre cracked! The
incidence of cracks in teeth seems to be on the rise.
Whether it is the stressful environment in which we live that
is forcing us into crack-producing habits such as bruxism and
clenching or just the fact that we keep our teeth to an older
age, the cracked tooth and its symptoms are here to stay. The
key to saving these teeth is early diagnosis and treatment.
The diagnosis of a cracked tooth can be a frustrating and
time-consuming experience for dentist and patient. If it is
not done correctly, it can result in too little treatment, which
can lead to premature tooth loss or unnecessary treatment.
Symptoms
Cracked Tooth Syndrome symptoms are variable and may
not present themselves consistently due to difference in
direction, location, and extent of the crack. Teeth with cracks
may have erratic pain on mastication, particularly on the
release of pressure rather than with the increased biting
force. Additionally, pain, especially to cold, is a telltale sign.
However, absence of pain does not rule out the presence of a
crack.
Usually there is no percussive pain and no radiographic
pathology. Some patients will note a prolonged history of
pain or discomfort that could not be diagnosed or treated.
The presence of the crack does not always involve the pulp,
but if the crack extends to the root surface, a periodontal
pocket may be associated with it. Cracks usually start out
small and then grow with time and function. Thus, an early
diagnosis will lead to a better prognosis.
Clinical Tests
When a patient presents for a cracked tooth diagnosis, a
number of clinical tests should be performed. Prior to these
tests, a thorough dental history should be taken. Check for a
history of trauma, clenching or bruxism habits, other
masticatory habits (such as chewing ice), or a history of
occlusal adjustments for relief of the symptom or a history of
other cracked teeth.
A clinical and visual exam comes next. Have the patient
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk03crackedtooth.html[2/21/2011 10:25:45 ]
point you in the right direction, keeping in mind that the

patient's perceptions may not be accurate. Examine the teeth
with a sharp explorer, check for craze lines in the enamel that
are stained darker, palpate and probe the gingiva for
pocketing that may be related to a vertical root fracture.
Usually these pockets are narrow with little movement of the
probe from side to side.
Check for cracked restoration and use transillumination
with magnification to help visualize the suspected crack. The
surgical microscope is a wonderful adjunct and may be all
that is necessary to visualize and diagnose the crack. Using
a cotton roll, have the patient chew down on it like chewing
gum, isolating each tooth in the suspected area. A rubber
wheel or bite stick can also be used. A device called a
Tooth Sleuth can be used to isolate the individual cusp of
the tooth that is cracked.
A sharp and increased response to a stimulus as compared
to adjacent and contralateral teeth may also indicate the
presence of a crack. A long sustained response may indicate
pulpal involvement. Cracks generally do not show on
radiographs unless they are perpendicular to the X-ray film.
However, the long-term effects of cracks may eventually
appear. Changes in the pulp chamber, PDL, or even the
beginning of periapical radiolucency could be signs of the
presence of a crack. Look at endodontically treated teeth for
sealer expressed out of a fracture line or the position, length,
and thickness of a post in relation to the suspected fracture.
Restoration removal may be necessary to help visualize the
crack and assess its position in regards to pulpal involvement.
Cracks versus craze lines can be solved with
transillumination. Remember that most adult teeth have craze
lines, which are only in the enamel, are painless and only of
aesthetic concern. When illuminated, craze lines will allow
the light to pass through them and illuminate the whole
crown. If there is actually a crack in the tooth, the light will
not pass through the crack and will not illuminate the
complete tooth.
A common crack affecting the dentin but not requiring
endodontics is a cuspal fracture. These fractures are easy to
diagnose and the easiest to restore.
The Patients Needs

The diagnosis of a cracked tooth can be difficult, but there is
no doubt that it must be done with expediency.
Prividing a solution to your patients elusive problem, no
matter what the prognosis satisfies the patients reasons for
having sought your expertise and allows the patient to initiate
the appropriate treatment plan.
11/02/1999
FEEDBACK?
Putting an Old Spin on a New Technique
Doug Kase, D.D.S.

Putting an Old Spin on a New Instrumentation

Technique
Doug Kase
Doug Kase
hroughout issues of Endo-Mail, we have discussed in

great detail the Simplified Endodontic Technique
(S.E.T.). As we know, this system utilizes a combination of
instruments that includes both .02 stainless steel files, .04
files, and files of greater taper which are both made of nickel
titanium. The other important instrument that is used at
various times throughout the Simplified Endodontic
Techniques is the Peeso or Gates Glidden reamer.
It is used to widen the coronal one-third to one-half of the
canal, which greatly reduces the stress on the hand file or
reamer being used and on the operator using that file. Using
this rotary instrument in a canal should not induce fear or
hesitation, for we have been taught to use it proficiently for
post preparation since we were dental students.
First Use of the Peeso Reamer

The number 2-Peeso reamer is used three times during the
procedure. It has always been used with a passive pressure in
a wet environment allowing the wieght of the hand piece to
exert the force. Generally, this rotary instrument is first used
after the full length has been negotiated to a number 20 file
or reamer.
Why should we ask a thicker .02 tapered instrument or
even worse, a NiTi instrument that is easier to fracture to
continue to enlarge the full length of the canal? Once the
Peeso has been used, the dentist will find that instrumentation
of the remaining one-half to two-thirds of the canal will
proceed with much less resistance.
It is important to remember when using these rotary
instruments in the canal that one must keep the internal and
external anatomy of the tooth in mind. We never want to
widen a canal towards an external groove or concavity such
as the mesial concavity of maxillary bicuspids. Check your
radiographs for root and canal angulations and root
diameters. By using a passive pressure and staying in line
with the canal you will never create a ledge and never
perforate.
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk04puttingoldspin.html[2/21/2011 10:25:46 ]
Putting an Old Spin on a New Technique
Second Use of the Peeso Reamer

The second time we employ the use of the 2-Peeso reamer is
after the canal has been fully instrumented with the .02 series
of files or reamers which includes the back step to a number
45 instrument. The Peeso is placed back into the coronal
aspect and advanced under passive pressure perhaps only 1/2
to 1 more millimeter. In some canals that possess a greater
curvature, you may be able to widen the coronal aspect a bit
more which actually reduces the curvature for future
instrumentation.
Third Use of the Peeso Reamer

The third time the 2-Peeso is used is after instrumentation
with the .06 File of Greater taper. Again, you may only
advance the Peeso or widen the canal minimally, but after
using the final Ni-Ti hand instrument, the .08 GT., the
perfect resistance form for the insertion of a medium gutta
percha point to measurement control has been created.
Using a rotary instrument such as a Peeso reamer to augment
hand instrumentation will lessen stress for both dentist and
instrument and ultimately lead to a final endodontic
obturation that any dentist could point to with pride.
11/02/1999
FEEDBACK?
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk04puttingoldspin.html[2/21/2011 10:25:46 ]
Access the Key to Success
Doug Kase, D.D.S.


Doug Kase
Doug Kase
Endo Tip
Remember:
always use your
Peeso reamer to
straighten the
coronal aspect of
the canal away
from tooth
anatomy, such
as the furcation
in molars or
external grooves
in bicuspids.
HE STATEMENT THAT you must be able to walk

before you can run, has, believe it or not, a fair
amount of endodontic merit. In other words, a fair amount
of preliminary work has to be done when performing an
endodontic procedure. Diagnosis and treatment planning are
perhaps a bit of a given and could, of course, be discussed
at length. However, what we all may take for granted and
try our hardest to be conservative about is endodontic
access.
We anesthetize, place our rubber dam, pick our newest
bur and proceed to drill a small, conservative hole in a tooth
through which we will instrument and obturate this root
canal. What goes around and around in our head is to keep
the access small so as to preserve as much tooth structure as
we can. However preserving tooth structure unnecessarily
may interfere with your ability to perform proper
endodontics. Without proper straight-line access to the
canals, our ability to instrument, clean, shape, and
ultimately obturate them is greatly hindered.
Overhanging Tooth Structure
Figure 1
FIGURE 1: After attaining

access to the pulp
chamber, remove
overhanging tooth
structure.
WHEN YOU HAVE attained access to the pulp chamber, it

Figure 2
is extremely important to remove any overhanging tooth
structure (see Figure 1). Any remaining tooth structure
diminishes your ability to visualize the chamber and locate
the canals as well as any calcified or extra canals.
If calcified canals are an issue, then straight-line access is
imperative for exploration and excavation, particularly
when you are using magnification. In addition, remaining
tooth structure may force you to pre-curve instruments
unnecessarily and gain entry to the canal from impossible
angles. Access to the mesiobuccal roots of upper molars, for
example, is difficult enough without the presence of extra
tooth structure.
Once the pulp chamber has been penetrated, you can use
a large round slow-speed bur in combination with a barrel
diamond to widen the opening into the chamber so that
straight-line access can be achieved.
Straight-Line Access
FIGURE 2: Overhanging
tooth structure forces
endodontic instruments to
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk05access.html[2/21/2011 10:25:46 ]
ONCE YOU HAVE straight-line access, your

instrumentation and obturation procedures will be made
easier. If you do not have straight-line access, you will
subject your endodontic instruments to more stress during
reaming or filing because they will be negotiating an
unnecessary coronal curve, which becomes even more
accentuated as a result of the overhanging tooth structure
(see Figure 2).
Additionally, if there are any further curves or bends
within the canal anatomy, the stress on the instrument is
further multiplied. If we are dealing with a nickel-titanium
instrument, this could get dangerous very quickly and lead
to fracture. When the E. Z. Fill technique is used, having
straight-line access further facilitates our ability to use our
Peeso reamer to continue to straighten the coronal
curvatures, thus making instrumentation less stressful to
both the instrument and the dentist.
It is nice to preserve tooth structure and be conservative
when possible in performing root canal treatment. However,
improper access can lead to a plethora of problems for the
dentist and ultimately for the patient. Proper endodontic
access is the key to a successful outcome and a happy
patient.
negotiate an unnecessary
coronal curve, increasing
stress during reaming or
filing.
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk05access.html[2/21/2011 10:25:46 ]
Post Removal Revisited
Doug Kase, D.D.S.


Doug Kase
Doug Kase
ETS FACE IT: the discovery of a fractured post is

depressing! It is not only depressing and disappointing
to the dentist whose hard work may not have gone the
distance for some unforeseen reason, but also to the patient,
who is likely to be upset over what feels like a wasted
investment of time in the dental chair and dollars out of
pocket. The patient may lose confidence in the dentist,
especially if the failure occurs just a short time after the
endodontic procedure. Additionally if this post fracture
results in the loss of the tooth, the issues could become much
more complicated. All of a sudden the options of fixed
bridges, removable dentures, implants, oreven worsea
legal issue may loom overhead.
Ruddle Remover Kit
FIGURE 1: Components of
the Ruddle Post Remover
Kit.
Explaining the Situation

A REASONABLE explanation to the patient is a good start
toward rectifying the situation. The reasons for post fracture
can be multifaceted. Recurrent decay, habits of occlusion, or
unknown trauma are just a few causes of post fracture.
Whatever the cause, informing the patient that all is not lost,
especially the tooth, may take a potentially very negative
situation and turn it into a positive one with you as the hero
of the story. So how do we become the hero or heroine? We
remove the fractured post and save the day.
Slow-speed bur
FIGURE 2: The slowspeed bur is used to
Removing a Fractured Post

THE REMOVAL of a fractured post can be done in a variety
of manners. We can drill them out with very fine high-speed
burs under magnification. The endodontic microscope is an
invaluable aid during this procedure, especially as we drill
deeper into the root. Using a fine diamond ultrasonic tip
improves your ability to visualize the apical end of the post
and facilitates its removal by vibration. If enough of the post
is accessible, an ultrasonic tip can be used to vibrate the post
out of the tooth without the use of a drill.
We can also use an instrument called the Ruddle Post
Remover (Figure 1), which can provide an expeditious end to
a tough endeavor.
If there is enough of the post showing coronally, the
Trephine bur
FIGURE 3: The trephine

bur is used to shape the
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk06postremoval.html[2/21/2011 10:25:46 ]
expose the top of the post.
head cylindrically.
Ruddle Post Remover can extract it from the root with very
little effort. The Ruddle Post Remover can be used even if
the remaining head of the post is below the existing tooth
Ruddle post remover
structure, but use of this device becomes harder and perhaps
inappropriate the more submerged the head is. Additionally,
this instrument can be used only with passive posts, since the
post will be pulled out of the root and threads that engage
dentin will interfere with its function.
Using the Ruddle Post Remover
FIGURE 4: The tap with

protective cushion is
threaded over the
prepared post head.
THE FIRST STEP is to use the included slow-speed bur to

tunnel down and expose the top of the post (Figure 2).
Once access to the post head is established, an appropriate
trephine bur (Figure 3) is used to shape the head into a
corresponding cylindrical shape.
Then a corresponding tap with a protective rubber cushion
(Figure 4) is reverse-threaded in a counterclockwise direction
over the prepared post head.
It is this tap that the post remover (Figure 5) engages, and
as it is tightened the remover extracts the post coronally. An
additional benefit to the reverse threads of the tap is on a
threaded post. By its use in a counterclockwise direction it
can facilitate the actual unscrewing of a threaded post since
it cannot be extracted directly.
The end result is a happy patient due to a saved case
because we were able to save an abutment and perhaps save
our butts as well.
FIGURE 5: Ruddle post

remover with tap and
cushion in place and ready
to use.
Endo Tip
Have you ever opened the pulp chamber of a tooth and detected a
fetid odor? I have. Using a syringe to irrigate the pulp canal with
mouthwash works to eliminate that odor. Many times Ill leave the
rinse inside the chamber for a few minutes. Afterwards, Ill rinse
with sodium hypochloride. Then the odor will dissipate. Patients
who smelled the initial odor feel terrific for there is no longer an
odor. Furthermore, they feel that you (as a practitioner) have
really done something for them.
Amy Dukoff
FEEDBACK?
We welcome
your responses
and questions.
Please feel free to
visit the Endo
Forum and add
your comments
about any of the
articles in EndoMail.
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk06postremoval.html[2/21/2011 10:25:46 ]
The Kase of the Bifurcated Bicuspid
Doug Kase, D.D.S.


Doug Kase
Doug Kase
HERE ARE TIMES when I look at an x-ray and

discover root anatomy complicated enough to make me
exclaim, Oy Vey! The case that Im going to discuss in
this column concerns one of those teeth that not only looks
complicated, but is also a challenge to our endodontic
technique.
The tooth shown in Figure 1 is a perfect example of a
lower bicuspid that bifurcates in the apical one-third or onequarter of the root. The fact that coronally there is a common
canal within one main root rather than two separate canals
within a common root makes every stepnegotiation,
instrumentation, and finally obturationa very tough
endeavor.
Accessing the Bifurcated Canal
Figure 1: A lower bicuspid

that bifurcates in the apical
one-third or one-quarter of
the root.
WHEN YOU GAIN ACCESS to the pulp chamber, it is

important to open wide enough to attain straight-line access
to the canal. If the common section of the canal is wide
enough to begin with, then finding the split toward the apex
will be easier. Placing two instruments into the tooth at the
same time initially may be impossible. If the common
section is very thin initially, thenwith copious irrigation
and RC Prepthe common section can be instrumented to a
number 20 file or reamer and then widened with Gates
Figure 2: Follow-up
Glidden or Peeso reamers or a combination of the two. After
radiograph taken to verify the widening is complete, access to the split canals will be
which canal the instrument easier.
is in
A sufficiently wide coronal section will allow you to place
a small 45-degree bend in the initial instrument tip and then
rotate this tip into each end of the bifurcated canal. After you
have established a working length with an apex locator, you
should take a follow-up radiograph to verify which canal you
are actually in (see Figure 2). It is important to remember
how your initial instrument was inserted into the common
canal (for example along which wall) so that you can guide it
back into each of the splits properly.
Instrumentation can be achieved by alternating between the Figure 3: Each canal and
the common section of the
canals with the same instrument. In other words, do not
canal widened sufficiently
instrument one side of the split totally for you will surely
to allow a smooth
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk07bifurcated.html[2/21/2011 10:25:47 ]
Figure 4: Radiograph of
the completed fill (suitable
for framing).
block the other side with debris.

When you are alternating between canals, please keep in
mind the internal and external root anatomy. Your object is
to widen each canal and also to widen the common section of
the canal to allow a smooth transition into each split (see
Figure 3). Widening the common section with a number 2
Peeso reamer will enable you to accomplish this transition,
using the EZ Fill technique with the stainless steel series of
instruments, and ultimately the nickel-titanium instruments
will also pass easily into each split. You are now ready to
obturate.
transition into each split.
Obturation
TRYING TO OBTURATE this anatomical freak of nature
may actually undo all the good work you accomplished in the
instrumentation phase. By filling one canal perfectly, you
may actually block access to the other side of the split.
In the situation illustrated here, I was only able to widen
the coronal section enough to accommodate one medium
gutta-percha point at a time. However, due to the taper of the
point and the widening of the mid-root canal area, once the
first point was placed to the apex in one canal with EZ-Fill
epoxy-resin cement I could remove the coronal section of
gutta-percha with a Peeso reamer. Then by using a very thin
stainless steel finger spreader as a path-finding instrument, I
was able to re-establish access to the other side of the split
with ease.
Additionally, the thin finger spreader pushed the mid-root
mass of gutta-percha against the appropriate wall of the
common section of the canal, further facilitating the
placement of a second medium gutta-percha point.
When you have achieved the final fill of a case as
complicated as this one, the radiograph (see Figure 4) would
be one to frame as an 8 x 10 glossy and hang on your office
wall.
March-April 2001
Endo Tip
Always use SafeSiders in a wrist-watch-winding tip

movement. This applies to both reamers and files.
Never use them with an up-and-down filing motion. The
up-and-down motion will cause ledging and blockage of
the canal with dentin debris.
FEEDBACK?
We welcome your responses
and questions.
Please feel free to visit the
Endo Forum and add your
comments about any of the
articles in Endo-Mail.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk07bifurcated.html[2/21/2011 10:25:47 ]
The Kase of the Blunderbuss
Doug Kase, D.D.S.


Doug Kase
Doug Kase
Endo Tip
Did You Know?

The surgical
masks that we
wear lose their
effectiveness in
30 minutes under
normal use.
According to New
York States
mandated
guidelines for
infection control,
autoclaves should
be tested weekly
with a spore test
and a permanent
record should be
maintained.
S JERRY SEINFELD would say, did you ever wonder

whats the deal with the word blunderbuss? Oh, I
know that a blunderbuss was a short musket with a
wide bore, but how often do you run across one of those
nowadays? Now if I were on the corner of 57th Street and
7th Avenue, waiting for the downtown bus, but accidentally
boarded the crosstown bus, I might consider that a
blunderbuss. However, in the world of endodontics, a canal
so wide apically that you may not even have the
instrumentation to obturate it would be called a blunderbuss.
That kind of canal certainly can evoke feelings of
helplessness. You might even turn to immediate unnecessary
apical surgery in order to correct any overfill of gutta-percha
and sealer that comes spilling out of an uncontrolled apical
foramen.
Figure 1: The blunderbuss.
This is the case of a 28-year-old male patient with a
history of trauma to tooth number 8 when he was a child. As
Figure 1 clearly shows, there was incomplete root formation
including the absence of apical closure. There was also
evidence of a periapical radiolucency. The patient came in
with symptoms of abscess, including pain and periapical
swelling. I placed him on antibiotics and analgesics to
control the acute symptoms and we scheduled another
appointment for treatment. Initially, it looked as if it would
be a cut-and-dried case of obturation and immediate
apicoectomy.
When he returned in two weeks, the acute symptoms had
abated, and I initiated treatment. I opened the access as wide
as possible without compromising the crown, achieved
measurement control with an apex locater, confirmed it by
radiograph (Figure 2), and accomplished instrumentation
Figure 2: Verifying
with instruments as wide as a #140 reamer. I utilized largemeasurement control.
diameter hedstrom files along the canal walls to check for
tissue and debris.
Now, how in blazes was I going obturate? I was able to
dry the canal and then pack MTA cement to the apical
measurement, using the reverse side of a coarse paper point
until there was some apical resistance, thus creating a stop.
Using cotton wrapped around a large diameter file, I cleaned
the excess cement from the canal walls. I then placed EZ-
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk08blunderbuss.html[2/21/2011 10:25:47 ]
Packaged
autoclaved
instruments
should be
resterilized every
six months and
unwrapped
instruments every
six days.
Even one
complaint from a
patient about your
office can cause
an O.S.H.A.
investigation
(informal or
formal).
Fill cement, using the bi-directional spiral, and thus the canal
was flooded with sealer.
I reversed a large gutta-percha cone, dipped it into solvent
for three seconds, and placed it to measurement control.
Using a spreader with no apical pressure, I laterally
condensed the mass of gutta-percha, then coated a second
large cone with sealer and placed it into the canal in the
normal direction.
Since research has shown that AH-26 based EZ-Fill sealer
alone would be good enough to seal the canal, the guttapercha core only helps to force the sealer against the MTA
stop and the canal walls, leading to the final result seen in
Figure 3.
Immediate surgery was not necessary, and the patient
walked out very happy. The dentist also felt satisfied with
the result, but only time will decide the ultimate success in
the case of this blunderbuss.
Figure 3: The final result.
May-June 2001
You must supply

four pieces of
personal
protective
equipment
(gloves, eye
protection, mask,
and garment) to
all employees in
contact with blood
and saliva.
Sodium
hypochlorite is a
good hard-surface
disinfectant? A 1 :
10 ratio of bleach
to water will
disinfect in three
minutes; however,
it can eventually
cause damage to
the item you are
disinfecting.
Doug Kase
FEEDBACK?
The Zen of Root Canal
Doug Kase, D.D.S.


Doug Kase
Doug Kase
AITHFUL READERS, I know you are expecting

another bizarre and twisted tale of endodontic
experience that keeps your eyes glued to the page and your
stomach on an emotional roller coaster. This time, however,
I am going to wax a bit philosophical! To do endodontics
and enjoy what you do, you must accomplish it with the least
amount of stress. In order to have less stress, the first thing
you must master is to visualize your final product. Once you
can do this, you can create a plan that will lead you to that
goal.
My philosophy is simply be one with the tooth. Now, I
am no Obi Won Kanobi; however, being one with the tooth is
the most important starting point of stress-free endodontics.
We are, of course, making the assumption that the tooth in
question has been properly diagnosed and the need for
endodontics is apparent. Now it is time to observe and
think! Make sure your radiograph is current, and take a new
one if necessary. Take any additional radiographs to check
for additional roots or canals by varying the angle. Try to use
the paralleling technique so that there is a realistic one-toone relationship between the tooth and the film, thus
eliminating foreshortening or elongation. Look at the
distance between the occlusal table and the roof of the pulp
chamber to avoid drilling too deep and to avoid an
unnecessary perforation. Check for mesial and distal
angulations of the tooth so that your access will be in line
with the coronal and root anatomy. It is also important to
check for radiographic calcifications and visibility of the
canals in addition to root curvature. A calcified curved canal
will change your expectations and thus your final product.
Knowing this and accepting it may alter your treatment plan,
thus extending a one-visit endodontic procedure to two or
more. It may also mean that you require the use of the
endodontic microscope to locate the canals, so perhaps this
isnt one of those 45-minute one-visit molar root canals that
we have all been speaking of. Make sure you check the
clinical root anatomy and compare it with the radiograph.
Sometimes it may be beneficial to gain access without the
rubber dam so that your perception of actual anatomy is not
distorted. You will find that your patient will actually be
The patients
expectations
are
critical to a
positive
endodontic
experience.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk09zen.html[2/21/2011 10:25:48 ]
pleased to be informed that you have changed your

expectations before the longer procedure begins, and you will
find that by informing the patient you reduce your stress
astronomically. Sharing your expectations with your patient
makes you a better practitioner in your patients eyes and
your own!
You now give the local anesthesia. This is one situation in
which it cant hurt to over-do. Make sure that your patient is
numb. To patients who arrive after a rough night of pain and
discomfort, give marcaine so that they are anesthetized for a
longer post-operative period of time and can go home or to
work and enjoy the feeling. You can even give them an
additional injection just as they leave your office to extend
the anesthetic relief that much longer! Dont be afraid to use
the periodontal ligament injection. If used conservatively,
this can be a great adjunct to anesthetize a hot tooth, but tell
the patient that using this injection may cause a bit more
post-operative discomfort during chewing. The patients
expectations are critical to a positive endodontic experience.
Its time for access. Go back to your radiograph and look
at the external anatomy of the tooth to verify your plan of
action. Once inside the pulp chamber, find the canals and
always suspect the bizarre. Look for that extra mesio-buccal
canal in maxillary second molars and check for a lingual
canal in mandibular first bicuspids. Again remember . . . be
one with the tooth.
O. K., you found the canals and its time to whip out your
faithful apex locator. Make sure your reading is repeatable.
Watch out for contact with metallic restorations either
physically or by conduction with blood or irrigating solution.
Use an instrument that fits the canal intimately so that there is
adequate contact in the apical regions. A good fit will give
you a very accurate reading. Make sure you check your
measurement control before you obturate, for the working
length will change in curved canals as they are instrumented
and straightened coronally.
Now you are in the meat-and-potatoes of endodontics, and
the E-Z Fill Technique will show you the way. If you follow
the technique, you will achieve the end result you visualized.
Do not try to shortcut the technique, for the slower you work,
the quicker you will achieve your expected result. That
sounds like a paradox, but its so. If the canals are calcified,
start out with a .06 or .08 instrument. To avoid blocking the
apex, be careful to use the instrumentation with the correct
motion when filing the canal. If you have to reiterate the
canal with the same instrument, its O.K. to make sure the
apex is clear. Do not worry about taking an extra five or ten
minutes to achieve the result you want! Close your access
with a temporary restoration that will not leak and will not
wash out. Nothing can be more frustrating for patient and
dentist than to have to retreat a perfectly done root canal
because the temporary restoration washed out and leaked. I
use ZOP or glass ionomer cement to close my access
cavities.
Your post-operative instructions and a patients postoperative expectations can be as important as the procedure
itself. Use medications as needed and when needed! Do not
be afraid to tell your patients that they will have discomfort.
A patient in the know is a happy patient. Information is
the key to a post-operative night that is smooth and
telephone-call free.
July-August 2001
Endo Tip
For a free subscription to the Endo-Mail

newsletter, just fill in this form and click the
SUBMIT button.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
about any of the
Enter my NEW subscription to the Endo-Mail

Newsletter.
Change my address.
NAME
ADDRESS
CITY
STATE
ZIP
COUNTRY
Never Give Up! Never Surrender!
Doug Kase, D.D.S.


Doug Kase
Doug Kase
OMETIMES a patient may present to your office with a

problem (related to dentistry, of course) that after a
careful clinical and radiographic exam makes you kind
of say to yourself . . . why bother? Sometimes taking a shot
at treatment might be well worth the result, ultimately saving
the patient from a surgical procedure or an extraction and the
eventual replacement of that lost tooth.
This story starts out more than twenty years ago, when a
patient had endodontic therapy performed on tooth #3. The
tooth was obturated using silver points and ultimately
restored. Years later, it was found to have developed a
periapical radiolucency over the distobuccal root, and the
patient was subsequently referred to an oral surgeon for an
apicoectomy. The procedure was completed, and our patient
was expected to live happily ever after, which he did for a
number of years.
Figure 1
FIGURE 1: Large
retrograde filling, shortened
root, and (arrow) fistula
traceable to the
distobuccal root.
Figure 2
The Plot Thickens!

THE PATIENT described above became my patient when he
developed a fistula traceable to the distobuccal root where the FIGURE 2: Extrusion of
sealer around retrograde
apicoectomy was performed. There was quite a large
filling (arrow), completely
retrograde filling, the root had been shortened quite a bit, and
sealing the canal and
adding insult to injurythe palatal root also had a
closing the fistula.
periapical area (Figure 1). There now were treatment
alternatives to discuss, such as extraction, another
Figure 3
apicoectomy, root amputation or resection, or retreatment.
The patient wanted to save the tooth and did not want a
bridge or to have to go through an implant procedure.
Because the root was so short, any other surgical procedure
would have to be very conservative to preserve as much root
as possible. Performing an apicoectomy on the palatal root
could have been much more complicated and could have
FIGURE 3: The core
involved the maxillary sinus as well. The alternatives of root
rebuilt and the crown
amputation and root resection also would not have addressed
recemented permanently
the problem of the failing palatal root.
with Ketac cement.
An interesting question is why did the original apico fail?
The reasons could be that it did not seal the apex, eventually
leaked, or there were lateral canals that eventually reinfected
the case from the original silver point obturation. Whatever
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk10nevergiveup.html[2/21/2011 10:25:49 ]
Figure 4
the cause, I decided to retreat the case and try to create a
better internal seal on the distobuccal root and the other roots
as well.
It is always better to remove a crown if possible when
attempting to remove silver points. With the crown off, you
have much greater access to grab the point rather than
attempting it through a smaller access opening in the crown.
The crown was removed with no damage and, using very fine
hemostats, the points were lifted out of the canal with little
effort. There was evidence of breakdown within the tooth.
(You know . . . schmutz!) Measurement control was achieved
with an apex locator, and the canals were re-instrumented
using the EZ-Fill technique until clean filings were seen on
the instruments. Care was taken on the distobuccal canal not
to dislodge the retrograde seal. The canals were obturated
with EZ-Fill Cement and single point gutta-percha cones. It
is important to note in Figure 2 the extrusion of sealer around
the retrograde filling, which completely sealed the canal and
ultimately resulted in closure of the fistula. The core was
rebuilt, and the crown was recemented permanently with
Ketac cement (Figure 3).
The patient returned recently for a follow-up radiograph
(Figure 4). He remains symptom-free.
Sometimes the easy way may not be the best way for our
patients. Remember: never give up, never surrender!
FIGURE 4: Three-month
recall radiograph.
Endo Tip
Give 600 mg. Motrin along with two

Tyenol every eight hours. The Tylenol
potentiates the effects of the Motrin.
Result: better pain control!
Young Bui
FEEDBACK?
and questions.
about any of the articles in
Endo-Mail.
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk10nevergiveup.html[2/21/2011 10:25:49 ]
Its a Dangerous World!
Doug Kase, D.D.S.


Doug Kase
Doug Kase
ELL, FAITHFUL READERS, we all have managed

to get back in gear and resume our everyday lives in
light of September 11th. Learning to live with what
happened and what could happen is something we must all
master, and must master rather skillfully. So, if you think the
world has turned into a hazardous place to live, youre right,
but for now lets concentrate on some of the occupational
hazards that we encounter every day in our dental practices.
Numerous communicable diseases can rear their ugly
heads within a dental office environment. Among the most
common that are spread by inoculation are the blood-borne
pathogens hepatitis viruses B, C, Delta, and G, human
immunodeficiency virus (HIV), and herpes. Additionally, a
number of respiratory viruses, from the common cold to
tuberculosis, can be spread by inhalation.
How do we protect ourselves?
The answer is simple, for we do so by implementing
universal precautions and viewing every patient as a
potential source of infection.
Make sure your patients medical history is complete, and
dont be lazy. Put on your mask, gloves, and protective
eyewear.
Inoculation most commonly occurs through a needlestick
or sharps-related injury. Thus it is important to establish
routines within your office to minimize exposure to this
hazard for you and your staff. Use disposable items when
possible and try not to recap a contaminated needle without
the correct single-handed technique or a safety device. All
sharps should be disposed into a proper container and any
instruments should be carried to the sterilization area in a
closed container. All clinical waste should also be disposed
of properly.
Ionizing radiation can also be a dental office hazard.
Make sure all x-ray units are well maintained and inspected.
Using newer faster film or digital radiography will reduce
exposure time. Using the lead apron for your patient and
maintaining a proper distance from the x-ray head for the
dentist should be common sense. Also, a radiationmonitoring device can provide additional insurance for you
and your staff.
Your
psychological and
physical health
are intimately
entwined.
Maintaining one
will help maintain
the other.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk11dangerous.html[2/21/2011 10:25:50 ]
When my father, who was also a dentist, lost his highpitch hearing, we all blamed it on his handpiece. The
evidence that sound hazards in the dental office can create
hearing loss is inconclusive. Our high-speed handpiece
operates in ranges from 3900 to 12500 Hz and more.
Duration and degree of exposure can be the critical factors in
hearing loss.
A good piece of advice that I could give my readers is
Watch your back! And while you are doing that, watch
your wrist and other parts of your body, too. Musculoskeletal problems can be induced while practicing dentistry
either correctly or incorrectly. Sit correctly and practice good
posture. Make sure you have a comfortable operators chair
that is set to the correct height to avoid pressure on your
sciatic nerve. Take breaks, stretch properly, and maintain
your physical fitness. To help prevent carpal-tunnel
syndrome, try to avoid repetitive movements and overly
flexed positions of your wrist. Take rest periods, and dont
grip your instruments too tightly.
When it comes to stress there is only one thing I can say
It stinks. Lets face it, our beloved profession can be
psychologically stressful. Office problems, staff problems,
and patient problems can snowball into an unmanageable
mess. Try to practice behaviors that reduce this stress.
Manage your time properly and try not to overbook your
day. Taking a routine lunch break may help to buffer a busy
schedule. Frequent staff meetings and scripted scenarios for
dealing with problem patients will certainly also help.
Obviously, your psychological and physical health are
intimately entwined, so maintaining one will help maintain
the other.
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk11dangerous.html[2/21/2011 10:25:50 ]
Never Assume!
Doug Kase, D.D.S.

Never Assume!
Doug Kase
Doug Kase
ell, readers, its time for some bizarre stuff. A patient Figure 1
presented to our office with pain to cold stimulus
and chewing pressure associated with a mandibular
right first molar. A vitality test using the electronic pulp
tester and also one using Endo-ice gave a severely
hypersensitive and sustained response indicative of acute
pulpitis. Nothing strange here, but lets move on.
Using a cusp isolator, such as a Tooth Sleuth, I was able to
elicit symptoms when pressure was placed on the lingual
FIGURE 1: Debris in the
cusps.
isthmus between the
Transillumination under magnification confirmed a fracture
mesiobuccal and
line on the mesial and distal aspects of the tooth over the
mesiolingual canal.
marginal ridges. I was now dealing with cracked tooth
syndrome, and I informed the patient that the prognosis was
guarded and that endodontic therapy and full coverage would Figure 2
be needed. Nothing too strange here, either, but wait!
Using the EZ-Fill SafeSider technique, I performed
endodontic therapy on four canals. After I had gained access,
I established under magnification that the fracture did not
involve the pulpal floor and stopped short of the cervical
area. I measured the canals, instrumented, and dried for
obturation, and that was when things started to take a turn
FIGURE 2: Note the five
toward the unusual.
instruments.
In the isthmus between the mesiobuccal and mesiolingual
canal (Figure 1) some debris remained; I proceeded to
remove it with an explorer only to find some trapped tissue.
Figure 3
To my surprise, after one swipe with the explorer this area
began to bleed. Excavation with a small round bur was then
extremely productive because, lo and behold, I discovered an
extra mesial canal (Figure 2). I established measurement
control and instrumented the extra canal. I completed
obturation, and the prognosis is good (Figure 3).
Searching for the presence of extra canalssuch as a
FIGURE 3: Completed
second mesiobuccal canal in a maxillary molar, a second
obturation.
canal or even double-rooted mandibular canine, or even a
fifth canal in a mandibular first molarshould become
second nature to the treating dentist. By taking an angled
radiograph and using magnification beyond our standard 2
times operating loops, we should make the discovery of these
extra canals much easier. Using either 4 times wide field-
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk12neverassume.html[2/21/2011 10:25:50 ]
Never Assume!
magnifying loops or the endodontic operating microscope

further enhances our ability to locate these elusive passages
to the apex. Those procedures, coupled with the use of finetipped ultrasonic instruments to excavate these areas, makes
access possible. Thus, in the end, it is our job to become
more suspicious of these teeth and look for the unusual. My
motto is If you see three, look for four. If you see four, look
for five. If you see five, its probably a third molar!
Endo Tip
It is important to determine whether two

canals join apically to avoid frustration when
placing your gutta-percha point. Place two
number 30 files in each canal simultaneously
after complete instrumentation. If one
instrument stops short of the apex, remove
the other and retest. If it now reaches the
apex then the canals join.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
Doug Kase
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk12neverassume.html[2/21/2011 10:25:50 ]
Angulation Is Good for Your Health
Doug Kase, D.D.S.


Doug Kase
Doug Kase
ery often while doing endodontics, what you see is not Figure 1
what you actually may get. Frequently, root anatomy
and canal position will be so closely superimposed that
clinical or radiographic identification may be very difficult. If
it is difficult to see the problem on your final film, you may
shrug your shoulders and walk away with a false sense of
satisfaction. This difficulty commonly leads to nonnegotiated, unclean, and unfilled canals, resulting in ultimate
FIGURE 1: starting
failure down the road. Of course this occurs (using Murphys radiograph of tooth #19,
showing a mid-root dropLaw of Dentistry) just after you have permanently cemented
out.
a multi-unit restoration. So it becomes very important to
identify these anatomical situations before you obturate the
obvious canals.
Figure 2
First, we must identify the common culprits that give us
this pain in our nether region. The mesiobuccal root of the
maxillary first molar may be a good candidate. We all know
of the existence of either a second canal or even a second
root occurring at a varying position on a line between the
mesiobuccal canal and the palatal canal. Another candidate is
one of the lower bicuspids. Usually, the first bicuspid is the
FIGURE 2: angled film
more frequent problem. It is important to look for a lingual
showing a distolingual
canal that branches from the main and larger buccal canal
canal.
about 1/4 to 1/2 way down its length. This canal can
represent the existence of a completely separate root. This
condition can also occur in the second bicuspid as well, but is
much less frequent. Watch for two canals, usually within one Figure 3
root, when it comes to lower central incisors. An even rarer,
but not unheard-of occurrence is the presence of two canals
or even two roots in the lower canines. A common mistake is
assuming that, in lower first and second molars, a large distal
canal, the kind you can drive a Mack truck down, means that
there is only one canal! Very often there is another.
FIGURE 3: confirming the
So how do we fix the problem, ormore importantly
final result.
how do we avoid the problem? Taking angled radiographs
and observing the position of canal orifices relative to
external crown and root anatomy is the way to avoid the
pitfalls. A dead-on parallel starting film may be more
important than an angled film for diagnostics such as caries
proximity to the pulp, depth of existing restorations, marginal
integrity, bone height, existence of periapical pathosis and
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk13angulation.html[2/21/2011 10:25:51 ]
approximate root length. It certainly gives a more realistic

and one to one relationship of tooth to radiograph. It also
may show a large canal that drops out on the radiograph midroot. This may be an indication that the canal splits into two
at this level. However, a second mesially angulated film is
equally as important, especially if diverse root and canal
anatomy is suspected. If a tooth is rotated, make sure
whatever angle you take your radiograph from, the
radiograph separates the canals on the film. A mesial
angulated x ray on a tooth with a rotation toward the distal
will cause superimposition of the canals. Also, it is important
to see how an orifice is positioned on the pulpal floor in
relation to the others and to the external aspect of the tooth. If
a distal canal on a lower molar seems to be oriented too far
to one side of the tooth and for the most part not centered
then suspect another canal.
Trying to ascertain the existence of these canals is
obviously more advantageous before obturation, so dont be
shy about taking an extra radiograph before starting and even
a working film (not to establish measurement) if you suspect
extra canal and root anatomy. Also if you discover this fact
on your final film, try to correct it on the same visit if
possible. The set sealer may block your ability to access the
canal.
Figure 1, the starting radiograph of tooth # 19, shows a
mid-root drop-out. The canals were instrumented and it
appeared that there was only one large distal canal. The tooth
was obturated and an angled final film (Figure 2) was taken
to make sure that the canals were filled properly. Oops! The
angled film showed me that a distolingual canal existed. The
gutta-percha was removed quite easily from the distobuccal
canal, and, using a #2 slow-speed round bur and a fine
Spartan ultrasonic file, the lingual aspect of the existing distal
canal was slowly excavated. With a pre-curved number 10
file, I was able to find the mid-root split. The canals were
instrumented and obturated and the final result was
confirmed (Figure 3).
May-June 2002
Endo Tip
When hunting for calcified canals try to

rubber-dam clamp the tooth behind it and
drag the dam material to the tooth in front,
exposing three teeth in the field. Doing this
exposes external tooth anatomy, which can
be obliterated by the clamp. This exposed
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
view may help to orient your excavation for

this calcified canal.
Doug Kase
A Good Foundation Ensures a Solid House
Doug Kase, D.D.S.


Doug Kase
Doug Kase
Many
ELIEVE IT OR NOT, this is not a builders guide to
practitioners have
doing endodontics. As a philosophy to help ensure
had to deal with
dental success and patient satisfaction the idea of
the discomfort
building a good foundation may help steer us down a path to
that a patient
better diagnosis and treatment. The good-foundation
feels from a
philosophy applies to all phases of dentistry, but the focus of
pulpitis after
this Tale is endodontics, both pre-operatively and postpermanent crown
operatively.
cementation.
Many practitioners have had to deal with the discomfort
that a patient feels from a pulpitis after permanent crown
cementation. The situation is extremely frustrating for the
dentist, and it is likely to lead to patient dissatisfaction (and
we all know the possible consequences of that). We all tell
our patients to wait it out and give it time. Dont worry,
we say. It will go away. We make numerous occlusal
adjustments, grinding away the beautiful porcelain anatomy.
Although the tooth is symptomatically better, it is still
uncomfortable. The patient looks to us for answers, and
sometimes the ultimate answer may be endodontic treatment.
We all understand that developing a pulpitis is a risk of
any invasive restorative procedure. However, sometimes the
riskee is not as understanding. The dentist feels bad, and
the patient may feel worse. The patient experiences
continuing discomfort, a perceived esthetic compromise after
the access opening has been filled, and an investment of
more time and money. If the crown becomes undermined
structurally, then the tooth may require a post and core and
new crown, imposing a burden of time and money on the
dentist.
How can we avoid this pulpitis problem? The unfortunate
truth is that we cannot! However, we can try to minimize the
conditions that lead to it and the trouble that results from it.
What Can Be Done?

FROM A DENTAL-LEGAL point of view, communication
is the key word. Because an informed patient is ultimately a
happy patient, it is important to inform the patient of the
possible risks. Signed consent is great, but some consider it
overkill. Tell your patients before you start that there is a
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk14goodfoundation.html[2/21/2011 10:25:51 ]
possibility of a pulpitis after a restorative change to a tooth.

Explain that the risk increases as the procedure becomes more
invasive (as for an onlay or crown), and that existing deep
fillings or fractures or current deep decay can also increase
the risk. Let them know that pulpitis may become
irreversible and ultimately result in the need for a root-canal
procedure. Your patients should be active participants in the
decision-making process with you as their guide to proper
dental care.
So enough with philosophy and on to the clinical nittygritty. Although not foolproof, there are some techniques we
can turn to so that we may be able to better forecast the
pulpal future of a tooth that is in need of dentistry that will
be, from the patients point of view, time-consuming and
costly.
First and foremost, it is essential to pulp-test the tooth
before beginning your restorative procedure. Even if no
radiographic pathology or even clinical pathology is present
before a filling or crown change, the tooth may possibly
already be non-vital or barely vital. Finding this out before
placing a crown would certainly avoid your finding a
periapical radiolucency three months after placing it. A
minimal positive pulp test as compared to adjacent and
contralateral teeth may predict future non-vitality and the
need for preventive endodontic therapy. If the pulp test
shows that a tooth is extremely hypersensitive compared with
adjacent and contralateral teeth, it may have a present
pulpitis. Hypersensitivity often forecasts treatment
difficulties, such as an increased tendency to pericementitis,
difficulty in attaining adequate anesthesia during treatment,
and prolonged temperature sensitivity that may come and go.
These hyperemic symptoms, which may be present in the
temporary crown stage, can disappear; however, after
permanent cementation they have a tendency to return and
end in the need for a root-canal procedure.
Fracture lines are also predictors of the need for preventive
endodontics. Again, the presence of a fracture is not a
guarantee of ultimate pulpal demise; however, if you are
unable to prep away a fracture line in a restorative procedure,
that should set off an alarm. Normal pulp tests and lack of
symptoms may make you feel that fracture lines alone do not
indicate a need for preventive endodontics at present;
however, you should still inform the patient of the future
risk. If there is microscopic communication to the deeper
open dentinal tubules, the permanent cementation procedure
may ultimately be irritating to the pulp. If the fracture lines
are dark and on transillumination do not transmit the light to
other parts of the tooth, then this is a more severe fracture
that can influence pulpal longevity. A history of deep
fracture close to the pulp should also raise an eyebrow.
Calcifying receding canals can be another predictor of the
need for preventive endodontics. As the pulpal tissue
calcifies, it does so non-uniformly, and the calcifications can
choke off the circulation to other parts of the pulp, resulting
in eventual pulpal death and eventual abscess. This

sometimes can be preceded by a severe symptomatic
pulpitis. From a practical point of view, it will always be
easier to locate calcifying canals before a crown is placed
rather than afterwards through a conservative access opening.
It also is important to look for signs of resorptive changes
on the radiograph. If asymptomatic internal resorption is
suspected, then endodontics is indicated prior to full coverage
to insure a better long-term prognosis.
Restorative history may also predict the necessity of
preventive endodontics. A tooth with a long and large
history of deep restorations is more prone to pulpal
pathology. Obviously, a small and short clinical crown
preparation, which may be more prone to fracture or loss of
crown retention, would need endodontics for post placement
and core buildup.
The Dividend
UNFORTUNATELY, none of us possesses the great dental
crystal ball. (If I had it, I would have tuned it to stocks and
sold two years ago.) Dont be afraid or shy about doing the
endo if its needed or you strongly suspect that it will be
needed in the future. With the techniques available,
particularly the EZ-Fill SafeSider instrumentation
technique, your clinical decision will have a safe and
predictable outcome. No dentist can absolutely predict
whether a tooth will end up in endoville soon after the new
crown is cemented or when the patient is given his six-month
recall exam. However, the time and effort you invest in
determining whether there is a strong likelihood that
endodontics will be needed will certainly pay the dividend of
alleviating some post-operative pains in your gluteus area.
FEEDBACK?
Have I Got a Hot Tip for You!
Doug Kase, D.D.S.


Doug Kase
WANT TO pass along to you a number of tips that I think

you will find especially useful.
Test-Bending
Doug Kase
Breaks in your hand, not in the tooth! It is very important

to remember to test-bend nickel-titanium instruments in your
hand by bending them 90 degrees before using them. Testbending will reduce the likelihood that the instrument will
separate in the canal.
Rubber Dam
The rubber dam may sometimes obscure tooth anatomy and
root angulation, making access difficult, particularly when
you are hunting for thin or calcified canals. Thus it is
sometimes necessary to place the rubber dam by clamping the
tooth behind the one you are working on and then dragging
the dam forward over the tooth in front. Doing so allows you
to view the tooth in a more open field without losing the
protection of the rubber dam.
Working Length Changes

Recheck your working length with the apex locator as you
instrument and straighten a curved canal. The length will
change by .5 to 1.5 mm.
Formocreosol
Heres a new use for an old medicament. Like chicken soup,
a little formo couldnt hurt. It couldnt hurt to place a
squeezed dried cotton pellet of formo in the chamber and
over a post prep after a one-visit root canal. The
formocreosol may help to ensure and maintain sterility until
the restorative is started.
Carbocaine
Carbocaine has a quicker onset than lidocaine, so use
carbocaine before lidocaine as a local anesthetic; then follow
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk15hottips.html[2/21/2011 10:25:52 ]
it up with a lidocaine 1:100,000 epinephrine injection to

vasoconstrict and augment the carbocaines effect.
Apex Locator Readings

Using a loose-fitting file to obtain measurement control with
an apex locator can lead to an inaccurate reading. A slightly
tighter-fitting instrument that contacts the walls of the canal
will allow the apex locator to electronically read the canal
better. Also a loose instrument may move too easily as you
try to obtain a reading while attempting to manipulate the
stop, thus giving you a false length.
Removing a Post
When you are trying to remove a prefabricated post, use an
ultrasonic instrument and vibrate the post in all planes
(buccal-lingual and mesio-distal).
Remove Core Material

Remember to remove as much core material as possible
around a prefabricated post and try to trephine around its
base with a fine diamond at the prep orifice before you start
to use ultrasonics.
Fractured Post
Use a one-half or one-quarter round surgical-length highspeed bur with magnification to drill out a post that is
fractured or not removable by ultrasonics. Take an extra
check radiograph when necessary to check your progress.
Reduce the Core-Tooth Interface

When you are removing a cast post and core, remove as
much core as you can to reduce retention caused by the coreand-tooth interface before you attempt ultrasonic removal. If
there is a larger area of contact between tooth and core, less
of the force of the ultrasonic vibration will reach the postand-post-prep interface.
Tapping a Post Out

Sometimes a small notch can be cut into the core material
and the post can be tapped out with a back action crown
remover. Do this prudently because the force of the tapping
can cause a root fracture.
Revealing Old Gutta Percha

If retreatment is the goal, then using a microscope and a fine
Spartan ultrasonic diamond tip may be necessary after post
removal to cut through any remaining cement at the base of
the post prep in order to find the old gutta percha.
Retreating Canals Without Posts

If only the canal or canals without the post are failing, then
you can drill through the crown and core material
conservatively and retreat these canals without disturbing the
post and crown. (See Figures 1 and 2.)
Figure 1 (before)
FIGURE 1 (before)
Figure 2 (before)
FIGURE 2 (before)
Figure 1 (after)
FIGURE 1 (after)
Figure 2 (after)
FIGURE 2 (after)
Apicoectomy or Retreatment?
When a patient presents to your office with failing
endodontics under a post and core, your first instinct may be
to refer the patient for an apicoectomy. This instinct is
particularly well founded when the restorative is relatively
new. However, we must remember that an apicoectomy on
top of a root canal that failed because it was inadequate may
result in a failure of the apico as well. The failure of the
apico usually occurs because lateral canals coronal to the
retrograde filling were not obturated properly. Even in the
case of calcified apices or a calcified apical third of the root,
it is important to have a solid obturation coronal to that point.
Thus retreatment becomes a rational option. Also, if the
surgery is risky anatomically, such as apex proximity to the
mandibular canal or maxillary sinus in the case of maxillary
palatal roots, retreatment may be a better option. We must
also take into account the possibility of the patients lack of
compliance and cooperation regarding the surgery and must
consider whether the patient is a poor medical risk for the
procedure. If the restorative is in question and is slated for a
redo, then without question disassembly is the treatment of
choice.
The radiographs in Figures 3 through 9 illustrate what can
be accomplished.
Figure 3 (before)
FIGURE 3 (before)
Figure 4 (before)
FIGURE 4 (before)
Figure 5 (before)
Figure 3 (after)
FIGURE 3 (after)
Figure 4 (after)
FIGURE 4 (after)
Figure 5 (after)
FIGURE 5 (before)
FIGURE 5 (after)
Figure 6 (before)
FIGURE 6 (before)
Figure 7 (before)
Figure 6 (after)
FIGURE 6 (after)
Figure 7 (after)
FIGURE 7 (before)
Figure 8 (before)
FIGURE 8 (before)
Figure 9 (before)
FIGURE 9 (before)
FIGURE 7 (after)
Figure 8 (after)
FIGURE 8 (after)
Figure 9 (after)
FIGURE 9 (after)
FEEDBACK?
Looking at the X-ray Is Not Enough
Doug Kase, D.D.S.


Doug Kase
Doug Kase
MONG ALL THE endodontic cases that we all do,

there is always the one that turns into that horror
movie called Attack of the Killer Root Canal! Its
the one we begin with a good deal of confidence and an
internal voice that says, I can do thatno problem, but
we finish wishing that we could call our dental school
instructor to bail us out, have him pat us on the shoulder
and tell us its OK. With that horror movie in mind, it is
important when beginning treatment of an endodontic case
to make sure that you have looked at the radiograph not
only for the diagnosis but also to assess the clinical picture
of the tooth in question as it appears in the mouth.
Restorations, tilts, rotations, and gingival root angulation all
become factors when you are gaining access and searching
for canals. The radiograph is important, but it is only 50
percent of the road map we use to plan our trip to the pulp
chamber and beyond.
Looking at root angulation and emergence profiles at the
gingival margin is particularly important in cases with
calcified pulp chambers and when you are searching for
calcified canals. Periodontally probing the tooth while
gaining access will give you a visual indicator of the
external anatomy and allow you to judge how far you
should excavate the area while searching for canals. This
knowledge is very important in maxillary molars, where the
position of the palatal root may be shifted distally, or when
you are looking for the mesio-buccal canals. Also compare
the location of existing canals in the access cavity with the
external shape of the tooth. For example, comparing the
external lingual surface of the tooth and the position of the
wider buccal canal as it appears in the access cavity will
help you detect the presence of a secondary lingual canal in
lower incisors. If there is more tooth structure on the
lingual side than the buccal side and the canal is oriented to
the buccal, then suspect an extra canal. Check the position
of furcations and measure them not only on the radiograph,
but clinically as well to avoid perforations. This
measurement is especially important if the chamber is
calcified or the coronal aspect of the tooth is obscured on
the radiograph by a radio-opaque restoration. Trans-
POP
QUIZ
Identify the foreign
object shown in the xray below. Is it . . .
Pop Quiz X-ray
1. a surgical pin
2. a dislodged
silver point and
retrograde
amalgam
3. a fragment of
endodontic
endosseous
implant
4. a traumatic
projectile
fragment
5. every parents
nightmarethe
dreaded nose
stud!
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk16xraynotenough.html[2/21/2011 10:25:52 ]
illumination from the buccal and lingual will help

immensely.
Look at teeth for rotations and tilts that are likely to
throw off your orientation when drilling toward the pulp
chamber. Severe mesial tilts of lower molars can move the
distal canal into the mesial position. If youre not aware of
the orientation, you may drill farther distally in search of a
canal that doesnt exist and perforate. Rotations obviously
also shift the positions of canals, so be aware when gaining
access.
When we are doing root canal we cannot have blinders
on. We cant let our confidence keep us from looking at
the whole picture, both clinically and radiographically.
Each component can have great value in determining the
ultimate success or failure of the case.
(Click for the answer.)
Kase Presentation
A PATIENT presented to our office with a calcified lateral
incisor, tooth #10, which was excavated deeply and widely
for the canal (Figure 1). Using the endodontic surgical
microscope, I was able to find the canal and also locate a
small perforation on the distal aspect of the excavation. I
instrumented the canal and fitted a medium-large guttapercha point to the apex. I mixed MTA cement and, using
an apico amalgam carrier and fine pluggers, packed the
cement around the gutta-percha point (Figure 2). After
twenty minutes, the MTA cement was hard enough to
remove the point, and I sealed a damp paper point in its
place for 24 hours. When the patient returned, the MTA
was fully set and I removed the paper point. I then sealed
the canal, using EZ-Fill cement and a single cone of gutta
percha (Figure 3), and post-prepped on that visit (Figure 4).
Figure 1
FIGURE 1: Tooth #10,

excavated deeply and
widely for the canal.
Figure 2
FIGURE 2: MTA cement

packed around the guttapercha point.
Figure 3
FIGURE 3: Canal sealed

with EZ-Fill cement and a
single cone of gutta
percha.
Figure 4
FIGURE 4: The tooth after

post-prepping.
February-March 2003
Endo-Tip
Use the trial fit of your medium gutta-percha point to

the apex in a canal with an apical curvature as a guide
for the maximum apical extent of the EZ-Fill cement
spiral. The gutta percha usually retains the shape on
withdrawal, so it is easy to measure to the beginning
of the curvature.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
Doug Kase
POP QUIZ ANSWER: # 5: the dreaded nose stud!

A Pair of Kases Cases
Doug Kase, D.D.S.


Doug Kase
Doug Kase
DENTIFYING, instrumenting, and obturating a bifurcated

root can be a very frustrating and difficult procedure.
The following cases are examples of endodontic
procedures performed on teeth of this kind and may give
some insight into how to treat them.
In the first case, by taking a radiograph from a mesial
angulation I was able to identify the possible existence of a
secondary root or canal on tooth number 28 (Figure 1).
After some minor excavation under magnification, I found
a centrally located orifice and gained access into the buccal
canal (Figure 2). I established measurement control with an
Endex apex locator and instrumented the canal using
SafeSider reamers according to the EZ-Fill technique.
Opening the coronal aspect of the canal with a number 2
Peeso reamer enabled further investigation for the lingual
canal.
Figure 1
FIGURE 1: A radiograph
from a mesial angulation
reveals the possible
existence of a secondary
root or canal on tooth
number 28.
Figure 2
FIGURE 2: Access into the

buccal canal achieved
through a centrally located
orifice.
After additional excavation toward the lingual, I was not

able to find an additional orifice for the lingual canal. When
excavating for an additional canal it is most important to
keep in mind the external anatomy of the root to avoid a
perforation. So by placing a 45-degree bend at the tip of a
number 10 reamer, I was able to find a catch on the lingual
wall of the main canal about 4 mm from the apex. The
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk17pairofcases.html[2/21/2011 10:25:53 ]
radiograph (Figure 3) confirmed that I was dealing with a

bifurcated canal. I instrumented the lingual canal, using
plenty of RC Prep and irrigation. An apical bend in all of the
instruments helped to re-negotiate the apical anatomy. It is
also important to continually check the already instrumented
buccal canal to make sure that you do not block it with
debris.
The case was obturated using the EZ-Fill technique. I
placed EZ-Fill cement into the canal with the EZ-Fill cement
spiral and inserted a medium gutta-percha point to the apex
of the buccal canal. Note on the radiograph (Figure 4) the
movement of cement into the lingual canal caused by the
lateral force generated by the cement spiral and the lateral
pressure occasioned by the placement of the gutta-percha
point.
Figure 3
FIGURE 3: Radiograph
confirms that the canal is
bifurcated.
Figure 4
FIGURE 4: Note the

movement of cement into
the lingual canal.
Due to the widened common coronal two-thirds of the

canal, I was able to use a number 25 finger plugger, not for
apical condensation, but to move the coronal mass of gutta
percha against the buccal wall and to create a passageway for
my lingual gutta-percha point. A small curve was placed in
the apical end of the plugger to facilitate its passage into the
lingual split. I used a plugger rather than a reamer to make
sure not to pull out the buccal fill (Figure 5). I did an
immediate post prep, and thus the final product (Figure 6).
Figure 5
FIGURE 5: Using a plugger

rather than a reamer left the
buccal fill undisturbed.
Figure 6
FIGURE 6: The final

product.
The next case was also a two-canal bicuspid, but the canals
diverged at a more coronal level. With a second angled
radiograph, it was easier to see the divergent canal
architecture (Figure 7). This case was referred to our office
because the referring dentist thought that he had perforated
with an instrument out the mesial aspect of the root. This
tooth had a centrally located common canal, but it split off
into two canals at a higher point than the canal in the first
case did. What the dentist had actually done with his
instrument was to locate the lingual canal and negotiate it
rather than perforate the tooth (Figure 8). The apex locator
indicated a short measurement of this lingual canal, which
corresponded to the location of the radiolucency on the
mesial aspect of the root. I instrumented this canal and then
initiated excavation for the buccal canal.
Figure 7
FIGURE 7: The divergent

canal architecture of a twocanal bicuspid.
Figure 8
FIGURE 8: Showing that

the tooth had not been
perforated.
By opening the common canal with a number two Peeso

reamer, I was able to use a fine Spartan ultrasonic diamond
tip to further widen the buccal aspect of the common canal.
With a 45-degree bend in a number 10 file I was able to
snake it into the buccal canal orifice (Figure 9). I
instrumented this canal fully while also making sure that
there was continuous access to the already instrumented
lingual canal. The canals were filled using the E-Z Fill
technique. Note on the final radiograph the puff of cement
from the lingual canal toward the mesial-lingual at the same
level as the radiolucency (Figure 10).
Figure 9
FIGURE 9: A number 10
file snaked into the buccal
canal orifice.
Figure 10
FIGURE 10: Note the puff of

cement from the lingual
canal toward the mesial-
lingual.
It is extremely important to examine both radiograph and

root morphology when dealing with a suspected bifurcated
canal in any root. Mandibular first bicuspids commonly have
two canals (approximately 21 percent) with quite a bit of
variation in the location of the lingual orifice. Please take an
extra working radiograph if you have to so that you can
confirm its existence. Remember what Doug Kase told you:
The canal that forks like a snakes tongue toward the front of
the mouth can be a big pain in the rear.
May-June 2003
FEEDBACK?
questions.
A Variation on the Theme
Doug Kase, D.D.S.


Doug Kase
Doug Kase
S THOUGHTS OF SUMMER begin to fade from our

minds and visions of falling leaves, colder temperatures,
and inches of snow start to permeate our consciousness,
there is one thing we all can take comfort in: our patients need
root-canal therapy! Now the old saying that says you have to
walk before you can run certainly has validity when it comes to
the SafeSider technique and EZ-Fill obturation. The
techniques that we teach you allow dentists to incorporate their
own nuances into the system without compromising the
fundamentals of ultimately creating the proper taper of the canal
(.08 taper) and its single-point obturation using the EZ-Fill
armamentarium, which emphasizes the use of .02 stainless
SafeSider endodontic instruments and the # 2 Peeso reamer to
accomplish 90 percent of our canal instrumentation and hand
NiTi SafeSiders to place the finishing touch (taper).
As a dental student at NYUCD and a resident at the
Manhattan VA hospital, I had the opportunity to perfect the use
of the Gates Glidden reamer as aid and shortcut to the core
technique that we were all taught way back in dental school.
Now you may know that Barry Musikant has taught all of us the
equation that Gates Glidden reamers = Peeso lights! However, I
do vary the EZ-Fill technique to incorporate the use of Gates
Glidden reamers. Please understand that in no way am I saying
that this variation is better than the EZ-Fill core technique that
we have taught in the past, but this variation does help my
technique. Remember that the function of the NiTi .04 and .08
SafeSiders is to do the final shaping of the apical canal after the
apex has been negotiated with a stainless .02 #30 or #35
SafeSider reamer and appropriately back-stepped. The
SafeSiders are not meant to be used to negotiate the apical 5 to
10 mm of the canal, but rather to shape the canal and eliminate
the back step cross-section it developed due to the use of the
Peeso reamer and back-stepped instrumentation. Thus the
further the NiTi instruments are seated on initial try in, the less
work the instrument and dentist have to do to achieve this final
shape. If you already can accomplish this with standard rotary
instruments that you are accustomed to using, such as the Peeso
reamer, you may find that incorporating Gates Glidden reamers
in your procedure may make it easier.
How? you may ask.
The sequence that I have usedand remember that it is only
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk18variation.html[2/21/2011 10:25:54 ]
a variation on the theme that happens to work in my handsis

the following.
I instrument to my measurement control to an .02 #20
instrument. Then I widen the coronal aspect of the canal with
passive pressure, starting with a Gates #1, then #2, then #3,
and then I use a #2 Peeso reamer. I move the instruments
apically until I meet resistance and go no further. Wait a second
. . . I hear gasps about using a #1 Gates! Wont it break? If you
use passive pressure in a wet canal and do not force the
instrument, it will never separate. Passive pressure means to
use only the weight of your handpiece and tactilely feel for
resistance because you may meet a curve or constriction in the
canal. Initially I do not attempt to move beyond this point.
Doing so can separate the Gates or ledge the canal. Obviously,
in a straight canal you will be able to sink the Gates and
eventually the #2 Peeso to the hub of the handpiece. Remember
to straighten the coronal aspect of the canal away from
furcations and grooves by applying selective pressure in the
proper direction with a pecking motion of the handpiece.
Now we have debris to deal with. Reiterate the apex with a
#15 and then a #20 SafeSider instrument to break up the debris,
and be sure to irrigate and use RC-Prep continually. Now I
instrument a #25 and #30 to the apex with very little resistance
because the rotary sequence I have used has done quite a bit of
coronal instrumentation, perhaps moving more apically than by
just using a #2 Peeso initially. Back-stepping with a #35 and a
#40 is a piece of cake, and even moving the 35 to apex is not an
obstacle.
I cant stress it enough: irrigate, irrigate, irrigate and use lots
of RC-Prep.
Now I do it again. I use the same sequence of Gates and
Peeso reamers and believe it or not with the same passive
pressure, the #1 and #2 Gates are apparently flexible enough to
negotiate a bit more of the curve in a canal and move further
apically. Forcing these instruments into a curve can cause a
strip perforation, so be careful. This further rotary
instrumentation of the canal facilitates deeper penetration of the
NiTi instruments and thus puts less stress on the instrument and
dentist. In my experience, the .04 #30 NiTi becomes a debris
breaker and remover, and the .08 #25 NiTi usually can be
inserted to within 1 to 2 mm of the apex and worked to
measurement to create our .08 taper with very little effort and
thus prepare us to obturate the canal according to the EZ-Fill
technique.
Now here is my Tale.
The following case is an interesting one. This patient
presented with a buccal fistula associated with quite a bit of
bone loss in the furcation of a lower molar and what appeared
on the radiograph to look like some sort of perforation in the
mesial aspect (Figure1).
Figure 1
FIGURE 1: Showing a possible perforation in the mesial aspect.
I was not sure at the time whether it was resorptive or

iatrogenic. Access was gained and from the looks of the pulp
chamber it was virgin territory, so we were dealing with
something pathologically natural. I extirpated the tissue and was
able to isolate the canals. Measurement control was taken by
apex locator and confirmed by radiograph (Figures 2 and 3).
Figure 1
Figure 1
FIGURES 2 AND 3: Measurement control taken by apex

locator (left) and confirmed by radiograph (right).
The mesiolingual canal gave me a wild and inaccurate reading

on the apex locator in comparison to the mesiobuccal; thus I
knew that the mesiolingual was the canal with the perforation. I
managed to find the apical portion of the canal by hugging the
mesial wall of the canal. I widened the mesiolingual canal with
my sequence of hand and rotary instruments and was ultimately
able to visualize the perforation and canal with the endodontic
microscope. I obturated all the canals using the EZ-Fill
technique and then removed the coronal gutta percha in the ML
canal to the level of the perforation. I packed a plug of Colicote
into the communication to the furca and then back-filled the
coronal portion of the canal with MTA cement (Figures 3 and
4).
Figure 1
Figure 1
FIGURES 3 AND 4: A plug of Colicote packed into the

communication to the furca (left), and the coronal portion of
the canal back-filled with MTA cement (right).
Two weeks later the fistula remains closed and the patient will
be recalled in three months to evaluate healing.
FEEDBACK?
questions.
Please feel free to visit the Endo Forum
and add your comments about any of
the articles in Endo-Mail.
Legally Yours!
Doug Kase, D.D.S.

Legally Yours!
Doug Kase
Doug Kase
VER THE PAST YEAR, I have had the opportunity to

participate in a few malpractice cases. Wait . . . hold back
the gasps! My participation took the form of expert exam
and testimony in the defense of my fellow dentists in regard to
any endodontic involvement that their case may have had. As
such, my assuming this role has given me the chance to observe
some common problems and themes of risk management that
may infiltrate and perhaps interfere with our ability to defend
ourselves in the event of the dreaded malpractice case.
To startand this is usually where we should all start with
our patientsconsider the issue of informed consent. The
question of written versus oral has always been an issue.
Obviously, a signed consent form would offer the best
protection, but alternatively as long as you inform the patient
orally of the risks of endodontic treatment and note in your
chart that you have done so, you will have protected yourself as
well. Creating a standardized office script that you can read
from would be very helpful to maintain uniformity from patient
to patient. It is important to include, for example, the issue of
calcified canals, which may result in the dentists either not
finding a canal or not negotiating the canal to its full extent.
This leads us to the next recurring topic in risk management
and endodontics, which is a missed or inadequately filled canal.
If you cannot find a canal or you cannot negotiate it to the apex,
for heavens sake tell your patient and note it in your chart. It is
not malpractice to not find a canal, such as the MB2 canal in a
maxillary first molar, if you have made the effort to look for it
and explained to the patient the possible ramifications. Then, of
course, enter it in your chart!
Next topic of course is your chart. There are certain things
that we all remember from grammar school, particularly our
three Rs. Forget for a minute about the reading and the
rithmatic, and lets concentrate on the riting. For an expert
trying to defend his brethren, there is nothing more frustrating
than trying to read a chart that is written so illegibly that it
might as well be in an intergalactic language. It is one thing not
to be able to understand the language, for that is subject to
interpretation; however, not to be able to make out any
intelligible markings really puts a damper on an effort to defend.
What I am getting at is to please write up your charts legibly
and express yourself clearly. A good defense is much more
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk19legallyyours.html[2/21/2011 10:25:54 ]
Legally Yours!
likely if everyone involved is able to read a legible chart and

understand the language.
Separated instruments are a real stomach turner! Any
endodontists who tell you that they have never broken an
instrument must not have done much endo in their lifetimes.
Separated instruments are a usual risk of endodontic treatment
and should never be considered an act of negligence. Just tell
your patient that it happened and then enter it in your chart!
S**t happens! Thus far, I have not met any dentists so infallible
that they deserved to have Supermans S tattooed on their
chests. Dont be afraid to tell your patient the truth, for silence
has a way of biting you on the rear end. Breaking an instrument
in a canal is not an intentional act of malpractice, but only
represents an effort to do a root canal on a difficult tooth.
Remember that it all comes down to expectations.
Endodontics is 90 to 92 percent successful. Eight to ten percent
of the best cases fail for some unknown reason. Some we can
fix, and others we cannot. If your patient is informed and
understands the risks involved and we as dental professionals
maintain open lines of communication to our patients, this
combination may help to minimize our exposure to any
malpractice issues in the future.
Kases Case
I GUESS you have all been waiting for the Kase of the month.
When I first saw the starting film for this lower second molar
(Figure 1), I took one look at those apices and said to myself,
Self, you are never getting to the end of these canals!
Figure 1
FIGURE 1: The starting film for a lower second molar.
I quickly informed the patient of her bizarre anatomy (her

roots) and also informed her of the probability that I would not
be able to negotiate the apex due to the tortuous path my
instruments would have to follow. Additionally, due to the
proximity of the apices to the mandibular canal, there was a
possibility of some paresthesia, more than likely temporary, but
possiblythough rarelypermanent. This of course was
entered into her chart very clearly along with her consent to
proceed after understanding all the alternatives.
Using an apex locater, I took measurement control, and I
achieved negotiation to the apex, starting with .06 (pink)
instruments. This was a situation where throwing out overly
used instruments was certainly warranted to avoid separation.
Legally Yours!
Using a tremendous amount of RC Prep and irrigation helped,

but didnt make matters easy. As I straightened out the coronal
aspect of the canal with Gates and Peeso reamers, I continued to
recheck my measurement control, for I knew that it would
change as the coronal canal curvature was straightened. I
continued to instrument according to the SafeSider/EZ-Fill
technique and ultimately achieved a result that I can reach
around and pat my own back for. P.S., the patient is pretty
happy too. (See Figures 2 and 3.)
Figure 2
Figure 3
FIGURES 2 and 3: The ultimate result, after negotiating

tortuous paths.
FEEDBACK?
questions.
Two Cases of Kases
Doug Kase, D.D.S.

Two Cases of Kases

Doug Kase
Doug Kase
s you have all read in past issues, we are staunch

believers in the use of the apex locator. It is the only way
to get an accurate measurement control to which we can
instrument. Accurate apex location results in fewer postoperative complications, such as pain, because it reduces overinstrumentation and resulting overfills. The following case is a
perfect example of the importance of using an apex locator
when doing endodontics.
This patient was first referred to our office for continued
discomfort on tooth #12 after the completion of endodontic
therapy. Radiographs showed an acceptable root-canal
obturation on #12, but also a periapical radiolucency on tooth
#13 (Figure 1). Symptoms, however, were specific to #12. I
suggested a re-treatment of the endodontics prior to any surgical
intervention. The patient returned two months after the retreatment (Figure 2) with continued symptoms, and he also had
developed a small pea-sized swelling over the buccal plate
approximating the apex of #12. He was placed on a regimen of
clindamycin and advised to return for an apicoectomy during
which we would also investigate tooth #13.
Figure 1
FIGURE 1: Showing an
acceptable root-canal obturation
on #12, but also a periapical
radiolucency on tooth #13.
Figure 2
FIGURE 2: Two months

after the re-treatment.
The patient returned for the surgery, whereupon, after a local

anesthetic had been given, I created an incision from the mesial
of #14 to the mesial of #11 in attached gingival and also made a
vertical release incision on the mesial of #11. Upon flapping
back the tissue, I was able to visualize the root tip of tooth #12
sticking through the buccal plate with a 3 mm extension of
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk20twocases.html[2/21/2011 10:25:55 ]
Two Cases of Kases
gutta-percha through the apex. Additionally there was a bony

defect over the apex of tooth #13. I beveled back both the apex
of #13 and buccal apex of #12 and curetted any tissue out of the
site. A check radiograph was taken to help visualize the
location of the palatal root of #12 (Figure 3), and I excavated for
that and beveled it back as well (Figure 4). I made retrograde
preparations using ultrasonic diamond surgical tips, and placed
amalgam seals (Figure 5). I sutured the site, and the patient
tolerated the procedure quite well. The patient is now
asymptomatic and doing well.
Figure 3
Figure 4
FIGURE 3: Check
radiograph taken to help
visualize the location of the
palatal root of #12.
FIGURE 4: Palatal root of

#12 beveled back.
Figure 5
FIGURE 5: After placing amalgam seals.
If the original endodontic therapy had included the use of an

apex locator, perhaps this overfill would have not occurred and
thus the surgical intervention on this tooth would have been
avoided. Unfortunately, not all overfills can be avoided. Some
may occur due to open apices combined with an obturation
technique that utilizes condensation or thermoplastics. But it is
apparent that overfills are minimized when accurate electronic
apex location is used in conjunction with single-point obturation
in an appropriately tapered canal, as in the EZ-Fill technique.
The next case is just an example of practical dentistry. A
patient presented to our office with endodontics started on tooth
#12 (Figure 6). This tooth was part of a very recent long-span
bridge with tooth #13 as a terminal cantilevered pontic. Teeth
#10 and #11 were present as abutments. Because there had been
some loss of marginal seal on the mesial and a distal angulation
of the root, I placed an instrument in the canal to verify and
confirm the results from my apex locator (Figure 7). I
completed the endodontics using the EZ-Fill technique (Figure
8), and the patient was to return for a post and core.
Two Cases of Kases
Figure 6
Figure 7
FIGURE 6: Showing
endodontics begun on
tooth #12.
FIGURE 7: Instrument
placed in the canal to
verify and confirm the
results from the apex
locator.
Figure 8
FIGURE 8: Endodontics completed using the EZ-Fill

technique.
Under normal circumstances, one might ask why we are trying

to restore an abutment for a cantilevered restoration when there
is a definite loss of marginal seal and cantilevers are somewhat
unfriendly to the abutments anterior to them. In this case,
restoration was the practical solution due to the age of the
restoration and the patients economic wants and needs. Thus,
on the next visit, I prepared the tooth and placed a #1 FlexiPost (Figure 9). I packed an internal amalgam core into the
marginal opening and sealed the access (Figure 10). The patient
is happy, and the referrer is happy as well.
Figure 9
FIGURE 9: Showing a #1
Flexi-Post in place.
Figure 10
FIGURE 10: With an internal

amalgam core packed into the
marginal opening and the
access sealed.
Spring 2004
Two Cases of Kases
FEEDBACK?
questions.
Doug Kase, D.D.S.


Doug Kase
Doug Kase
HE USE OF SafeSiders instruments in the EZ-Fill

technique facilitates a standardization of procedure that
leads to a standard superior result. However, certain clinical
circumstances may require a slight deviation from the formula
that we have taught our loyal readers. As Im sure you have all
seen, the technique over the years has evolved to a point where
you can achieve a superior result with minimal stress to the
dentist, the dentists hand, schedule, and instrumentsand, of
course, to the dentists patient. There are, however, those
annoying situations that arise in which, when we try to follow
the EZ-Fill technique map, we find that we are not getting to the
final destination as easily as we want to.
Certain anatomical situations may pop up, such as severely
curved canals, that really throw a monkey wrench into the
machinery of the finely tuned EZ-Fill assembly line. Sometimes
inherently harder dentin, calcifications within the canal, or both,
compound an already difficult situation. In such cases, working
each instrument to the apex becomes much more difficult,
particularly as the instruments increase in diameter. As a result,
we must sometimes remind ourselves of our old philosophy that
it is OK to work a little slower and longer to ultimately finish a
little faster. The issue of not biting off more than you can chew
applies both to instrument design and to instrumentation
technique. Now, of course, the design aspect is a built-in no
brainer! The SafeSiders instruments are reamers by design and
have a flattened surface to ultimately engage less dentin when
negotiating the canal walls. This unique design thus facilitates
reaching apical measurement more easily with each increase in
diameter of each instrument we use.
The issue of technique is an entirely different story. The EZFill formula in its present form utilizes a one millimeter back
step when progressing from a #35 instrument to a #40.
Sometimes, in curved or very tight canals, initially using an
incremental one millimeter back step from apical measurement
helps us achieve our final .08 tapered resistance form with less
stress to instruments and dentist. First take each of the number
6, 8, 10, and 15 instruments to the apex. Then step back one
millimeter with a #20 and then two millimeters with a #25. At
that point you can use your #2 Peeso reamer to widen and
straighten the coronal anatomy of the canal as needed. Return to
the apex with a #15 instrument and then try moving apically with
the #20 and #25. If reaching the apex with the #25 is still
difficult, then step back in half-millimeter increments from
measurement control with this instrument and then a #30 and
then try again. Once the #25 makes it to measurement, follow
the same procedure with the numbers 30, 35, and 40, making
sure that you reintegrate the use of the #2 Peeso and #2 Gates as
described in the EZ-Fill technique to gain a little more coronal
canal straightening and depth. From this point, using the NiTi
.04 and .08 tapered instruments and moving them to the apex
will be a simple process. Remember to use the reamers with a
light rather than heavy touch; the light touch is very important.
Dont try to engage the dentin as if the reamers were files.
Please keep an eye out for instrument fatigue and remember to
test-bend all NiTi instruments before use. Remember that the
final result will be the same (.08 taper and fitting a medium
gutta-percha point) even though we used a slightly modified
formula to achieve our goal.
Case Report
THIS CASE is an interesting retreatment. The patient presented
with an old silver point RCT having both clinical symptoms and
radiographic evidence of breakdown at the apices (Figure 1).
Figure 1
FIGURE 1: Showing evidence of breakdown at the apices.
He was placed on Clindamycin 150 mg three times a day for ten

days to reduce the mild symptoms, which began to abate within
three days. Retreatment was started on day four, and the crown
was removed with out any damage. In this situation, I felt that
retreating with the crown off would be easier because of the
necessity of removing a post from the palatal root and the silver
points from the buccal canals. Was I right! Under the crown
was an amalgam core, which I removed with a fine diamond
around the remaining tooth structure. I then used an ultrasonic
scaler to selectively loosen any remaining amalgam from the
post head and silver wires in the pulp chamber. The patient
indicated that he had a problem on the contra lateral tooth with
an undiscovered fourth canal (MB2), and after the points and
post were removed I did find an MB2 canal that had not been
treated. The case was instrumented with SafeSiders and
obturated using the EZ-Fill technique (Figures 2 and 3). The
patient is doing well and is asymptomatic.
Figure 2
Figure 3
FIGURES 2 and 3: After instrumentation and obturation

using the EZ-Fill technique.
Summer 2004
Do not add more EZ-Fill Cement liquid

to thin the viscosity of a perfectly mixed
batch of sealer that has begun to
thicken. Instead, re-spatulate the mix,
using a lightly heated spatula to bring it
back to a usable viscosity for obturation.
Doug Kase
Use a cotton pellet saturated with alcohol
to remove excess EZ-Fill from the pulpal
floor.
Young Bui
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and add
your comments about
any of the articles in
Endo-Mail.
Always place a little topical anesthetic on

the reverse side of the rubber dam. It will
let the dam slide over the clamp much
more easily.
Allan Deutsch
Reciprocation Innovation
Doug Kase, D.D.S.

Doug Kase
Doug Kase
ERTAIN INNOVATIONS or techniques in a dentists life

make a dramatic difference in the way he or she practices.
For some its a new procedure or technique; for others its
a new instrument or product. As an endodontist I have been
subject to a barrage of all of the above over the years. New
techniques and philosophies, such as crown-down
instrumentation; new instruments, such as nickel-titanium in
various tapers; a slew of constantly changing rotary techniques
and a slew of different handpieces; and of course the many
different methods of obturation techniques are only a few that
have had their impact on the practice of endodontics. For my
father, who graduated in 1943, moving from stand-up to sitdown dentistry made a big difference. For me, leaving the
stomach-churning world of rotary Ni-Ti for the safer pastures of
a more reliable, predictable, and safer system of doing root canal
was the ticket!
I am sure you all remember our Simplified Endo Technique
(S.E.T.), which used .02 tapered standard stainless steel reamers
in combination with .04 and .08 tapered NiTi hand instruments
to create a greater tapered canal. This was the beginning of a
stress-free endodontic evolution in my professional life. When
our technique further evolved with the advent of SafeSiders and
a further refinement of the system, so came another level of
stress reduction and predictability. Using this technique in
combination with electronic apex location has allowed me to do
one-visit endodontics in a safe and stress-free way with
incredibly predictable results.
Well, something else has come along! For weeks, Barry
Musikant has been asking me whether I have tried adding a
reciprocating handpiece to my armamentarium for doing our EZFill SafeSiders technique. Being the stubborn person that I am, I
asked myself why I should add a handpiece when the system is
so easy the way it is? I was already doing one-visit molars in
under an hour with little stress, so I wondered how this
handpiece could improve my technique. Well, readers, I gave it
a try and needless to say since that day I have used my
reciprocating handpiece for all instrumentation over a # 20,
including NiTi, in the EZ-Fill SafeSiders technique.
The advantages of using a reciprocating handpiece are many
besides the obvious one of decreased hand fatigue for the
operator. I have been using the NSK reciprocating contra-angle
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk22reciprocation.html[2/21/2011 10:25:56 ]
on a Star slow speed engine. Its 30-degree reciprocation from

center in clockwise and counterclockwise directions provides
stress-free instrumentation of the canal without the instruments
reaching a resistance point. We all know that we try to replicate
this movement with our hands; however, the proprioceptive
feeling that we get prevents us from moving past this subjective
resistance point. Since this can be a subjective boundary, it
differs for different operators. Moving beyond this point can
distort an instrument oreven worseeventually cause an
instrument to fatigue and fracture. Since the movement of the
instrument in the handpiece never meets and moves beyond this
point, the risk of fracture becomes incredibly low with stainless
steel instruments and, even more importantly, with NiTi
instruments. Coupling this low risk of fracture with a pre-bend
test for NiTi instruments makes the likelihood of a separation
within the canal almost non-existent. When the reciprocating
handpiece is used in a pecking motion, its rapid reciprocation
works synergistically with SafeSiders reamers to provide a more
rapid and efficient instrumentation. Remember that the flat on
the SafeSiders reamer not only helps with negotiation to the
apex, but also acts as a chisel that allows the instrument to cut in
both directions. I have tried using the NSK in both straight and
curved canals, and it really works!
A note to my Rotary colleagues: if you love rotary
endodontics because you need a handpiece to reduce hand
fatigue during instrumentation, then this is the innovation for
you. Using a reciprocating handpiece with the EZ-Fill technique
will fulfill all your requirements for performing stress-free
endodontics.
The following case is an example of the results that can be
achieved using this technique in a curved canal with the addition
of the NSK handpiece. (See Figures 1 and 2.) The results are the
same, but the effort and operator stress required to achieve the
results are greatly reduced.
Figure 1
Figure 2
FIGURE 1: The canals

were instrumented by hand
to a # 20 and then the # 2
Peeso reamer was used to
straighten the coronal
architecture of the canal as
much as possible before
the NSK reciprocating
handpiece was used for
the rest of the SafeSiders
instrumentation.
FIGURE 2: The final film

shows the same
predictable results that we
have all become
accustomed to when using
this technique.
Figure 3
Figure 4
FIGURES 3 AND 4: Different cases, same technique, same

results!
Fall 2004
FEEDBACK?
Please feel free to visit the Endo Forum and add your comments
about any of the articles in Endo-Mail.
Medidenta Handpiece
Doug Kase, D.D.S.

Tales from the Chamber
Product Review:
Medidenta Handpiece
Doug Kase
Doug Kase
ELLO AGAIN, my loyal readers. Since my last

Tales about adding a reciprocating handpiece into
the SafeSiders technique, I have had the opportunity
to use a handpiece manufactured by Medidenta and NSK
(Figure 1). It is a standard four-hole air motor (Meditorque
America E type Air Motor) with an E attachment to
which the NSK sheath (Model E4R) and NSK head (Model
TEP-Y) are attached.
Medidenta Handpiece
FIGURE 1: The Medidenta handpiece consists of, left to right,

an NSK head, an NSK sheath, and a Meditorque America air
motor.
The Medidenta engine has plenty of torque and operates at

20,000 rpm; however with a 4:1 reduction in the sheath, the
contra-angle is operating at 5,000 rpm.
The instrument latch button is very easy to use and
opening it to change SafeSiders endodontic instruments in
rapid succession requires little effort. Its smaller head
facilitates ease of use in tight posterior areas where limited
jaw opening or tooth angulations could create limitations.
This flexibility is also particularly useful when in certain
circumstances an instrument must be placed into a canal by
hand due to dilacerations or extreme apical curvatures. This
small-headed handpiece can then be placed easily onto the
inserted instrument and activated.
The NSK Head will reciprocate through a full arc of 90
degrees, 45 degrees in either direction from neutral center.
The SafeSiders technique recommends using the handpiece at
about 2,000 rpm; however, I have been using it at full speed
(5,000 rpm) and it works great! Instrumentation with
instruments from #25 to #40 proceeds with little effort. The
use of the NiTi SafeSiders instruments is equally as easy, and
the handpiece eliminates any hand fatigue that you may have
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk23medidenta.html[2/21/2011 10:25:57 ]
Medidenta Handpiece
experienced, especially after a long day of dentistry. I have

also found that in cases that are difficult to instrument due to
calcifications or just harder dentin, the reciprocating motion
in combination with small-diameter instruments, such as #08
and #10, works equally as well. In general, when it comes to
reciprocation it is almost impossible to distort an instrument.
The 45 degree reciprocating arc it travels never allows the
instrument to meet severe distortional resistance; thus there is
no instrument deformation. This fact is even more important
while using the NiTi instruments.
So, in closing, I have to give this product a great review,
five out of five stars. I advise all practitioners who are using
SafeSiders to add this to their technique. And as I said in my
last article to all you rotary guys, if the only reason you are
staying with rotary is that you want a handpiece to ease hand
fatigue, then you dont have an excuse any more. Try it,
youll like it! Just a note: EDS will also be selling a version
of this reciprocating handpiece in the future, so keep
checking in. So with that in mind here are . . .
Dr. Kases Top 10 Reasons He Loves Reciprocation

# 10 The myths your mother told you are wrong. . . . You
dont really go blind! Ooops, hold on, thats something else.
Let me continue.
# 9 Because it works!
# 8 Less operator hand fatigue.
# 7 Ease of instrumentation in tight anatomical access to
posterior teeth or distally angled teeth.
# 6 Because it allows more rapid instrumentation of calcified
canals.
# 5 Reciprocation makes it easier to penetrate and remove old
gutta percha with less solvent when retreating a case.
# 4 Its much less expensive than rotary crown down and
quicker = less chair time = more productivity.
# 3 Less chair time = a happier patient.
# 2 It will probably prevent an ulcer because its safer than
rotary, hence less gut-wrenching to use than rotary. It can be
used with all SafeSiders instruments, stainless and NiTi, and
it doesnt distort and break instruments as rotary does.
And the # 1 Reason Dr. Kase Loves Reciprocation: Because
it really, really, really works fantastically and makes doing
endodontics a pleasure.
Winter 2004
Medidenta Handpiece
Remember to examine the

external anatomy and root
angulations with a perio probe
and radiograph when looking for
calcified canals to avoid
perforations.
FEEDBACK?
and questions.
Please feel free to visit the
Endo Forum and add your
comments about any of the
Doug Kase
Everything Old Is New Again
Doug Kase, D.D.S.


Doug Kase
Doug Kase
he topic of the month is: old comfortable shoes! Im

sure we all have a pair. We wear them, and although
they look a bit dated and worn, they are just too comfortable
to put into retirement. They may go well with our equally
tattered and worn comfortable pair of blue jeans, but we may
not want to wear them when were out on a night on the
town. Well, with that in mind we have an announcement. The
office of Musikant, Deutsch, Kase, Dukoff, Bui, and
Hoffman is upgrading. Yes folks, its a total makeover from
soup to nuts! Since even before our most recent millennium
we have helped the practice of endodontics evolve into the
21st century with our E-Z Fill technique and SafeSiders
instrumentation, and we now are also bringing our physical
plant along as well.
The reconstruction of our office has always been more
than just a thought over the years, but it was only recently
that all the ingredients came together in a recipe whose end
result will be a wonderful workplace for us to practice and a
pleasant surprise for your patients. Additionally, our
remodeled space and new equipment will continue to be a
focus of continuing education for our fellow dentists with the
addition of an endodontic microscope for every room. We
will have the ability to capture and record intra-oral images
for you and present them to you in future lectures and
newsletters. You will also have the ability to use these
microscopes during our hands-on courses to augment your
endodontic technique.
After months of research, I finally had the opportunity to
work closely with Becker-Parkin and DentalEZ to start the
planning phase of our makeover. With Becker-Parkins
recommendation of a general contractor, Fred Marsilisi, we
all started to put our heads together to pick our equipment
and plan our operatory designs, utilizing our existing physical
plant. Designs for sterilization and our front desk reception
area were also accomplished. However, throughout all our
planning and plotting the most important factor that had to be
considered was that we would never close our office during
the remodeling. I would like to end this by saying that its
history in the making, but that would be too simple an
ending.
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk24everythingold.html[2/21/2011 10:25:57 ]
The plan was to start phase one (remodeling five out of

nine operatories) on December 22, 2004, and be up and
running by January 5. So, after two weeks of working
evenings and weekends we were up and running by the 7th
and in the grand scheme of things, considering the holidays,
thats a big winner. For us, this is a group effort, and through
successful coordination we have maintained our goal of
continuous coverage for our referrers and uninterrupted
treatment of your patients. As the remodeling continues
through the end of February, we deeply appreciate your
patience and your continued confidence in our practice. I
look forward to keeping you all updated on our progress and
to presenting you with our final product. Take a look at some
pictures from our past and some from our present.
In the beginning, circa 1978 . . .
The first steps . . .
Stages in the installation of updated cabinetry by Dental EZ,

equipping the practice for 21st-century endodontics
January-March 2005
FEEDBACK?
Construction Update
Doug Kase, D.D.S.

Construction Update
Doug Kase
Doug Kase
HE MONTHS have gone by, and except for our waiting room
furniture order I can finally say that our new construction and
upgrade is 99.9999999 percent complete. Its certainly taken awhile, but
its been well worth the wait.
Our DentalEZ chairs, units, and cabinetry are functioning without flaws
and serving all our ergonomic needs. The Silhouette Chair we chose for
our patients comfort is so well designed that it allows for a physically
stress-free practice of endodontics with no obstructions to our legs and
thighs. Positioning the patient has become a simple matter, using the four
programmable preset positions. Also, keeping the chairs and units clean
and aseptic has been an easy task, thanks to their flush-mounted controls,
which can easily be covered with disposable plastic tape. The DentalEZ
Lumina Light in our operatories is track-mounted and provides two levels
of great shadow-free illumination. These lights can be operated in a
sensor mode and activated by merely passing your hand under the light,
providing contamination-free operation.
All our operatory cabinetry was designed and built by DentalEZ and
customized to fit the operatory floor plan that was laid out by Becker
Parkin. As I mentioned in last issues Tales article, we have both
under-chair and rear-delivery units that eliminated any over-the-patient
delivery issues we all had. If any of my readers are left-handed or have
partners or associates who are left-handed, these units and chairs can be
quickly adapted to either persuasion. The sliding counters behind all our
patient chairs have come to replace the old Alabama carts we used in
our old operatories. They are easily positioned, since they have the
ability to move not only left and right but also in and out.
Storage is more than adequate in drawers and cabinets and easily
accessible to doctor and assistant. Everything has been manufactured to
last with heavy-duty sliders and hinges. All our operatories are now
equipped with endodontic microscopes, which are now the standard of
practice.
I must say that Becker Parkin and DentalEZ have made themselves
incredibly accessible in the process of final tweaks to our equipment.
Collaborating with Becker Parkin has been a great experience. Although
we have used them for many years for supplies, repair, and maintenance
of our older equipment, their input regarding our new equipment and
subsequent installation has been invaluable. The size of the company
allows for a large support staff, but its not so large that a personal touch
and individual concern for an ongoing project are ever put on the back
burner. Barry Salzman, the president of the company, has always made
himself available and has been in constant contact throughout the
project. The same can be said of the DentalEZ Company; they have also
participated in and followed our progress closely like a proud parent.
When it comes down to the final analysis, both Becker Parkin and
DentalEZ are great companies to work with because they are experienced
and large enough to do the job right, but not so big that you become just
another invoice in a pile of customers. A very special thanks to Carl
Bretco, president of DentalEZ, and all his staff who helped to bring our
project to a happy ending.
New Seiler endodontic microscope.
DentalEZ Galaxy under-chair

delivery unit.
Sliding countertop work surface.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk25construction.html[2/21/2011 10:25:58 ]
Construction Update
The front desk of any office has to be a masterpiece. It is not only the
welcome mat that you extend to your patients, but also a gateway to the
clinical part of their visit. We wanted our front desk to have an open
look and invite patients to feel actively able to communicate with the
staff, ask questions, and voice concerns. The thought of a root canal can
elicit quite a range of emotions, and being able to interact with our staff,
not through a bank teller window, was very important to us to make
every patient feel at home. With that in mind DentalEZs designer came
up with a couple of choices, and the final product was built and installed
after a detailed preparation of the space by our General Contractor, Fred
Marsalisi of D.E.S. Interiors in Danbury, Connecticut. The input of our
front desk staff was greatly appreciated when the design parameters were
considered. Remember, they are the ones who have to work there.
Seating area, computers, telephone, and interoffice communication all
have to be taken into account when you plan.
There will be more to say about our new office in future issues, but
suffice it for now to say please enjoy our new digs; we certainly do. Feel
free to stop in for a visit if you are in the neighborhood.
DentalEZ Lumina Light.
Galaxy rear delivery unit.
Welcome! This is the new front-desk as our patients see it upon arrival.
Auxiliary front desk work space.
The front desk from behind the scenes.
Construction Update
DentalEZ operatory cabinets.
Sterilization area.
Construction Update
Sterilization area.
New operatory.
Front desk and new files.
Construction Update
July-September 2005
FEEDBACK?
Please feel free to visit the Endo Forum and add your comments about any of the
If at First You Dont Succeed . . .
Doug Kase, D.D.S.


Doug Kase
Doug Kase
HIS MONTH I will start Tales with an

interesting case. A patient presented with a
fistula associated with tooth # 3. This tooth had quite
an active history, which included prior endodontic
treatment approximately one and one-half years ago
and a subsequent PFM crown. Nine months later the
case failed, and the patient had an apicoectomy on the
mesiobuccal and distobuccal roots, leaving the palatal
root untouched. This now brings us to the present
situation (Figure 1) with an actively draining fistula,
which seemed to be associated with the mesiobuccal
root and a periapical radiolucency at the palatal apex.
Well, we all like to think of ourselves as heroes, so
being the hero that I amI initiated an endodontic
retreatment of the tooth with the goal of finding an
MB2 canal and retreating the palatal endo. Eureka! I
found the MB2 and retreated the palatal root as planned
(Figure 2). I prescribed clindamycin 150 mg TID and
dismissed the patient with the expectation of a closed
fistula on the checkup visit in two weeks. To my great
dismay the fistula was still present and draining in all
its glory.
Frustrated but nontheless very determined, I decided
to retreat the entire tooth. Using the apex locator, I was
able to remove the existing gutta percha and reinstrument the canals with the retrograde amalgam
seals without dislodging them. Once again victory was
in sight as I re-obturated the canals (Figure 3) and told
the patient that all was well. Needless to say, my
patient returned, as did the fistula. It was time to take
out the big guns! Extraction and replacement was not
an option, so an apicoectomy was scheduled.
After two carpules of Septocaine, an incision was
made in attached gingival from the mesial of # 2 to the
mesial of # 4, where a vertical release incision was
done to achieve greater access without stressing the
tissue on reflection of the flap. It was apparent when
the flap was raised that there was a fenestration in the
buccal plate over the MB root. Using a # 4 surgical
round bur, I opened a window over this area to
Figure 1
FIGURE 1: An actively draining

fistula associated with tooth # 3.
Figure 2
FIGURE 2: Following retreatment

of the palatal root.
Figure 3
FIGURE 3: After retreatment of

the entire tooth.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk26ifatfirst.html[2/21/2011 10:25:58 ]
Figure 4
discover that the DB root was involved as well. Using

a 557 surgical length bur, I beveled the MB and DB
roots back, removing the old retrogrades. On the MB
root, I identified both the MB and MB2 canals, which I
then prepared for retrograde amalgam seals, using my
Newton Ultrasonic unit and retrograde prep tip that is
integrated into our DentalEZ chair side units.
Now when I beveled back the DB root, thats when
things got a bit interesting. As I beveled, I identified
the DB canal, but 3 to 4 mm palatal to that I saw
another vein of gutta percha in this dumb-bell shaped
root. I thought, Could this possibly be the palatal
root? How could the great God of endodontics be so
good to me? Sure enough it was the palatal root, for
this was a great example of fusion of the distobuccal
and palatal root anatomy and explained why this
radiolucency actually involved all three roots. The DB
and palatal were prepped and sealed and the surgical
site closed (Figure 4). Clindamycin and NSAID
analgesics were again prescribed, and the patient
returned one week later for suture removal without any
post-operative complications. Persistence paid off, the
fistula has not returned, and the patient is healing well.
A happy ending for all!
FIGURE 4: Showing the DB and

palatal roots sealedpersistence
pays!
July-September 2005
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk26ifatfirst.html[2/21/2011 10:25:58 ]
Its Not What You Say; Its How You Say It
Doug Kase, D.D.S.


Doug Kase
Doug Kase
Figure 1
N AN OFFICE, particularly a large office, it is
extremely important to be able to communicate
with your staff efficiently and of course equally as
important, vice versa. Good intra-office
communication results in an efficiently run practice.
When your front desk can notify you that your next
patient has arrived, the chart is filled out, and the
patient is ready to be seated without staff members
having to leave their posts, and without your having to
divert your attention from your present task, practicing
in general becomes that much easier. If this
communication for the most part is silent, then your
FIGURE 1: The Comlite 4000
patient in the chair will never have the feeling that you
series unit.
are rushing a procedure to move to your next
appointment. For some strange reason, screaming down
the hallway just doesnt set the right professional
Figure 2
atmosphere. Additionally, a silent communication
system becomes much more important with the
increased need for confidentiality when communicating
information regarding patient treatment.
When I talk of silent communication, I am referring
to a light signaling system. For years, dating from the
time when our office was originally built, we used the
Visicom system with a series of indicator lights and
private intercom. As the office aged, so did the system,
FIGURE 2: Maybe with a little
and eventualy it suffered from old age. When we
luck . . .
reconstructed the office, we considered a new Visicom
system; however, that systems higher cost and our
Figure 3
history of repairs led us to choose the Comlite 4000
series unit (Figure 1). This very affordable system
offered a quiet and discreet way to communicate our
intra-office messages, such as new patient arrival,
important phone call, patient seated, come to
location, and personal message. The system uses
lights and chimes to communicate these messages.
Since it was similar to what we had and so easy to
customize to our needs, the transfer and learning curve
FIGURE 3: Mission
for our staff was quick and easy.
accomplished!
The Comlite 4000 series we chose was the
LAS4000, which also includes voice intercom
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk27notwhat.html[2/21/2011 10:25:59 ]
Figure 4
communication, which can be routed to any of the 17
individual units we have throughout the office. The
units can be placed on a desktop or wall mounted.
There is no master unit, and all can send or receive
messages. They can be customized to your needs with
appropriate included adhesive labeling. This system
uses your power grid in your office to link up; hence
all that is necessary to get started is to just plug it in.
However, in a larger office such as ours with more
Figure 4
individual stations, it was suggested to use the option
of hardwiring the units together using standard
telephone wire to insure that all units would
communicate properly, which they did flawlessly.
Using a series of dip switches on the back, each unit
was designated individually for intercom
communication that allows one to one or one to all
voice communication. The buttons can be lit in a
FIGURES 4 AND 5: A second
steady mode by pressing once or be made to blink by
case of a curved canal.
pressing twice and each message is followed by a
pleasant chime which is volume controlled at each unit.
The LAS4000 front surfaces are flat membranes that
are easily cleaned and also can be protected easily with
additional plastic wrap for infection control purposes.
These can also be controlled with an optional IR
remote up to 35 feet away, which makes placement an
easy task.
So how do they perform? I have to give them five out
of five stars. After working through some wiring issues
that had nothing to do with the system itself, they have
functioned flawlessly. They were easy to customize for
our inter-office communication purposes and continue
to help maintain a quieter and less stressful
atmosphere. The quality of the voice communication
feature is good when we need it and simple to
implement and direct. The Comlite LAS4000 is a
valuable addition to our office.
A Case From Kase

Danger Curves Ahead!
Curved roots are a pain in the ass. There I said it. I am
quite sure we all feel the same way. You take a look at
your pre-op film (see Figure 2) and say to yourself Oy
veh! Maybe with a little luck and lots of sealer I can
squash something around that curve. With a little
persistence and patience, curved roots and curved root
apices can be somewhat easily instrumented and
obturated. This case was a doozie. The need for
endodontic therapy was self-explanatory after taking a
glance at the x-ray; however, a successful completion
was in question. The mesial canals were a no brainer,
so I will confine my technique explanation to the much
more complicated distal canal on tooth # 18.
To attain measurement control with my apex locator

I had to pre-bend the tip of a .08 stainless steel file at
about 45 degrees, and with very gentle hand
reciprocation I was able to negotiate the apex after a
few tries. Using plenty of RC Prep and hand placement
of my instrument in the canal to apex, I placed my
reciprocating handpiece on the head of the .08 while
still in the tooth and stepped on the gas. There was
very little fear of instrument separation due to the
nature of the 45-degree arc of movement from center
not creating instrument stress as less accurate hand
motion could while in such a curved apex. Once I was
able to move the handpiece coronally and back apically
with little resistance, I moved on to a # 10 reamer and
repeated the process, which I also did for a # 15. I then
widened the coronal aspect of the canal with Gates
Glidden and # 2 Peeso reamer. I reiterated the apex
with a pre-bent # 15 and continuous reciprocation, and
I continued the sequence of instrumentation up to a #
25. I then re-widened the coronal portion with a # 2
Peeso. At this point I started to back step with # 30, 35,
and 40 one mm per instrument and each time renegotiating the apex with my # 25. Once this was
accomplished, I was able to move my pre-curved #30
and 35 to the apex, still using reciprocation. Then I
additionally gave each of my new NiTi instruments a
bit of a bend at the tip and under reciprocation they
moved readily to the apical measurement. The case was
obturated using the standard EZ-Fill technique, and I
patted myself on the back for mission accomplished!
(See Figure 3.)
In most canalsand especially curved canals
reciprocation is the instrumentation technique of
choice. Due to the nature of the circumscribed arc the
instrument takes in the reciprocating handpiece, there is
much less mechanical stress on the instrument because
you never reach and surpass mechanical engagement.
Additionally as an instrument increases in diameter it
becomes stiffer. Thus pre-programmed reciprocation in
a handpiece greatly reduces mechanical distortion or
zipping of the curved canal apex because there is no
rotation of the instrument, either stainless or NiTi.
Here is a second case of a curved canal that was
instrumented with SafeSiders and obturated with the
EZ-Fill technique. (See Figures 4 and 5.)
July-September 2005
FEEDBACK?
Looks Can Be Deceiving
Doug Kase, D.D.S.


Doug Kase
Doug Kase
IAGNOSIS of an endodontic problem can sometimes be obvious.

You take a look at a particular tooth that a patient is complaining
about, and you see clinical caries that has created a hole so large you can
park a Mack truck inside it. Or if it is not that obvious, usually on a
radiograph there is some sign of pathology, either caries or a periapical
radiolucency, that points you in the right treatment direction and thus you
say to yourself that this is a no brainer. Well my loyal readers, not
everything is what it seems!
The case I am going to present to you was somewhat of an initial no
brainer. A patient was referred to our office with an obvious need for
endodontic treatment on tooth number 3. The X-ray showed a clear
radiolucency associated with the apicies of tooth #3 and a relatively large
restoration (Figures 1 and 2).
Figure 1
Figure 2
FIGURES 1 AND 2: X-rays showing a clear radiolucency associated with the

apicies of tooth #3 and a relatively large restoration.
Upon conducting a clinical exam, I also found a fistula on the buccal

gingival, where I placed a gutta percha point to trace its origin (Figures 3
and 4).
Figure 3
Figure 4
FIGURES 3 AND 4: X-rays showing a fistula on the buccal gingival, traced to its
origin.
The diagnosis seemed pretty clear-cut in my opinion. Feeling pretty

cocky, I informed the patient that this would be a simple root canal, there
should be very few post-operative complications due to the fistula, and we
would be able to complete it in one visit. I was a hero and everyone was
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/dsk28looks.html[2/21/2011 10:26:00 ]
happy!
I administered buccal infiltration local anesthesia and gave a small
palatal injection at the gingival margin also to numb for the rubber dam
clamp. Because this was a non-vital case, I felt that there was no need to
give a deep palatal injection, which can be uncomfortable for the patient.
Actually, due to the non-vitality, I could have done the treatment with very
little to no anesthesia. No symptoms + dead nerve + fistula = no pain. I
started a conservative access opening through the onlay, and as soon as my
bur touched dentin the patient gave me a sign that he was feeling something
he jumped! Impossible, I thought, so I tried again and got the same
response from the patient. Now I had to start up the diagnosis machine. I
looked back at the radiographs. Perhaps due to internal calcification in the
pulp chamber, the palatal root was still vital and walled off and all the
pathology was associated with the non-vital buccal roots. Or perhaps was
this a bony lesion that was not even associated with an endodontic problem
at all. I removed the rubber dam and placed Endo-Ice on the palatal aspect
of tooth #3 and got a clear vital response. Using the logic that if there was
not enough palatal anesthesia to anesthetize tooth #3, there certainly was not
enough to anesthetize #2 as well, I pulp-tested tooth #2 with Endo-Ice, and
believe it or not there was no response. How could this be? Everything
preoperatively pointed to #3, but there was obvious vitality. Instead of
numbing further and proceeding to complete a root canal on #3, which
would have looked like a winner on an x-ray, I closed up shop for the day
so that I could bring the patient back to retest the area without the presence
of local anesthesia.
The patient returned the following day, and upon a pulp test of tooth #3,
I found that I was able to elicit a vital response from the buccal and palatal
surfaces. However, #2 gave no vital response at all. The patient was
informed that perhaps tooth #2 was the actual culprit and the radiographic
pathology was just presenting mesially. Since this was the only reasonable
explanation, endodontic therapy was performed on tooth #2 and the
radiographic result on the final films gave me the final answer to this very
interesting diagnostic case (Figure 5).
Figure 5
FIGURE 5: Showing the lateral canal off

the mesial aspect of the mesiobuccal
root and the corresponding puff of sealer
into the periapical radiolucency.
Note the lateral canal off the mesial aspect of the mesiobuccal root and
the corresponding puff of sealer into the periapical radiolucency. The
patient returned one week later without any postoperative symptoms, and
the fistula was closed.
So remember, dont always believe what you see. It is OK to do a little
second-guessing.
FEEDBACK?
Please feel free to visit the Endo Forum and add your comments about any
of the articles in Endo-Mail.
Experience HODEC
EDSs New State of the Art Hands-On Dental Education Facility
HODEC
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/hodec01.html[2/21/2011 10:26:00 ]
In the News
In the News
DentalTown
Dentistry Today
HE JANUARY 2005 issue of dentaltown profiles
Essential Dental Systems and its founders Barry
Musikant and Allan Deutsch. In two decades, the article
states, EDS has gone from being the dream of two of New
York Citys most notable endodontists to a pioneering force
in the dental universe. Combining their inventiveness and
business savvy, EDS has utilized cutting-edge research and
state of the art technology and advancement to blaze a path
of innovation and creativity in the field. In the process, it has
educated practitioners the world over and brought relief to
untold multitudes of patients; and its future is still being
written.
In the March 2005 issue of Dentistry Today, you will find
Allan Deutschs Pulp Chamber Morphology: Basic Research
Leads to Clinical Technique, in which he reports the
research that led to the development of the PulpOut Bur.
This remarkable research has shown that there is a critical
depth from the cusp tip to the pulp chamber of teeth with
furcations. The fixed stop feature of the PulpOut Bur
allows you to take advantage of this depth and gain access
without the fear and anxiety of furcation perforation.
April-June 2005
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/inthenews.html[2/21/2011 10:26:01 ]
In Search of Modern Endodontics
Jay Vuong, D.D.S.

Jay Vuong
Jay Vuong
NCREASED public awaremess of endodontic treatment

and increased public demand for it are both realities. This
increased demand and the financial rewards for
practitioners who use predictable and time-saving strategies
to render treatment have helped fuel a so-called endodontic
revolution in recent years.
A variety of endodontic products and techniques have
been in the forefront of this revolution. Terms such as
crown-down rotary instrumentation and thermoplastic
gutta-percha are now buzzwords equated with superior
endodontic technique, and those techniques are sold by
manufacturers as the cure to all woes.
How does the average dentist make sense of all of this?
What does this mean to the seasoned generalist, the recent
graduate, or the dental student who have been taught or still
use endodontic techniques and materials deemed outdated
by the many self-anointed endo gurus?
To many, this endodontic revolution has raised more
questions than it has answered. The standards for treatment
outcome have risensome without justification. Many
practitioners now question consciously or subconsciously
their own ability to render acceptable endodontic treatment.
Some do so to the point of having feelings of inadequacy.
Many generalists I have spoken to say that they have no
choice but to be defensive. Many others have attended
expensive continuing education endo courses. These courses
often leave those who attend them with a feeling that
something is still missingthat modern endodontics is still
beyond their grasp.
If you have those feelings of confusion, or even
inadequacy, let me assure you that you are not alone.
Ironically, there is still some confusion and debate in the
endodontic community regarding the best way to render root
canal treatment.
There are several schools of thought on these matters
each of them with an interest in preserving their way of
practicing. Academic and clinical arguments in philosophy
and practicality have left many endodontists close-minded in
their attempt to justify their positions. Dental research
deemed good or bad, past or current, can be manipulated or
interpreted to support any of these positions.
In the midst of all this, my advice has been to do what
SEARCH FOR
APPROACHES
THAT WORK
FOR YOU.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/jv01insearchof.html[2/21/2011 10:26:01 ]
works for you. In light of the fact that there are no

conclusive empirical findings regarding many endodontic
matters, I have always preferred practicing in a way that is
the easiest and most economical for me. Successful patient
management and reduction of stress are always major goals
when I look to evolve my approach to root canals. I have
found that the S.E.T. and EZ-Fill techniques have several
strong points regarding practicality; they have worked well
for me, and they may work for you. Nevertheless, I urge you
to continue your search for approaches that work for you, not
just in dentistry, but in your life as a whole.
In the upcoming months, I would like to try to answer
any questions, or to discuss thoughts concerning endodontic
philosophy, technique, materials, and anything else.
Comments and questions from readers of this newsletter are
not only welcome, but are needed to shed light on what
people in our dental community may be thinking about. Email us or write to us with your questions or comments.
Endo-Tip
When the length of a tooth approaches the maximal

depth of a 25-millimeter instrument, the interference
of tooth structure or a metallic restoration may make
placing the probe of the apex locator difficult. In such
cases, it is easier to attain proper measurement
control using a 31-millimeter instrument rather than a
25-millimeter instrument.
Doug Kase
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/jv01insearchof.html[2/21/2011 10:26:01 ]
Oscillating Your Way to Success
Jay Vuong, D.D.S.

Negotiating Calcified Canals

Jay Vuong
Jay Vuong
EVE ALL ENCOUNTERED the situation in which

a preoperative film shows calcification of the root
canal system. Upon seeing the film, you may feel a
little hesitant in starting the root canal treatment. Upon
starting the procedure and making your access, you may
spend countless minutes unsuccessfully trying to introduce
very fine instruments in orifice areas where you find a stick
in the explorer. Let me reassure you that you are not alone
theres nothing inadequate about your manual dexterity or
skillbut there are alternative techniques to help you
negotiate these calcified canals.
Maybe Im clumsy or impatient, and maybe a little of
both, but Ive never had much success using files smaller
than a #10 K-file or reamer. When using #6 or #8 files, I
would ruin them too easily and would become frustrated just
as easily. I would go through an entire box or more and then
begin to think about their replacement cost. They tend to be
too flexible, requiring exact placement and angulation in
order to prevent their bending irreversibly. I find the small
files very effective, however, in conjunction with a
microscope. Seen through the microscope, a calcified orifice,
once explored, shows up as an actual opening in which a #6
or #8 can be inserted carefully at the proper angulation.
However, suppose that you are a general dentist who doesnt
have a microscope handy. What can you do when youre
faced with a calcified canal?
The Oscillation Technique

LET ME DESCRIBE one technique that has helped me
negotiate a presumably calcified canal once an accurate stick
of the explorer is found. I call it the file size oscillation
technique. The technique uses larger file sizes to facilitate
the movement of smaller files deeper, and then uses a smaller
file to facilitate the movement of the previous larger files.
The technique assumes that you can make an access to the
anticipated level of the orifices, that an accurate feel for a
stick is present, and that you can judge and memorize the
penetration angle into the orifice. You also have to be patient
enough to use light apical pressure in a simple watchwinding, back-and-forth rotational movement of the file or
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/jv02oscillating.html[2/21/2011 10:26:02 ]
reamer.
After accessing to the floor of the tooth, I immediately use
the double sided endo explorer, usually a sharp Dg16. The
explorer helps me feel for the catch of the orifice. More
importantly, the explorer, once it is engaged in the orifice,
imparts an angulation that one can use to enlarge the access
at strategic points. Also, this angulation is the very important
angle that you need to place your initial file. In this
oscillation technique, I use #10, 15, and 20 files or reamers. I
initially begin with a #15, inserting it at the same penetration
angle as the explorer.
A rule to remember is that you should always allow the
file to go where it wants to go. Never force a file in a
preconceived direction that you want the file to take; forcing
the file is a precursor to ledging. An easy way to counteract
ALWAYS
the tendency to force the direction is to check and allow the
ALLOW THE
file to flutter every once in a while. Fluttering involves
engaging your file or reamer into the canal, letting go of the
FILE TO GO
instrument, and then flicking the handle and seeing how the
WHERE IT
file angles. It is at this angle that you want to apply all your
WANTS TO GO.
forces and motions.
I move the #15 file or reamer apically with a light watchwinding movement, fluttering the handle, checking the angle,
and applying my apical force in the direction that the file
wants to go, not where I want the file to go. I continue in
that manner until I encounter a binding point at which two
watch-winding cycles combined with light apical pressure
will not advance the file further. When the binding point has
been reached for the #15 file or reamer, it is necessary to use
the #10 or the #20 file or reamer in the same way.
If my initial #15 binds halfway into the canal or deeper, I
tend to oscillate up in file size, to the #20. Using the #20
in the same way as I used the #15, I will usually encounter
resistance at a shorter length than that to which the #15 had
penetrated, or, sometimes, at the same length. I then
oscillate down in file size, using the #15 again with the
same watch-winding apical movement. Because of the
crown-downing effect of the # 20, the #15 will now usually
reach the apex.
If my initial #15 binds less than half way down the canal, I
tend to oscillate down in file size, using #10 next. The
slimmer #10, used in the same way as the #15, will slide into
the canal deeper than the depth created by the #15.
Oscillating back and forth between these two instruments,
#10 and #15, I can gain enough apical depth to allow the #15
to reach halfway down the canalthat is, past the first curve
of the canal. The #20 is then introduced as in the first
scenario described above, and the #15 is then used to
approach working length.
The oscillating approach relies on the use of use of larger
instruments to facilitate the apical movement of smaller
instruments. Unlike a pure crown-down approach, however,
it uses smaller instruments to facilitate the apical movement
of larger instruments, then vice versa, until the entire length
of the canal is negotiated. One is never in a rush to reach the

apex, and no one instrument is ever used longer than
necessary in the canal. Each instrument is allowed to
penetrate at a passive angle, where it wants to go. A light
touch is essential. Learn to avoid picking at the binding
point in the canal. Instead, allow the endodontic game to
come to you.
I have found that using three file sizes, #10, #15, and #20,
switching among them as I have described, has allowed me
to negotiate most fine and otherwise calcified canals. Keep
in mind, however, that this oscillating approach is not rigid;
you can develop your own sequence, incorporating other
tools such as Gates Gliddens or Peesos, to meet your needs
more effectively. Personally, I have found that once the
canal is negotiated to the apex at a size 20, then incorporating
the practical measures that the SafeSider and EZ-Fill
techniques allow for becomes very easy.
I urge you to try. If you encounter difficulties or want
more information, contact us. Better yet, sign up for our free
continuation course in which you can explore this and other
topics more thoroughly. Youll find registration information
here.
May-June 2001
FEEDBACK?
Second Thoughts About NiTi
Jay Vuong, D.D.S.

Jay Vuong
Jay Vuong
With all of the

N THIS PRESUMABLY modern era of endodontics,
positive
many more dentists are experimenting with the newer
attributes of
nickel titanium instruments only to encounter their
nickel titanium,
limitations. Because of the alloys flexibility, nickel titanium
why do many
shaping instruments can be sized with larger and varying
endodontists,
degrees of taper. These increased tapers and computer-aided
including me, still
flute designs have helped impart a more uniform and
rely heavily on
predictable shape to the canal space, especially in the apical
the traditional
half. Depending on the usage, the shape defined or refined
stainless steel
by existing NiTi instruments may be used to enhance the
instruments?
effectiveness of cleaning and the ease of obturation through
standardization.
With all of the positive attributes of nickel titanium, why
do many endodontists, including me, still rely heavily on the
traditional stainless steel instruments? Besides the substantial
increase in cost, one reason lies in the physical property of
the nickel titanium metal itself. Stated plainly, nickel
titanium, although flexible, has a tendency to fracture when
strained, especially under the torsional strain that occurs when
instruments rotate in the confines of tight, curved, and long
canals. Predicting the likelihood that an instrument will
fracture is difficult. True, using newer instruments can
reduce separation rates. However, with such an increase in
operational cost, older instruments tend to appear usable
unless we remind ourselves of their age through the tedious
process of marking the instruments according to their number
of uses and factoring in the additional wear imparted with
prior uses in difficult canals. Even with all these precautions,
NiTi instruments can still separate without any prior visual
evidence of distortion. Once separated in the canal, NiTi
instruments are often difficult to remove or bypass. The flex
of the metal makes them difficult to unwind out of the canal,
especially around a curve. Their flexibility also allows them
to absorb the energy of ultrasonics without dislodging their
threads from the dentinal walls. Rather, under ultrasonic
vibration, the metal has a tendency to chip away. The silver
lining to this difficult situation may be that the NiTi
instrument often fractures at the apex when binding is
usually at its maximum, and that its radiographic opacity
matches well, if not inconspicuously, with adjacent guttapercha. The film may look good, but I still feel a little
uneasy, especially in infected cases.
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/jv03secondthoughts.html[2/21/2011 10:26:02 ]
Another main reason why I still rely on stainless steel

instruments is that although NiTi instruments are good for
shaping once a pathway in the canal is established, they are
not predictable penetrating and gauging instruments. Using
NiTi instruments in a rotary fashion will only allow them to
stay centered and penetrate the canal by screwing their way
into an existing pathway. Although this action should
facilitate the apical movement of these instruments in a
crown-down fashion, there are times when the existing path
in the canal is irregular in anatomy. This irregularity is a
precursor to the instruments binding and separation. The
centering effect of these instrument predisposes them to
remove dentin indiscriminately on the furcation or depression
side of the root as well as dentin in the roots thicker and
safer zones. Unless a straightening, anticurvature mechanism
is used at the coronal level prior to deep NiTi introduction,
the situation becomes predisposed to strip perforations,
especially in curved, thin, and long canals. An operators
tendency to abandon the very important endodontic doctrine
of straight-line access becomes a compromising habit when
one overestimates the abilities of nickel titanium.
Through trial and error, especially with rotary
instrumentation, most endodontists still feel the need to
explore, measure, and establish the canal using traditional
stainless steel instruments. This exploration, measurement,
and establishment of the main canal space with stainless steel
instruments is especially important with cases that present
with unusual pulpal anatomy or prior mishaps, such as
blockage, ledges, strip perforation, and apical distortions.
These are the very cases that require thoughtful manipulation,
usually requiring the tactile sensitivity of stainless steel
instruments.
NiTi instruments can therefore be viewed as dumb
instruments mainly having the ability to ream the walls of
the canal. Their smartness is the shape that is imparted into
their design, which then can be imparted to the final canal
shape. Their flexibility doesnt allow the operator to have
optimal directional sensitivity inside the canal space; rather,
sensitivity becomes a measurement of torque or resistance
controlthe operator becomes more preoccupied with
avoiding instrument fracture than exploring the pulpal
anatomy. NiTis amazing elastic memory, the ability to stay
straight no matter how you bend the instrument, is an asset
as the instrument threads its way into a cana; however, it
becomes a hindrance if you need to prebend the instrument or
its tip in order to explore or bypass a ledge or blockage. At
larger instrument sizes, this elastic memory translates to a
disposition to strip perforations and apical distortion in
straightening the canal and is easily underestimated by the
overconfident operator.
Taking some of these pluses and minuses of the NiTi
instruments as applied to endodontics, I have favored the
older, yet more reliable stainless stain instruments. Rather
than using NiTi instruments as a means to all ends, the
recognition that NiTis are used most effectively as sizing and

shape refining instruments has allowed me to use them more
sparingly.
July-August 2001
FEEDBACK?
Stressed Tooth, Stressed Dentist
Jay Vuong, D.D.S.

Jay Vuong
Jay Vuong
What is a
HEN I FIRST STARTED doing referral-based
stressed tooth?
endodontics, I was surprised by the number of
complaints that some patients had about their general On an endodontic
level, I see the
dentists. One group of complaints would center on typical
stressed tooth as
issues, such as how rough, uncaring, and unavailable their
a tooth (without
dentists could sometimes be. The other main group of
prior root canal
complaints would center on how the patients had gone to
treatment) that
their dentists for routine treatment and then for some
has a significant
unknown, unexplained reasons, they now had severe
risk of developing
toothaches or infections. Making matters worse, these two
an irreversible
types of complaint would often go hand in hand as the
pulpitis or
patients asked whether I could refer them to another dentist.
abscess once
Of course, I wouldnt and still dont. After a little persuasion
additional
and encouragement, on my part, the patients would feel better
procedures are
about their dentists; that is, they would feel better about their
judgment in choosing their dentists in the first place and then performed on the
tooth.
feel comfortable about giving their dentists another try.
Why do patients get upset in the first place? From
complaints like the ones described above, it sometimes
appears that the patients dental experiences fall short of their
expectations. With reasonable patient expectations and a
little sensitivity and foresight on the dentists part, stressful
situations like the upset patient with a toothache can often be
avoided. One clinical situation that tests the patient/dentist
dynamic is the recognition, presentation, and treatment of the
stressed tooth. Often, the patients who give their dentists
compliments when they present in our endodontic practice
are patients of dentists who recognize the stressed tooth and
present it through their treatment plans. These patients are
usually well informed or informed enough to enable them to
rationalize the reason for their now needing a root canal,
especially after just getting a new restoration. The patients
dental pain and blame is vented on their own dental situation
rather than on the ability of their general dentists. The
dentists are seen, by these patients, as the wise caretakers
who foresaw the stressful predicament that the patient is now
in. These dentists had taken their patients expectations into
account and, as a result, their patients are not surprised or
confused by their current position of needing a root canal.
What is a stressed tooth? On an endodontic level, I see
the stressed tooth as a tooth (without prior root canal
treatment) that has a significant risk of developing an
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/jv04stressed.html[2/21/2011 10:26:03 ]
irreversible pulpitis or abscess once additional procedures are

performed on the tooth. Examples of the stressed tooth might
include a tooth with a deep amalgam filling, once replaced
with a white filling or crown that now has a persistent
sensitivity to cold, then to heat, with the sensitivity finally
turning into a full-blown toothache. Another example is the
periodontically compromised tooth, crowned years ago,
which with a recent root scaling then develops an acute
endodontic abscess. The stressed tooth, as seen in these
examples, tends to be recognized once the endodontic
problem arises. Wouldnt it be nice to recognize the stressed
tooth before it becomes a problem to you and your patient?
One way to increase ones recognition requires the dentist to
view the tooth biologically.
It is often practical and productive to see the tooth as an
inert solid that the dentist can manipulation in a way that a
craftsman or artist manipulates a piece of wood or marble.
A problem with this view of the tooth arises, however, when
you take the pulp into account. Biologically, dentin can be
seen as an extension of the pulp. The dentin, which is not
solid at all, but rather porous because of is tubule construct,
houses the extensions of pulp odontoblast in a delicate fluid
dynamic. Drilling into dentin can then be viewed as cutting
into a living tissue. Lacerations in dentin, like lacerations in
skin, result in an inflammatory process. In the tooth, if the
inflammatory process is significant it leads to permanent
changes in the low compliance environment of the pulp.
These changes in the pulp can compromise the ability of the
pulp to recover from further inflammation resulting from
injury. The tooths inability to recover translates into clinical
symptoms when the patient develops temperature sensitivity
then percussion pain that doesnt go away and only gets
worse. Sometimes the pulp or nerve dies, often without
symptoms (sometimes in the presence of a temporary
sedative) until an abscess develops in the future.
To recognize the stressed tooth, one must be able to
recognize all the past injuries the tooth has undergone and
all the suggestive clinical symptoms the tooth has now.
Injuries to the pulp are usually revealed by looking at the
dentin. Usually, they can be seen in the radiographic and
clinical evidence. Carious lesions; extensive restorations in
dentin; periodontal defects adjacent to dentin; and clinical
evidence of abrasion, attrition, erosion, and recession may be
evidence of injury sustained by the pulp.
In addition to these factors, you might also be able to
recognize changes in the pulp directly. These changes may
include thinning or calcification of canals and chamber, pulp
stones, thickening of the PDL, or opacity of the bone beneath
the root (i.e., condensing osseitis). These pulp changes alone
may not present a risk to further restorative insult. However,
when they are present in conjunction with other previous
dentinal injuries, the situation should be questioned.
The patient should also be questioned and listened to. Has
the tooth ever bothered the patient in the past? Does the
tooth bother the patient in any way now? If you see an

accumulation of the factors above in an individual tooth, you
can define the tooth as a stressed tooth. The stressed tooth
has the potential to inflict endodontically related pain when a
further significant restorative or periodontal procedure is
performed on the tooth.
Once a questionable tooth is recognized, the dentist who
informs the patient about the situation is one step ahead of
the game. The decision to perform or not to perform
prophylactic endodontic treatment, however, requires a
good understanding of treatment planning in conjunction with
an accurate assessment of the patients risk tolerance . . . and
your own.
ENDO TIP
Make sure that you clean the

isthmus between the mesiobuccal
and mesiolingual canals of a
lower molar with a fine diamond
to remove trapped tissue and look
for extra canals.
Doug Kase
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
The State of the Pulp
Jay Vuong, D.D.S.

ABCs of Endodontic Diagnosis, Part 1

Jay Vuong
Jay Vuong
WAS PROMPTED to write this article because it had

occurred to me that many practitioners, while approaching
endodontic diagnosis from a practical, hassle-free
standpoint, do not have a complete understanding of pulpal
dynamics. An understanding of pulpal biology and how it
translates to clinical symptoms would help the dentist utilize
appropriate treatment regimens with the hope of maximizing
the likelihood of a successful outcome.
We must agree that when it comes to root-canal treatment,
there is a great deal that we can do to ensure a successful
outcome. However, there are times when the most heroic or
ideal procedural effort does not ensure a predictable outcome
or a symptom-free tooth on which to build a restoration.
Endodontic outcome, to me, then becomes a question of
probability or statistics. To increase the probability of a
successful clinical outcome, we must first start with an
accurate diagnosisto begin, we must ask, what state are
the nerve and pulp in?
When patients come in with tooth pain, we as dentists
should not dismiss their discomfort. Statistically, patients
complaining of dental pain significant enough to mention to
their dentist tend to have endodontically related pain. As
clinicians, we usually ask a few questions or perform a few
tests to see if root canal treatment is appropriate to address
the pain. Another way of looking at the situation is that we
are presented with an opportunity to match the pulpal
condition of a symptomatic tooth to a degenerative timeline
that most teeth tend to follow. The biological state of the
pulpal tissues tends to give correlating symptoms and
radiographic clues.
As the pulp initially becomes damaged, it becomes slightly
inflamed at the site adjacent to the insult, exemplified by
gross decay with resulting inflammation to the underlying
pulp horn. This initial inflammation results in a heightened
sensitivity to cold, with a sensation of pain, often followed by
a heightened sensitivity to heat at a later time.
At first, the pain is initiated and sustained only by the
stimulus (this is reversible pulpitis). Later, as the pulpal
swelling spreads from the initial area of damage or irritation
to the rest of the pulpal tissue in the chamber, the pain
initiated by the stimulus becomes more prolonged (this is
Statistically,
patients
complaining of
dental pain
significant
enough to
mention to their
dentist tend to
have
endodontically
related pain.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/jv05pulp.html[2/21/2011 10:26:04 ]
irreversible pulpitis). If enough pulpal tissue becomes

damaged, the pain may initiate or persist without any
stimulus at all. At the same time, the degenerative
inflammation of the pulp may reach down the entire length of
the root or roots and begin to cause the apical PDL to
become inflamed (this is irreversible pulpitis with periapical
involvement). Now the patient may have not only a
throbbing toothache but also pressure sensitivity (to the
pressure of chewing or percussion). This stage marks a later
point in the pulpal degenerative timeline when the tooth is the
hottest and usually the most difficult to get numb. It is at
this stage that most people would come in for dental
treatment if they hadnt done so already. Radiographically,
we may not be able to see anything unusual periapically since
x-rays only show hard-tissue changes and not soft-tissue
inflammation. The PDL may look thickened once the lamina
dura has resorbed slightly.
The Calm Before the Storm

IF THE PATIENT progresses past the period of pulpal
inflammation mentioned above without root-canal
intervention, the tooth usually enters a calming period. What
this really means is that the nerves or pulp have completely
degenerated past the stage of total pulpal inflammation to
became necrotic. In this state, pain provoked or sustained by
temperature would have disappeared. Constant throbbing
pain, or the continuous dull radiating ache usually associated
with pulpal swelling or degeneration, also subsides. The
tooth may still feel sensitive to pressure, since the PDL may
still be inflamed due to the presence of the adjacent irritating
necrotic debris of the pulp. Some teeth may become
asymptomatic, especially with the help of antibiotics and bite
adjustment. However, the tooth will not respond to
temperature changes or electronic pulp testing.
This later stage of pulpal death can be view as the calm
before the storm. Because of the bacteria residing in the
necrotic pulp, the situation always has the potential to
transition toward an endodontic abscess. However, the
transition can often take months or even years, depending on
a variety of factors. Although many dentists try their best to
medicate symptomatic teeth in the hope of avoiding rootcanal treatment before restoration, the truth is that many of
these teeth tend to feel better because they have slowly
arrived at this transitional stage of pulpal death.
The sedative dressing or temporary filling usually acts as a
nerve blocker (as eugenol does, for example) and is effective
as a topical pain medication. Unfortunately, the medication
does little to reverse the degenerative inflammatory process
that has already begun; pulpal recovery from acute
inflammation usually is more dependent on the degree of
tissue damage sustained and whether the damage is in
conjunction with a bacterial presence. Radiographic evidence
may appear within normal limits. However, if teeth stay in
this stage for a sustained period of time, the bone around the
root apex may resorb in the effort to limit the antigenic
irritation from the dead pulp. Periapical radiolucency is then
seen from a periapical film of the tooth. Sometimes, if the
cortical bone adjacent to the radiolucency is lost, a fistula
may develop from the area of inflammation or infection that
can be seen clinically as a stoma. Its formation is usually a
pain-free event, but the situation could become painful if the
stoma became clogged or impacted.
When a tooth develops an endodontic abscess from the
transition period of pulpal death, pressure pain slowly
becomes more and more pronounced. The tooth may even
become mobile. An infrequent or continuous ache can also
arise, not from the swelling of the pulp (which is already
dead) but from a swollen periodontal ligament or from a
buildup of pressure surrounding the periapical tissues of the
tooth. Edema, with a subsequent buildup of pus, usually
creates pressure that translates into pain. Swelling or
tenderness is usually seen intraorally adjacent to the root
apexes. If the infection is not allowed to drain (via a pulpal
opening, fistula, or an incision), extraoral swelling and
lymph node involvement may develop as the abscess spreads
beyond the local confines of the periapical area and into the
facial planes. Radiographically, a noticeable radiolucency
can usually be seen beneath the abscessed tooth.
From this short discussion of pulpal deterioration, you can
see that the process is a continuous and dynamic one. As
dentists we are usually presented with a snapshot of the
state of the pulp in time. This basic understanding of the
tooths pulp has given me more assurance in my endodontic
diagnosis. Although there are always some exceptions, the
symptoms that a patient presents with usually must fall into
the pulpal timeline discussed above if root-canal treatment is
to be helpful or meaningful. In the end, the root-canal
treatment only accomplishes the removal of the inflamed,
degenerative, or dead pulpal tissues from the toothand by
doing so removes the source of pulpal pain or limits the
potential for future ligamental inflammation and periapical
bone destruction.
ENDO TIP
Always check to see if there is

more than one canal in a lower
bicuspid. See the before and after
X-rays below. This tooth has
three canals.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
Figure 1
BEFORE
Figure 2
AFTER
Perforation Revisited
Jay Vuong, D.D.S.
Jay Vuong
Jay Vuong
DENTIST WHO creates a perforation in the process of Ultimately, success

performing a root-canal procedure may benefit from
depends on the
knowing the factors that influence success and failure
amount of bacterial
after a repair of the perforation.
Problems arising from perforations can ultimately be seen
contamination still
as problems associated with loss of attachment and
present beneath
destruction of bone in the area adjacent to the defect. Loss
the perforation
of structural support as a result of large perforations should
repair and the
also be a consideration. Coronal perforations in unattached
tooth surfaces (that is, coronal to the periodontal attachment)
potential of the
can be viewed as deep restorative areas, which, once
repair material to
repaired, have the potential for sulcular irritation unlike deep
seal against future
restorative margins. Considered in this light, perforations of
bacterial
this type can be repaired with a suitable restoration material
to support the remaining tooth structure and to reduce
contamination.
irregular margins, paying close attention to the strength of the
material and its ease of manipulation.
The perforations that require endodontic attention are the
ones that occur in areas adjacent to existing periodontal
attachment, which often includes the PDL and its associated
lamina dura. This type of perforation, if located near the
sulcus of the tooth, can be seen as a periodontal threat. If the
attachment in this area does not repair and the loss migrates
to join into the sulcular space, periodontal pocketing can
result. Problems that occur with this periodontal situation
then must be alleviated in a periodontal manner. If the
perforation occurs more deeply (for example, in strip
perforation of a canal), the attachment loss may create a
chronic potential for inflammation or infection. Not unlike
granulomas at the bottom of chronically inflamed root
apexes, the granulation tissue that may form in areas adjacent
to failed perforation repairs has a potential to cause pressure
discomfort and to progress to abcessing. In this situation, the
perforation initially lacks a communication with the sulcus
and may progress to eventually become a periodontal
problem if the inflammatory process establishes a
communication.
In light of the above discussion, the aim of perforation
repair should focus on repair of the attachment apparatus
using the appropriate endodontic or periodontic measure or
both. Eliminating (or reducing) bacteria at the site of the
perforation during the time of repair and in the future should
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/jv06perforation.html[2/21/2011 10:26:04 ]
be a priority. In choosing a reparative material, you should

consider
Biocompatibility: The chosen material should decrease
chronic inflammatory response, promote epithelial or
fibrous attachment, or both.
Stability: The material should be structurally stable
over time.
Strength: It should have sufficient tensile and
compressive strength if the perforation has substantially
weakened tooth support.
Sealing ability: It should seal well enough to decrease
future bacterial contamination.
Handling characteristics: It should be easy to use.
Allowing for a learning curve, the techniques for use of most
repair materials can be mastered with practice and an
attention to detail.
No matter who does a perforation repair (generalist or
specialist), success usually depends on timing, size, location,
and disinfection.
Timing involves repairing the perforation ASAP if
possible. Delayed repairs require more difficult disinfection.
A perforation that is larger or located near but beneath the
cervical attachment has a worse prognosis than a smaller
perforation located apically in the canal (away from the
sulcus). The larger the area of attachment loss and bony
damage, the more difficult disinfecting, sealing, and
regenerating will be. Also, the closer the defect is to the
sulcus, the less chance there is for a successful repair due to
the future ingress of bacteria from the pocket space. A
periodontal problem will result. Disinfection of the
perforation usually demands good isolation and the use of
disinfectants (such as NaOCl).
Ultimately, success depends on the amount of bacterial
contamination still present beneath the perforation repair and
the potential of the repair material to seal against future
bacterial contamination. Controlling those circumstances
becomes more difficult as perforation size increases.
Location plays a role in that the sulcus provides an additional
source of bacterial ingression that impedes attachment
formation.
February -March 2003
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/jv06perforation.html[2/21/2011 10:26:04 ]
Let's Talk Phones!
Michelle Verdi, Experdent Consultant
Lets Talk Phones!

would like to discuss the importance of the
telephone in making a good first impression
on patients. To begin, ask yourself the
following questions:
When your phone rings, do you know how
it is being answered?
Does your staff have the proper training to
represent your practice?
When patients (or potential patients) call your
office, they make judgments about you and your
practice based on what they hear over the
phone. They do not see the office decor, they
may not have met you, and if they are new
patients, they do not know the quality of your
care. You are relying on the verbal skills of your
receptionist to convey an image of your
practice.
Why dedicate an article to telephone skills? It
is a fact that despite the telephones widespread
use, it is often a misused communication tool. I
am sure that you have had many frustrating
business calls because of a poorly trained or
ineffectual person on the other end. I have
witnessed telephone communications go
hopelessly wrong, and I believe that telephone
etiquette is an acquired skill.
The proliferation of electronic devices, such as
answering machines and cell phones, is part of
the contemporary style of telecommunications.
The irony is that the more accessible we have
become through technology, the more
communication has become a one-way
dialogue. The practice of using answering
machines when an office is closed can be
positive or negative. If you use an answering
machine, be sure that your message includes
practice hours
emergency contact procedures
when the office will reopen
ENDO TIP
Have you ever opened the

chamber of a pulp and
experienced a fetid odor? I
have. Using a mouthwash in
a syringe to irrigate the pulp
canal works to eliminate that
odor. Many times I'll leave
the rinse inside the chamber
for a few minutes. Afterwards,
I'll rinse with sodium
hypochloride. Then the odor
will dissipate. Patients who
smelled the initial odor feel
terrific, for there is no longer
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/mv01letstalkphones.html[2/21/2011 10:26:05 ]
Let's Talk Phones!
If you leave a pager number, be sure that it

works!
Never just leave the traditional answeringmachine message that says, No one can take
your call at this time. Please leave a message at
the tone. This is possibly the most irritating
form of answering-machine abuse for a potential
patient or an existing patient to hear.
If you use an answering machine during lunch
breaks or meetings, include that fact in your
message, and also let callers know when to call
back or when to expect a call back from you.
Voice mail can also be an effective means of
communicating. Patients can be offered options,
such as
an odor. Furthermore, they

feel that you, as a practitioner,
have "really" done something
for them. I hope you have as
much success with this
technique and patients'
acceptance of it as I have.
Amy Dukoff, D.M.D.
scheduling appointments
general practice information
leave messages for individual doctors
A system that handles overflow can also be
used to prevent the caller from hearing
Doctors-office-please-hold as soon as the
calll is answered, something that is a common
phrase in busy offices.
If you use a voice mail system, be sure that to
check the messages and respond as soon as
possible. I cannot tell you how often I hear
complaints from patients who did not get a call
back or were lost in the system.
11/02/99
FEEDBACK?
Endo-Mail.
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/mv01letstalkphones.html[2/21/2011 10:26:05 ]
Post-Operative Pain Management
Young Bui, D.D.S.

Young Bui
Young Bui
PRIMARY PURPOSE for performing a root canal

procedure is to relieve the patient of dental pain.
Unfortunately, certain aspects of the root canal
procedure sometimes introduce post-operative pain in the
same tooth that we are trying to repair.
The most common type of post-operative pain is
hyperocclusal pain. Fortunately, this is also the easiest type
of post-operative pain to prevent. Before initiating the
procedure, reduce the occlusion on the suspected tooth at
least 2 mm or completely out of occlusion. This reduction of
the occlusion is very important if the tooth is a vital one or if
the patient has positive percussion pain at the start. If that
tooth is not going to be restored by a crown, then perform the
root canal procedure and reduce the hyperoccluded area,
using space occlusal paper to minimize tooth removal.
Another post-operative pain that can be prevented is
caused by stripping or perforating the apical constriction
upon instrumentation of the canal. By using an apex locator,
you can easily detect the anatomic apex and not perforate
through it. In a vital tooth, perforating the constriction will
Unfortunately,
cause trauma and inflammation to the periodontal ligament.
certain
aspects of
In a non-vital tooth, perforating the constriction will make it
the
root
canal
more likely that you will accidentally push the debris through
procedure
the apex and cause post-operative flare-ups.
sometimes
A related type of pain is caused by excreting cement or
introduce postgutta-percha through the apex upon filling. If you use the
operative pain in
SET method along with the SafeSider files, you can
the same tooth
develop a greater-taper canal. The taper will prevent the
that we are trying
gutta-percha from extending past the apex upon lateral
to repair.
condensation. If you then use the EZ-Fill method of coating
the wall with cement, you will prevent cement from excreting
out of the apex and thus prevent irritation of the apical
tissues.
No matter how good your technique is, there will always
be inflammation of the periodontal ligament from any root
canal treatment because the tooth is constantly being
disturbed in the socket during instrumentation of the canal.
This movement of the tooth puts a lot of tension and stress on
the periodontal ligament, causing it to become inflamed.
Many of us prescribe analgesic medication for postoperative pain, but we tend to forget about the inflammation.
Analgesics will provide comfort to the patient, but they will
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb01postoppain.html[2/21/2011 10:26:05 ]
not reduce the inflammation caused by instrumentation. This

inflammation can be managed with anti-inflammatory
medications, such as ibuprofen. Six hundred mg of
ibuprofen together with 1 g of acetaminophen will provide
both analgesia and anti-inflammation for up to eight hours.
This dosage is both economical and effective.
May-June 2001
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb01postoppain.html[2/21/2011 10:26:05 ]
Who Should Be Given Antibiotic Prophylaxis?
Young Bui, D.D.S.

Young Bui
Young Bui
EFORE TREATING patients, we should always take a

good medical history. Always go over the questions
with the patients to make certain that they understand
the technical terms. Be sure to ask whether they have had a
disease or medical problem that is not listed on the history
form. Investigate further about systemic diseases that they
mark and ask what medications they are taking. Certain
patients will need to be pre-medicated before treatment to
prevent systemic bacterial endocarditis (SBE).
Endocarditis occurs when bacteria enter the bloodstream
and infect damaged endocardium or endothelial tissue located
near high-flow shunts. The dentists goal is to prevent
endocarditis from occurring in susceptible dental patients.
Any dental procedure that causes injury to the soft tissue or
bone, resulting in bleeding, can produce a transient
bacteremia. Below is a list of the frequency of bacteremia
associated with various dental procedures and oral
manipulations based on Bender in 1984 and Pallasch in 1989.
Periodontal surgery
Extractions
Periodontal scaling
Chewing
Dental prophylaxis
Toothbrushing
Endodontic therapy (non-vital)
88 %
51-85 %
8-80 %
17-51 %
0-40 %
0-40 %
0%
Consider antibiotic prophylaxis (AP) for dental work to

minimize effects of bacteremia. Besides the usual heart
conditions that require AP, such as rheumatic fever, heart
murmur, mitral valve prolapse with regurgitation, and
congenital heart disease, many other conditions that require
prophylaxis may be overlooked. One example is HIV. We
seldom ask patients if they are HIV+ because we dont want
to embarrass patients or because we take universal
precautions against HIV. Not asking may be harmful to the
patient. A patient who contracted HIV from sharing needles
is very likely to have had SBE previously, due to injecting
bacteria directly into the bloodstream. Infective endocarditis
must be prevented in these patients. AP is best avoided in
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb02antipro.html[2/21/2011 10:26:06 ]
AIDS patients unless severe neutropenia is present (<500

cells per mm3). Under those conditions, the patient will
require antibiotic prophylaxis.
Patients who had surgically corrected cardiovascular
lesions should be given AP up to six months postoperatively.
Six months after surgery, most patients are no longer
susceptible unless foreign material was used or if they have
artificial heart valves. AP is required in patients with the
latter two conditions. In patients with pacemakers, a medical
consultation is needed to determine whether AP is necessary.
It is not recommended by AHA, but some physicians may
suggest it. Patients on hemodialysis should be off the dialysis
machine for at least four hours before a dental procedure
because of heparin, and AP should be considered. In patients
with joint prosthesis, AP is not necessary unless they are in
the high risk category, such as those with rheumatoid
arthritis, diabetes, immuno-suppressed conditions, or
previous infection.
The following bleeding disorders may cause the patient to
have post-operative infection and therefore AP should be
considered in surgical cases: thrombocytopenia, systemic
lupus erythematosus, vascular wall alterations, hemophilia,
von Willebrands disease, liver disease, and leukemia.
July-August 2001
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb02antipro.html[2/21/2011 10:26:06 ]
One-Visit Root-Canal Treatment
Young Bui, D.D.S.

Young Bui
Young Bui
S TECHNOLOGY in dentistry advances, we approach We can reduce

our treatment techniques in different manners. We
the number of
continue to strive for perfection while speeding up
visits and still
chair-time and reducing overhead costs. This methodology
applies to all specialties in dentistry including endodontics.
maintain a high
The fundamentals of endodontics remain the same. The only rate of success.
difference is the process by which we attain our goals. With
the many different hand files and mechanical systems in the
market today, we can reduce the number of visits for our
patients and still maintain a high rate of success. Root-canal
treatment usually required more than one visit in the past
because of the difficulty in cleaning and shaping curved and
calcified canals and the low success rate of non-vital or
necrotic cases.
Most root canal systems are straight and patent enough for
a size 15 file to fit down to the apex with ease. However,
there are cases where the root is severely curved or
dilacerated, and some canals are tight due to calcification.
To engage into such canals, we need a file that has great
tensile strength to resist deformation, flexibility to negotiate
the curves, and is thin enough to fit into such tight space.
Upon finding a tight canal, we automatically pull out the size
8 or 10 files either in Hedstrom, K-type, or reamers. The
problem with these files is that they have weak tensile
strength. They tend to bend or buckle at the tip when a little
pressure is applied. They do not have the strength to
withstand the force exerted upon them as you try to push
them down the tight canal. I love to use Hedstrom files, but
what I found to be a great file for a tight or partially calcified
canal is the EZ-Fill SafeSider size 10 file. This file can
negotiate a tight canal with ease and has the tensile strength
to withstand deformation. If you have not tried this type of
file in a situation like this, I would recommend it highly. I
used to be a strong proponent of Hedstrom files until I tried
out the SafeSider files.
The success or outcome of a root-canal treatment depends
on the ability to remove all infected pulp tissues and then seal
the canal completely with gutta-percha and sealers. In order
to have a tight, dense fill we must first clean and shape the
canals to fit the gutta-percha point. Most of the landmark
studies use a .02 tapered file to clean and shape the canals.
With a .02 file, you are not able to clean out the infected wall
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb03onevisit.html[2/21/2011 10:26:06 ]
of a necrotic canal successfully. Studies show that the

cleaning and shaping procedures do not remove all the
bacteria from necrotic root canals. Removing all the bacteria
requires the use of Ca(OH)2 in the canal as an inter-visit
medicament to aid in sterilizing the canal system; thus, the
patient is required to make a second visit.
However, there is another way. By using the new nickeltitanium greater-tapered files of .06 to .08, you can remove
more infected dentinal wall of the root canal system and
create a nice tapered canal wall to fit the greater tapered
gutta-percha cone. Another instrument you can use is the #2
Peeso reamer. It can reduce your cleaning and shaping time
significantly. Once you have cleaned and shaped the canal to
a .06 or .08 tapered, use EDTA to remove the smeared layer
against the wall. Then irrigate the canal with full strength
NaOCl and clean the wall with an ultrasonic tip. The
vibration will allow you to kill the bacteria embedded .5 mm
into the dentinal tubules. By shaping the wall to a .06 or .08
tapered and then using the ultrasonic tip, you eliminate
bacteria that are embedded at least 1 mm into the dentinal
wall. This will ensure a clean canal and eliminate the use of
Ca(OH)2 in between visits. By the way, Ca(OH)2 does not
kill enterococci such as E. feacalis. Potassium-iodine can kill
all bacteria in the canal in seconds. That is one alternative
irrigating solution you can use. Just be careful not to get it
on the patients clothing.
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb03onevisit.html[2/21/2011 10:26:06 ]
MTA: An Excellent Concrete Material
Young Bui, D.D.S.

Young Bui
Young Bui
Figure 1
TA, mineral trioxide aggregate, is a new material
developed for endodontics use. MTA appears to be a
significant improvement over other materials for procedures
in bone. Unlike ZOE cement, amalgam, and resin composite,
which resulted in the formation of fibrous connective tissue
adjacent to the bone, MTA allows osteoblasts to attach and
spread on it with little or no tissue inflammation. It is the
first restorative material that consistently allows for the
overgrowth of cementum. Schwartz et al (July 1999) showed
that root ends filled with MTA had a complete layer of
cementum over the filling. Comparing gap sizes between the
root-end filling materials and their surrounding dentin shows
that MTA had better adaptation compared with amalgam,
Super-EBA, and IRM. This improved adaptation allows
MTA to provide a better seal when used as retrograde filling.
showing a non-vital open
Keiser et al (May 2000) compare the cytotoxicity of MTA

apex before sealing.
to other commonly used retrofilling materials, Super-EBA
and amalgam. In the freshly mixed state, the sequence of
toxicity was amalgam > Super-EBA > MTA. In the twentyfour-hour set state, the sequence of toxicity at a low extract
Figure 2
concentration was Super-EBA > MTA, amalgam, and SuperEBA > amalgam > MTA at a higher extract concentration.
Torabinejad et al (July 1998) showed the tissue reaction to
implanted MTA, amalgam, IRM, and Super-EBA in the
tibias and mandibles of guinea pigs. The tissue reaction to
MTA implantation was the most favorable observed at both
sites. In the tibia, MTA was the material most often observed
with direct bone apposition.
There are many uses for MTA in addition to its use as a
root-end filling. MTA can be used to seal perforations; it
acts as a pulp capping material; it produces apical hard tissue
formation in immature teeth; and it acts as an apical barrier
in open apex cases.
Sealing off the perforation site immediately during the
initial visit will give the best prognosis for the tooth. The
showing a non-vital open
trick for sealing mid-root strip perforation is to first clean out
apex after sealing with
the canal completely and then fill it with gutta percha and
MTA and gutta percha in a
sealer. Next, remove the gutta percha to about 2 mm below
one-visit treatment.
the perforation and irrigate out the debris. Next, mix the
MTA to a putty consistency and pack it down the canal with
either a plugger or a medium-size gutta percha. The trick to
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb04mta.html[2/21/2011 10:26:07 ]
mixing the MTA is not to have it too dry. If it is too dry, it

will fall apart on you as you try to pick it up. Use enough
water to make it into a putty so that you can pick it up easily.
MTA can be used as a pulp capping material in vital
mechanical exposure or in primary tooth pulpotomy. Ford et
al (October 1996) found that pulps capped with MTA had no
pulpal inflammation after five months in five of six samples
and all six pulps in this group had a complete dentin bridge
formation. In contrast, all the pulps capped with Ca(OH)2
showed pulpal inflammation, and bridge formation occurred
in only two samples. Eidelman, Holan, and Fuks (January
2001) did a study to compare the effect of MTA with that of
formocresol as pulp-dressing agents in pulpotomized primary
molars with carious pulp exposure. They found that none of
the MTA-treated teeth showed any clinical or radiographic
pathology at a 17-month recall.
Ca(OH)2 has been the material of choice for apexification
in vital teeth. Shabahang et al (January 1999) showed that
MTA produced apical hard tissue formation with
significantly greater consistency than Ca(OH)2 or osteogenic
protein-1. For non-vital open apex cases, MTA can be
packed down to the apex and the canal can be filled in on the
same visit. The MTA will act as an apical barrier and allow
for bone to grow around it. The radiograph in Figure 1
shows the before and after of a non-vital open apex sealed
with MTA and gutta percha in a one-visit treatment.
Im sure that you are probably saying, Wow, great stuff!
But how much will it cost me? MTA is being sold in six
one-gram packages for $249, manufactured by Tulsa
Dentsply. Holland (2001) compared the healing property of
MTA and Portland cement as a pulp-capping material and
found no difference between the two. MTA has the same
chemical properties as Portland cement except that MTA also
has bismuth to give it a more opaque look in a radiograph.
FEEDBACK?
Case Report
Young Bui, D.D.S.
Case Report
ach of the following three cases is interesting and
educational in its own way. Each has its own
uniqueness and value to our everyday treatment.
Case 1
Young Bui
A 39-year-old male was referred to our office for evaluation

of tooth #2. The x ray (Figure 1) showed the beginning of a
lucency at the apex of the mesio-buccal (MB) root. The
restoration was shallow, with plenty of dentin separating it
from the pulp. There was evidence of perio bone loss on the
distal side of the tooth. The patient complained of having
episodes of dull aching pain over a two-week period. He had
pain to percussion but not palpation. He had no sensitivity to
cold on the buccal, only on the palatal side. The first thought
that came to my mind was a fracture in the tooth. When you
have a partial non-vital tooth with a shallow restoration, more
than likely there is a fracture in the tooth somewhere that
caused the tooth to die. Upon opening up the access, I did
not find any fracture line. There was no decay underneath
the restoration. The pulp tissues in the mesio-buccal and
disto-buccal (DB) canals were non-vital. The palatal (P) root
had the entire pulp tissue still intact and vital. My interesting
finding occurred when I was taking the working length
measurement with the apex locator. Both the MB and P roots
were 22 mm long. The reading for the DB root, however,
was at 16 mm. I verified it with an x-ray film. Apparently,
the DB root ended just above the level of the bone. Bacteria
in the saliva must have contaminated the canal, causing
retrograde necrosis of the DB root, which in turn infected the
MB root. You can truly appreciate my finding in the final x
ray (Figure 2).
Figure 1
Figure 2
FIGURE 1: showing the beginning of FIGURE 2: showing the DB

a lucency at the apex of the mesio- root ending just above the
buccal (MB) root.
level of the bone.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb05casereport.html[2/21/2011 10:26:07 ]
Case Report
Case 2
An African-American male in his 30s was referred for RCT
on tooth #29. The patient was asymptomatic. The pulp was
exposed upon excavation by the general dentist. The x ray
(Figure 3) shows two distinct roots on this tooth which in
itself is pretty rare. Upon instrumentation of the buccal canal,
I was able to locate another canal about 3-4 mm apically
from the buccal orifice. This is normally the case with
multiple-root bicuspids. I have done three maxillary
bicuspids with three roots. In all of the cases, the third canal
was located in the buccal root about 2-3 mm apically from
the orifice. Filling such a root is a little challenging. First,
coat the walls of all the canals with RC cement. The next
step is to fill the third canal first. Then sear it off and remove
the gutta percha down to the opening of the third canal,
exposing the main buccal canal. Now you will have an
unobstructive path to fill the main buccal canal and the
palatal or lingual canal. You can see the two canals
bifurcated almost one-third of the way down the root in
Figure 4.
Figure 3
Figure 4
FIGURE 3: showing two

FIGURE 4: showing the two canals
distinct roots on tooth #29. bifurcated almost one-third of the way
down the root.
Case 3
A 38-year-old female presented to the office with constant
throbbing pain in her lower left jaw. Tooth #18 had had
RCT done a year ago. She had pain to percussion and
palpation. The x ray (Figure 5) showed perio breakdown in
the furcation and periapical lucency on the MB root. The
tooth had a ++ mobility. When I saw the perio breakdown in
the furcation, the first thing that came to my mind was a strip
perforation. It could also possibly have been a lateral canal,
but in this case the gutta percha was situated too close to the
furcation, indicating a possible strip perforation. I proceeded
to remove the old gutta percha and cleaned both roots. When
I went in to dry the MB canal, I noticed some blotches of
blood on the paper point, confirming the strip perforation
diagnosis. I did not know where the perforation was located
along the root so I decided to fill the entire canal with MTA.
(See MTA: An Excellent Concrete Material.) By plugging
and laterally spreading the MTA, I was able to force the
MTA against the wall and out of the perforation site. I than
Case Report
went down the canal with the brown EZ-Fill SafeSider

file (25/.08 taper) to make a canal space for the gutta percha.
Finally, I filled the canal up with gutta percha and EZ-Fill
cement. You can see the puff of MTA extruding into the
furcation through the perforation site in Figure 6. It will
allow bone to grow around it without causing any
inflammation. You can see the furcation beginning to heal up
in the 3-month follow-up x ray (Figure 7). The tooth is
asymptomatic and the mobility has disappeared.
Figure 5
Figure 6
FIGURE 5: showing perio

breakdown in the furcation and
periapical lucency on the MB
root.
FIGURE 6: showing the puff of

MTA extruding into the furcation
through the perforation site.
Figure 7
FIGURE 7: the 3-month followup x ray.
May-June 2002
FEEDBACK?
Root Fractures
Young Bui, D.D.S.
Root Fractures
Young Bui
Figure 2
OOT FRACTURES occur in fewer than 8 percent of
traumatic injuries to permanent teeth. When they do occur,
hemorrhage from the pulp and periodontal ligament (PDL) flows
into the fracture site and clots. The fractured surfaces of dentin
and cementum are gradually remodeled by surface resorption
and apposition of calcific tissue. Root fractures heal differently
depending on the degree of separation of the fragments, the
severity of injury, and the ability of the pulp to heal. the
differences in healing may take any of the following forms.
Calcific healing is a form of healing in which a calcific
callus is formed at the fracture site on the root surface and inside
the canal wall. This type of healing requires a wide canal with
the fragments in close apposition with little or no mobility. The
pulp will be vital and the tooth will have little or no mobility.
Connective tissue healing is a form of healing in which a
fibrous attachment similar to PDL develops between the
fractured fragments. This results when the fragments are
FIGURE 2: Calcific callus
separated farther apart or because some mobility is present. The formation of the root in an
pulp will be vital and the tooth will have little mobility. The
extracted tooth.
connective tissue will appear as a fracture line on the radiograph.
Combined bone and connective tissue healing is healing in
which new bone may grow between the fractured segments if
Figure 3
further separation occurs or there is mobility of the parts. The
fractured surfaces are lined with cementum with new PDL
growing between the tooth and the new bone. The pulp is vital.
Healing with nonunion and granulation tissue formation is
a form of healing that occurs when the pulp is injured or
infected and becomes necrotic due to narrow root-canal space,
contamination of the pulp by oral fluids, or severe dislocation of
the fractured root. The pulp tissue in the incisal segment
undergoes necrosis and the apical segment will remain vital.
The tooth will be loose and sensitive to percussion, and it may
turn dark.
treatment on the coronal
segment of a tooth with a
horizontal fracture.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb06rootfractures.html[2/21/2011 10:26:08 ]
Root Fractures
Figure 1
FIGURE 1: Different forms of healing: A, Calcific callus; B,

Connective tissue; C, Combination of bone and connective tissue;
D, Nonunion and granulation tissue formation
With most root fracture maintaining vitality of the pulp, the

main goal of treatment is to enhance this healing process. The
clinician should try to reunite the fractured segments by calcific
callus formation because the tooth will be stronger than one
without the union of broken parts. The fracture should be
reduced as soon as possible and the broken tooth firmly
immobilized by splinting or bonding to adjacent teeth.
There are two types of root fracture:
fracture without communication with the oral cavity
fracture with oral communication
The noncommunicating fracture occurs in the apical or middle
third of the root. Perform a vitality test, check for color change
in the crown, and record the degree of mobility of each
traumatized tooth. If the pulp is vital, then immobilize the tooth
by splinting it to the adjacent teeth. A radiograph should be
taken after repositioning to confirm realignment. The length of
time to leave the splint on ranges from one week to three months
or more, depending on the degree of mobility and the location of
the fracture. There is no need to splint the tooth if the fracture is
in the apical third with little displacement or mobility. If the
fracture is at the crest of the alveolar bone with modest
displacement and mobility, the splint will have to stay for three
months or more.
When the splint is removed, the clinical status of the tooth
must be determined. The degree of mobility, color of the crown,
and vitality of the pulp should be recorded. If the periodontal
attachment has failed to heal, the prognosis for healing decreases
drastically. If the tooth responds as normal to a pulp test with
little or no mobility and the patient is comfortable, then there is
nothing more to do but follow up in six months and a year after
that. If mobility is present, the splint must be reapplied and the
occlusion adjusted. The tooth should be splinted permanently to
the adjacent teeth if mobility is present after six months.
If the fracture of any part of the root is coronal to the
periodontal attachment, the prognosis for healing is poor. There
is periodontal breakdown along the fracture line with pulpal
necrosis from the bacterial contamination through the fracture.
The most common type of fracture is seen in the maxillary
Root Fractures
incisor with the fracture on the labial surface 2-3 mm

supragingival but tapering obliquely to 2-5 mm subgingivally on
the lingual. This type of fracture can occur with premolar and
molar cusps. The fractured part should be removed during the
emergency visit, and endodontic treatment should be done in
one visit. Once the emergency has been taken care of, plans
must be made for restoring the tooth.
FEEDBACK?
Please feel free to visit the Endo Forum and add your comments
about any of the articles in Endo-Mail.
Endodontic-Periodontal Relations
Young Bui, D.D.S.
Young Bui
HE HEALTH of the periodontium is important to the

proper function of a tooth. The periodontium includes
the gingiva, cementum, periodontal ligament (PDL), and
alveolar bone. Disease that affects the periodontium usually
is a result of the direct extension of pulpal disease or due to
apical progression of periodontal disease.
When the pulp becomes infected, the disease can progress
beyond the apical foramen and inflame the PDL. The
inflammatory process results in replacement of the
periodontal ligament by inflammatory tissue. Without proper
treatment, the inflammatory response can cause resorption of
the alveolar bone, cementum, and dentin.
Besides going through the apical foramen, pulpal disease
can progress through lateral canals. Lateral canals are seen
mostly in the apical third of the root and in the furcation area
of molars. Pulp disease may cause an inflammatory response
of the PDL at the opening of lateral canals, resulting in a
lateral radiolucency on the root. The inflammatory response
at the lateral canals may extend crestally along the lateral
aspects of the root and ultimately involve the furcation or
crestal area of the attachment apparatus.
The effect of periodontal disease on the pulp is not as
clear-cut as the effect of pulpal disease on the periodontium.
Periodontal inflammation may exert a direct effect on the
pulp through the same lateral canal or apical foramen
pathways. The effect of gingival wounds on the pulp is
shown in irregular dentin formation in the pulp opposite the
wound site. This might be transmitted through irritation of
the odontoblastic process. This irregular dentin formation
may be aided by cemental resorption in periodontal
inflammation.
There are five types of endo-perio lesion that may occur at
any given time. We have to be able to diagnose the lesion
properly in order to provide the proper treatment.
Figure 1
and periodontal diseases
are occurring
independently of each
other.
Figure 2
disease is occurring
secondarily to a
periodontal condition due
to bacterial retrograde from
distal root.
Figure 3
Primary Endodontic Lesions

A sinus tract originating from the apex or a lateral canal may
form along the root surface and exit through the gingival
sulcus. This is a fistula that drains along the PDL into the
sulcus instead of exiting through the buccal or lingual
mucosa. This is not a true periodontal pocket. You may see
FIGURE 3: Periodontal
disease at the furcation is
occurring secondarily to a
pinpoint perforation at the
furcation floor.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb07endoperio.html[2/21/2011 10:26:09 ]
drainage in the sulcus area or swelling simulating a

periodontal abscess. The tract can be traced to the source of
the infection, usually the apex or lateral canal. This tract is
more tubular and thinner than an infra-bony periodontal
pocket. Because this lesion is an endodontic problem,
complete resolution usually occurs after routine endodontic
treatment.
Primary Endodontic Lesions with Secondary

Periodontal Involvement
If the primary lesion is left untreated, it may progress to
involve periodontal disease. An example would be plaque
formation appearing at the tract opening that was followed by
calculus formation resulting in gingivitis and periodontitis.
Once this result has occurred, both endodontic and
periodontic therapy will be needed.
Primary Periodontal Lesions

Periodontal disease may progress and spread along the lateral
aspects of roots and in the furcation areas. In periodontal
disease, vitality testing will reveal a normal pulpal response.
Periodontal examination will reveal pocket depths and
accumulation of plaque and calculus. The bony lesion is
usually more widespread and generalized than are lesions of
endodontic origin. Periodontal therapy is needed for this
situation.
Primary Periodontal Lesions with Secondary

Endodontic Involvement
Periodontal disease may have an effect on the pulp through
dentinal tubules, lateral canals, or retrograde from the apex.
If the tooth does not respond to periodontal treatment, a
necrotic pulp may be the cause. Once the pulp becomes
secondarily inflamed, it can in turn affect the primary
periodontal lesion. Scaling, curettage, and flap procedures
may open lateral canals or dentinal tubules to the oral
environment resulting in pulpal inflammation leading to
necrosis. This is likely to be the case when a patient
complains of tooth sensitivity or inflammation after a routine
scaling and root planing. If a root is exposed as a result of
severe periodontal disease, the exposure may allow bacteria
to enter through the apex and cause a retrograde necrosis. In
a situation such as that, both endodontic and periodontal
therapy are
required.
True Combined Lesions

Some teeth have both pulpal and periodontal disease
occurring independently. Each of these diseases may
progress until the lesions unite to produce a radiographic and
clinical picture similar to that of other lesions with secondary

involvement. Once the endodontic and periodontal lesions
join, they may be indistinguishable from endodontic and
periodontal lesions that are secondarily involved.
WITH ALL THIS IN MIND, always do a complete exam and
vitality test on a tooth. Together with a good radiograph,
these are the diagnostic essentials youll need before
performing endodontic treatment. An abscess can be of
endodontic or periodontal origin. A root-canal treatment on a
periodontally abscessed tooth will not resolve the problem.
FEEDBACK?
Anatomy of Multiple Canals and Roots
Young Bui, D.D.S.
Young Bui
E WERE TAUGHT in dental school the very basic

knowledge of root anatomy and the average number
of canals in certain teeth. This knowledge gives us
the basis to perform root-canal treatment. However, there are
times when we stumble upon a unique case with an extra root
or extra disto-buccal (DB) or extra palatal (P) canal. These
cases may not be too confusing if the canal is wide open and
is easily engaged with a file. Unfortunately, in some cases
the extra canal is located far from the other opening and is
partially calcified. We may not try to gain access into the
extra canal because we may think that it is just a dimple in
the floor of the tooth or because it is not at a normal
location for a canal.
The number one reason for failure of upper first and
second molars is not cleaning the second mesio-buccal
(MB2) canal. You should always check to see if there is a
little dimple or catch in the isthmus running from the MB
canal to the P canal. Dental textbooks say that MB2 occurs
in half of all upper molars. In my years of practice, I have
encountered MB2s in 75 to 80 percent. I tend to get nervous
when I can only find one canal in the MB root. Always
assume that there are two canals until careful examination
proves otherwise. If the two orifices are close to each other,
the two canals are more than likely to join at the apex. If you
have a second canal midway between the MB and P canal,
then you will probably have two separate apexes.
Figure 1 shows an upper first molar with three individual
MB canals and two palatals. There are also two DB canals,
but there was no more room to place in another file. The
three MB and P canals have separate apexes and the DB
canal joins together at the apex.
An upper first premolar usually has two canals with two
separate apexes, and an upper second premolar has one or
two openings ending in one apex. There are unique cases in
which you will find three canals or three individual roots in
an upper premolar. Sometimes the third canal is located right
next to the buccal canal. At other times, the third canal is
located a couple of millimeters below the buccal orifice. If
an inserted file is angulated toward either the mesial or distal
direction, that is a good indication of a third canal. You will
see this angulation when the two orifices are situated really
close together. If you have a large buccal orifice, but the file
Figure 1
FIGURE 1: Upper left first

molar with files showing
three individual mesial
canals.
Figure 2
FIGURE 2: Upper right

second bicuspid with three
roots.
Figure 3
FIGURE 3: Upper left

roots.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb08multiples.html[2/21/2011 10:26:09 ]
Figure 3
feels tight as it is being inserted, there is probably a third

canal situated a couple of millimeters below the orifice to the
FIGURE 4: Lower right
side. Widen the orifice with a slow speed #2 round bur and
examine for a second buccal canal.
roots.
Figure 2 shows an upper right second bicuspid with three
individual roots and canals. The two buccal canals are
situated side-by-side close to each other. Figure 3 shows an Figure 3
upper left second bicuspid with three individual roots and
canals. The second buccal canal is located a couple of
millimeters below the buccal orifice.
The frequency of occurrence of two canals in a lower first
bicuspid is about 24 percent, and it is 2.5 percent for the
second bicuspid, depending on the studies or textbooks you
read. The percentage for three canals or roots is given as
about 1 percent or less. I have been very fortunate, or maybe FIGURE 5: Lower right first
bicuspid with three
unfortunate at the same time, to have performed root canals
individual canals.
on these two rare anatomies. When you see on an x-ray that
the tooth does not have a clear, straight canal, start searching
for extra canals.
Figure 4 shows a lower right second premolar with three
individual roots. The third canal is located about 3 mm deep
into the buccal orifice. Figure 5 shows a lower right first
premolar with three individual canals.
When a patient has a tooth with a great-looking root canal
that does not seem to heal, there is probably another canal
somewhere that is causing the problem. Try to angle the xray and see if you can locate another canal.
February-March 2003
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb08multiples.html[2/21/2011 10:26:09 ]
Osteomyelitis of the Jaws
Young Bui, D.D.S.

34-YEAR-OLD African-American female presented
to our office on a Sunday morning with severe tooth
pain that had been keeping her up all night. She had
no significant illness. However, she was allergic to penicillin,
aspirin, and codeine. She had undergone root-canal treatment
before with no adverse reaction.
Young Bui
Dental History
She had gone to see a general dentist regarding pain in
response to heat and cold on tooth #19, which had an existing
composite restoration. The composite was removed and the
tooth was temporized to see whether the symptom would
subside. She came back with acute pain on #19 and her
dentist initiated root-canal treatment. She had one or two
days of comfort after the RCT and then pain began again.
Her dentist re-instrumented the canals, but the pain began to
return a day or so later. She said that her dentist had gone in
and instrumented the canals again on four or five other
occasions, but the pain had never gone away. The pain was
sharp and severe at times with no alleviation from
painkillers. Her dentist decided to refer her to me for
evaluation and treatment of this tooth.
Oral Examination
The tooth was very tender to percussion and finger pressure.
The buccal gingival was very tender from #18 to #21, with
most tenderness at the base of #19. It felt as though an
abscess was ready to break through the cortical plate.
Radiograph
The X-ray showed no periapical radiolucency (PAR) or
thickened PDL. Number 18 had had RCT done with no
PAR. The jawbone had normal trabeculation with no
significant pathology.
Treatment
I gave two carpules of 2 percent lidocaine with 1:100K epi as
an inferior alveolar block. I isolated #19 under a rubber dam
and gained access. The canals had already been instrumented
file:///D|/...ALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb09osteomyelitis.html[2/21/2011 10:26:10 ]
to at least a .04 taper. I completed RCT in a single visit

using the EZ-Fill SafeSider technique. There was no
drainage through the tooth. I temporized the access with
cotton and zinc phosphate cement and gave the patient Bextra
10 mg as an anti-inflammatory and Clindamycin 150 mg as
an antibiotic.
She came back the next day with severe pain and
swelling. I made an incision to relieve some pressure and
prescribed Demerol 50 mg for pain. She continued to have
pain for the next couple of days, with painkillers giving only
a couple of hours of relief. She came back four days later,
and I made another incision, which drained out at least 20 cc
of purulent exudate. I referred her to an oral surgeon for
apical surgery. The surgeon didnt want to perform the
surgery until the swelling had subsided. She was in so much
pain that she had the tooth extracted against the surgeons
advice. After the extraction, she felt better for about a week,
but then the same severe pain started up again. She was
admitted to the hospital by the same oral surgeon for
examination. A CAT scan, MRI, and blood work revealed
the patient to have osteomyelitis of the jaw. Surgery was
done to remove the entire buccal plate of necrotic bone
tissue, which had spread from #18 to #22. She was managed
post-operatively with IV antibiotic consisting of Clindamycin
600 mg and Levofloxacin 500 mg. The pain has since
subsided, and she is feeling a lot better.
Osteomyelitis
The cause of osteomyelitis is associated with Staphylococcus
aureus, a skin surface bacterium. The organism is
iatrogenically introduced into the deeper tissue planes by
surgery or trauma, resulting in an infectious process that is
either localized or hematogenously metastatic or both.
However, the idea of S aureus as the primary pathogen of
tooth-bearing bone does not hold true. Acute osteomyelitis
of the jaw is usually a polymicrobial disease, with
streptococci, Bacteroides, peptostreptococci, and other
organisms involved.
Hudson (1993) wrote that Acute osteomyelitis of the jaws
may manifest itself with fever, malaise, facial cellulitis,
trismus, and significant leukocytosis. Osteomyelitis of the
jaws of a chronic nature has findings consistent with
swelling, pain, purulence, intraoral or extraoral draining
fistulae, and nonhealing bony and overlying soft tissue
wounds. Computerized tomography gives a more definitive
picture of the calcified tissue involvement, especially with
regard to disruption of the cortical plates. Diagnosis is based
on the presence of painful sequestra and suppurative areas of
tooth-bearing jaw bone unresponsive to debridement and
conservative therapy.
The goal of definitive therapy is to attenuate and eradicate
the proliferating pathogenic microorganisms and to support
healing. Pathogenic supportive debris should be removed
and vascular permeability to the infected area must be

reestablished. This will aid the host immune response in
coming into contact with the offending organisms. A typical
treatment regimen for osteomyelitis of the jaws is presented
in the table below.
Treatment Guideline for Acute or

Chronic Osteomyelitis
1. Disrupt the infectious foci.
2. Debride any foreign bodies necrotic
tissue, or sequestra.
3. Culture and identify specific pathogens
for eventual definitive antibiotic
treatment.
4. Drain and irrigate the region.
5. Begin empiric antibiotics based on Gram
stain.
6. Stabilize calcified tissue regionally.
7. Consider adjunctive treatments to enhance
microvascular reperfusion (usually
reserved for refractory forms only).
Trephination
Decortication
Vascular flaps
Hyperbaric oxygen therapy
8. Reconstruction as necessary following
resolution of the infection.
Adapted from Osteomyelitis of the Jaws: A 50-year
Perspective, J. W. Hudson, D. D. S.
May-June 2003
FEEDBACK?
Mineral Trioxide Aggregate
Young Bui, D.D.S.
Young Bui
T HAS BEEN almost two years since I first wrote about

Here is a list
the many uses of MTA (Endo-Mail, January-February
of clinical
2002). Since then, there have been many articles
situations that
published in dental journals praising the success of the
material. For those of you who did not get a chance to read
benefit from the
that article when it was first published, here it is again,
use of MTA and
expanded, and in greater depth.
the proper
MTA was developed by Dr. Torabinejad at Loma Linda
treatment for
University in 1993. It is a compound mixture of hydrophilic
tricalcium silicate, tricalcium oxide, and tricalcium aluminate
each case.
with some other oxides. An independent analysis reveals that
MTA is identical to Portland cement with the addition of
bismuthoxide. Because MTA has a pH of 12.5, some of its
biological and histological properties can be compared to
those of Ca(OH)2. The material sets in a moist environment
and has low solubility. The compressive strength of MTA is
equal to that of IRM and Super EBA but less than that of
amalgam (Nahmias and Bery).
There are clinical situations in root canal therapy that
would require the use of a product that would provide a
reliable clinical outcome and long-term prognosis. Pulp
capping, lateral root or furcation perforation, apexification,
apicoectomy, and internal and external resorption are some of
the cases that would rely on the use of such a product. An
ideal root repair material should be non-toxic, bacteriostatic,
and non-resorbable. It should also promote healing and
provide a good apical seal. Compared to other materials,
MTA shows less microleakage, less toxicity, and better
bacteriostatic effect. Histologic examination has revealed
that it has actually induced cementogenesis, and bone
deposition with minimal or absent inflammatory response.
Below is the list of clinical situations that benefit from the
use of MTA and the proper treatment for each case.
Pulp Capping
If you happened to cause a mechanical perforation,
immediately place a rubber dam over the tooth for proper
isolation. Rinse the cavity with sodium hypochlorite to
disinfect the area. You do not have to dry the area since
MTA sets in a moist environment. Mix the MTA powder
with enough sterile water to give it a putty consistency.
Apply it over the exposed pulp and remove the excess. Blot
the area dry with a cotton pellet and restore the cavity with
an amalgam or composite filling material. MTA provides a
higher incidence and faster rate of reparative dentin formation
without the pulpal inflammation that is seen when Dycal is
used.
Internal and External Root Resorption

In the case of internal root resorption, isolate the tooth and
perform RCT in the usual manner. Once the canal has been
cleaned and shaped, prepare a putty mixture of MTA and fill
the canal with it, using a plugger or gutta-percha cone. Next
insert a SafeSiders 25/.08 down the canal to spread the
cement laterally and create a new canal. Flood the canal with
EZ-Fill cement and obturate it with a single gutta-percha
cone. The MTA will provide structure and strength to the
tooth by replacing the resorbed tooth structure.
In the case of external resorption, complete the root canal
therapy for that tooth. Next raise a flap and remove the
defect on the root surface with a round bur. Mix the MTA in
the same manner as above and apply it to the root surface.
Remove the excess cement and condition the surface with
tetracycline. Graft the defect with decalcified freeze-dried
bone allograft and a calcium sulfate barrier.
Lateral Perforation and Strip Perforation

If you happened to cause a strip or lateral perforation during
instrumentation, first finish cleaning and shaping that canal.
Irrigate the canal really well with sodium hypochlorite and
dry it with a paper point. The paper point will allow you to
see where the perforation is located. If the perforation is
down at the mid to apical third, then follow the directions for
treating an internal resorption, above. The MTA will seal off
the perforation as it is spread laterally by the SafeSiders
25/.08 file and the gutta-percha cone. If the perforation is
closer to the coronal third, then fill the canal up with EZ-Fill
cement and gutta percha as usual. Next, remove the gutta
percha about 23 mm below the perforation using the Peeso
reamer. (Be careful not to perforate again!) Now mix the
MTA and fill the rest of the canal up with a plugger.
Furcation Perforation
If you create a furcal perforation while accessing the tooth,
there are two ways to repair it.
If you can finish the root canal in one visit, then do that
first. Next remove the excess gutta percha in the chamber
and soak it for 5 minutes with sodium hypochlorite. Now
mix the MTA and fill the chamber with it. Using a moist
cotton pellet, plug the MTA down into the perforation site
and remove the excess cement from the chamber. Place a
moist cotton pellet in the chamber to help with the setting of
the MTA and close the tooth up with a temporary cement of

your choice.
If you cannot do a one-visit root canal, then first seal the
perforation with the MTA mixture. Make sure that you can
locate the canal while the MTA has not set and remove the
excess material from the area. Close the tooth as above and
do the root canal the next visit.
Apexification
Vital pulp: Isolate the tooth with a rubber dam and perform a
pulpotomy procedure. Place the MTA over the pulp stump
and close the tooth with a strong temporary cement until the
apex of the tooth closes up.
Non-vital pulp: Isolate the tooth with a rubber dam and
perform root canal treatment. Once the canal has been
cleaned and shaped, irrigate it and dry it with a paper point.
Mix the MTA and plug it down to the apex of the tooth,
creating a 2 mm thickness of plug. Wait for it to set; then fill
in the canal with cement and gutta percha.
FEEDBACK?
The EZ-Fill Technique Using SafeSiders
Young Bui, D.D.S.
Young Bui
M SURE THAT many of you have tried using the EZFill technique in doing your endodontic procedures. With
every new technique there is always a learning curve. Dr.
Musikant has explained the steps in using the SafeSiders
reamers more than once in recent newsletters (and you can
download his full explanation). Do not be disheartened if
you are not able to create the perfect-looking canal. It is
okay to go back on certain size reamers to open up the canal
wide enough to get the Peeso reamer down the canal. The
SafeSiders reamers are great instruments, but their results are
only great if the dentists using them are able to adapt to
certain situations.
In this article, I will explain the different approaches to
certain root anatomy and complicated situations as they
occur. I hope that it will help you to understand the
methodology behind the technique. This understanding will
in turn make root canal treatment easier and more enjoyable.
I tend to deviate a little from the method that Dr. Musikant
teaches. You have to find a pattern that is comfortable for
you to work with. I follow the same initial sequences for
every case I encounter. I will then determine the next step
upon analyzing the situation Im in at that time. You cannot
expect the technique to work out the same way in every case.
The only thing you can expect is the end result, which is a
continuous tapered root canal filling using a single guttapercha cone.
I do mostly molars, so I will explain the steps I use in
performing the root canals. I would start out with a #6
reamer to get to the apex. I continue to instrument the canal
with a #8 and a #10 reamer until the canal feels loose. I will
then get the working length with a #15 reamer, because the
apex locator gives a better reading with a snugly fit reamer in
the canal. Once I have the proper working length, I then
proceed to instrument the canal up to #25 to the apex. The
chamber is filled with sodium hypochlorite the entire time to
aid in the cleaning process and to prevent debris impaction.
Now I will open up the canal using a #2 Gates Glidden
(GG). The GG should have no problem following the curve
of the canal because the shank is a little flexible. The width
of a #25 reamer is wide enough to allow the GG to follow.
Do not use force to push the GG into the canal. Just use a
gentle pecking motion to drive the instrument down the
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb11ezfill.html[2/21/2011 10:26:12 ]
canal. This pecking technique will prevent debris impaction.

The reason I do not go to the #2 Peeso reamer is that the
canal is not wide enough at this point to allow a smooth
cutting. You may have encountered this problem once or
twice. After I have widened the canal with the GG, I irrigate
the canal to remove the debris. I then go back with a #10
reamer to break up the debris created by the GG.
Next I use the #2 Peeso reamer (PR) to widen the canal.
The PR should cut smoothly down the canal by following the
path of the GG. Remember to lean the PR toward the wall
away from the furcation. Do not force the PR, but use a light
pecking motion. It is okay if the PR does not go far into the
canal. It is not important at this point. Remember to irrigate
the canal to remove the debris. I then re-instrument the canal
starting with the #10 reamer to #30 to the apex. The reason I
go back to #10 is to make sure the apical foramen is patent.
This is the general sequence of steps I go through with
every case. Now during these steps, certain situations arise in
which you have to deviate a little from the general sequence.
Lets say that you used the GG with a little too much force to
go down the canal and found out that you cant get back into
the canal again. You have probably caused debris impaction
in the canal. What you want to do is to make sure the
chamber is filled with sodium hypochlorite. Next, go back in
with a #10 Hedstrom and gently turn clockwise one
revolution and pull out. This procedure will help you to
remove the debris and renegotiate the canal. Do not rush and
push too hard or you will make your own canal instead.
If you used too much force with the PR and cant get back
into the canal, you have probably caused a little ledge at the
curve of the root. In that case, you would take a #15
SafeSiders reamer and bend the tip a little bit. Insert it into
the canal and gently twist it back and forth slowly until it
renegotiates the canal. Continue in the same manner up to a
#30 reamer. If the ledge is too tight for you to get the NiTi
files to engage the canal, you will have to go back in with a
Hedstrom and strip the curvature a little bit to allow the NiTi
file to engage. This procedure will take a little time, but
dont rush.
If you are working on a molar with a sharp curve like the
Figure 1
one in Figure 1, do not use the GG or PR until you have
opened up the canal to at least a #30 reamer. The reamers do
not have to reach the apex at this point as long as they go
past the curvature. Now go in with the GG slowly with a
gentle pecking motion. Dont worry if the GG doesnt go in
too far. Its not supposed to because of the sharp bend in the
root. Now irrigate the debris and make sure that the chamber
is filled with sodium hypochlorite. At this point, I make
another deviation from the general steps. Take a #10
FIGURE 1: Upper molar
Hedstrom and instrument to the apex using the technique of
with a very curved mesial
making one clockwise revolution and pulling out. This
buccal root.
technique will allow you to widen the canal and reduce the
sharp curvature at the same time. Follow this with a #15
SafeSiders reamer to open up the canal for the #15 Hedstrom
Figure 2
to engage. Continue with this SafeSiders-Hedstrom routine
until you get the #30 Hedstrom to the apex or close to it.
Remember to irrigate well after each SafeSiders-Hedstrom
set to prevent debris impaction. Now use the #2 GG, and it
should be able to go a little farther down the canal. After
that, go in with the #2 PR with a light pecking motion. Do
FIGURE 2: Upper first
premolar with a lateral
not push when you feel resistance. After all these steps are
canal filled with EZ-Fill
completed, take the orange NiTi 30/.04 and instrument the
cement.
canal to the apex with a watch-winding motion. You do not
have to get the brown NiTi 25/.08 down to the apex. You
Figure 3
just need to get it past the curvature to give a continuoustaper shape to the canal.
The most important part of the instrumentation process is
the constant contact of the sodium hypochlorite with the
canal wall. It will assist in debris removal and also in
removing pulp tissue in lateral canals and apical fenestration
as seen in Figures 2 and 3. What I normally do is to flood the FIGURE 3: Lower second
chamber with the solution and leave it there while I
molar with a distal root
instrument the canal. The bi-directional spiral will coat the
apical fenestration filled in
wall very well and force the EZ-Fill cement to fill in the
with EZ-Fill cement.
lateral canal and apical fenestration.
I hope that this article will help you in the future if you
happen to encounter such problems.
February-March 2004
FEEDBACK?
Using Concrete to Seal the Crack
Young Bui, D.D.S.
Young Bui
OW MANY TIMES have you crowned a root canal

tooth with a history of a vertical fracture and had the
patient return within a few months or a year
complaining of pain when chewing? The patient becomes
upset because he or she wasnt informed of the fracture and
because the crown and root canal were costly investments. I
have encountered many cases in which root canal therapy
was needed due to vertical fractures. The prognosis for a
vertically fractured tooth ranges from good to poor depending
on the extent of the fracture. The prognosis also depends on
the symptoms that a patient is experiencing when he or she
presents to the office for treatment.
If the fracture is down one wall but does not enter the
canal, the prognosis is good. This is just a coronal fracture
that will hold up well with a PFM crown. If the fracture
extends down the canal, then the prognosis is guarded to
poor, depending on other factors.
A thick, dark fracture line indicates that the fracture has
been there for a long time. The pulp in these canals tends to
be necrotic, and the patient has no pain when chewing. The
only reason such patients need root canal therapy is either a
radiographic finding like PAR from the infected pulp or
swelling from the infection. This type of fracture has a
guarded prognosis as long as the root canal therapy was done
well and the tooth was restored right after with a PFM
crown. The tooth may hold up for as little as six months or
longer than five years.
A tooth with a lighter fracture line indicates a recent
fracture. The pulp will still be vital, and the patient tends to
have pain when chewing. This type of fracture would have a
poor prognosis because the pressure from mastication is
spreading the fractured parts, causing the pain.
Another type of fracture with a poor prognosis is a vertical
fracture that goes down the canal, crosses the floor of the
tooth, and extends down the other canal. This through and
through fracture is always a failure.
With any type of fracture, patients should be informed of
the situation so that they can participate knowledgeably in the
decision making. Let the patient know the prognosis and see
what he or she would like to do. Some patients are willing to
try to save the tooth even if it is for one extra year. Some
prefer an extraction and an implant. If the patient wants to
file:///D|/...LTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb12usingconcrete.html[2/21/2011 10:26:12 ]
try to save the tooth, then the tooth should be crowned as

soon as possible after the root canal therapy to help hold the
tooth together.
Sometimes even when the crown is placed the tooth can
still fail if there is leakage through the fracture. In a case like
that, MTA would be needed to seal the fractured root. The
reason for the success of MTA is not really known. I know
that MTA provides a great seal in apicoectomy and also
allows for periodontal ligament (PDL) to grow on it. This
would allow for complete sealing of the fractured root and
allow new PDL to grow along the fracture line. You are
probably asking why I dont just seal the canal with MTA to
begin with and avoid having to go back in there a second
time. Well, there is no study out there that shows the success
of MTA in sealing a fractured root. Gutta percha and EZ-Fill
cement have been successful so far for me in many cases.
There is also the potential of legal exposure resulting from
the fact that it is nearly impossible to go back and retreat a
canal filled with MTA. If this case fails, the patient would
ask why you didnt use gutta percha and cement first.
The following case illustrates a failure of conventional root
canal therapy and a successful use of MTA to seal a vertical
fracture in the distal root of tooth #30. The patient presented
to the office complaining of pain in the presence of heat and
cold. The tooth was tender to percussion. She had no pain
when chewing. The x-ray showed thickened PDL at the
apexes. The tooth was a virgin tooth with a fracture line in
the distal margin of the crown. In Figure 1 you can see
thickened PDL at the apices of #30. The patient was
informed of the fracture, and she wanted to try to save the
tooth. Root canal therapy was done in one visit.
After instrumentation, the canals were filled with gutta
percha and EZ-Fill cement. (See Figure 2.) She went back
to her dentist soon after and had the tooth crowned with a
PFM crown. She came back a year and eight months later
with symptoms on #30. The x-ray (Figure 3) showed
periodontal breakdown along the distal root on the furcation
side. Apparently there was a vertical fracture along the
furcation wall that I had not noticed during the first visit. I
told the patient of the problem and informed her that the
prognosis for the tooth was poor. I gave her a choice of
either having the tooth extracted or letting me try an
experimental procedure on it using a new material. The distal
canals were cleaned completely of old gutta percha and the
canals were dried with paper points. I mixed the MTA with
lidocaine into a putty consistency and then packed it down
the two canals with gutta percha points and x-coarse paper
points. A seven-month follow-up x-ray (Figure 4) shows
complete healing of the periodontal defect along the distal
root. If this case holds up well at one-year and two-year
follow-ups, I think we will have found a new way to save
vertically fractured roots.
Figure 1
FIGURE 1: Showing
thickened PDL at the
apexes of tooth #30.
Figure 2
FIGURE 2: Showing root

canal therapy completed
and no perio destruction
along the root.
Figure 3
FIGURE 3: Showing
periodontal breakdown
along the distal root.
Figure 4
FIGURE 4: Healing of
tooth #30 with MTA in the
distal root.
Summer 2004
FEEDBACK?
Ways to Improve the End Result of Root Canal Therapy
Young Bui, D.D.S.
Ways to Improve the End Result of Root Canal

Therapy
Young Bui
HE RUBBER DAM is one of the most important

pieces of equipment in the endodontics
armamentarium. One should never perform root canal therapy
without first isolating the infected tooth with a rubber dam.
The rubber dam protects both you and the patient. Imagine
the patients accidentally swallowing a reamer. The resulting
lawsuit is one that you do not want to endure. The rubber
dam provides unobstructed access to the tooth. It prevents
saliva contamination and sodium hypochlorite spillage.
Remember to place a rubber dam over the tooth when you
are placing in a post. Many dentists do not use a rubber dam
in that procedure; without a dam, the saliva can enter and
contaminate the post space. This contamination will result in
failure of the root canal in the future.
Once you have achieved proper isolation, the next step is
to create the access opening. The best bur to use for this is
the PulpOut bur by Essential Dental Systems. This bur allows
you to create an access opening in less then two minutes
without the fear of perforating the chamber floor. The first
bur is a #4 round bur with a side of it cut flat and a stopper 7
mm away from the tip. The flat side creates a sharper cutting
edge that goes through metal with ease. The stopper prevents
you from going down too deep; thus there is no danger of
perforation. Once you get into the chamber, use the barrel
diamond with the non-cutting tip to create the straight-line
access. Having straight-line access allows you to find the
canals more easily because of better lighting in the chamber.
If the tooth has advanced caries, use a #8 slow-speed round
bur and remove the decay completely before you instrument
the canal. Leaving decay along the chamber wall will prevent
proper lighting and make locating the canals difficult. If a
wall has been destroyed by caries, remove the decay and
restore the wall temporarily with Ketac Cement. You need to
have the walls intact to hold the sodium hypochlorite during
instrumentation.
You can instrument the canals with any of several
techniques. The SafeSiders reamers have a flat side that
creates a sharp cutting edge. The flat side also makes these
reamers more flexible and less likely to bind. These qualities
allow the reamers to engage tightly curved canals better than
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb13waystoimprove.html[2/21/2011 10:26:13 ]
Ways to Improve the End Result of Root Canal Therapy
Figure 1
any other reamers in the market. If you like rotary because of

the reduction in hand fatigue, then use the NSK oscillating
handpiece with the SafeSiders reamers. Remember to flood
the chamber with sodium hypochlorite during the
instrumentation process. The sodium hypochlorite will
provide lubrication, prevent debris impaction, and disinfect
the canal walls all at the same time. Leave the solution in the
canal long enough to kill the bacteria embedded in the canal
wall and to remove tissues in the lateral canal. The most
important part of the root canal process is to remove all the
tissues in the canal. Open the canal wide enough to get
FIGURE 1: A premolar
adequate cleaning of the apical few millimeters. The number with a lateral defect at the
one reason for root canal failure is not short or long fill but
coronal third of the root
not adequately removing all the tissues impacted down at the
sealed with EZ-Fill
apex. You would be amazed at how much debris is left at the
cement.
apex of the root after a complete cleaning. The SafeSiders
Figure 2
30/.04 NiTi file is a great instrument to remove impacted
tissues. Even if you do not use SafeSiders reamers to do your
root canal treatment, invest in the 30/.04 NiTi and try it out
for tissue removal. You will be surprised at what you see.
Once instrumentation is complete, dry the canals
completely with paper points. Use the bidirectional spiral to
coat the canal wall with EZ-Fill cement. The spiral will force
the cement laterally so that it will enter any lateral canal
present. Use a single gutta-percha cone to fill the canal. Use
alcohol-soaked cotton pellets to remove excess cement from
FIGURE 2: Complete
the chamber. Figure 1 shows a premolar with a lateral defect
healing of the defect in a
at the coronal third of the root sealed with EZ-Fill cement.
six-month recall.
Figure 2 shows complete healing of the defect in a six-month
recall.
Fall 2004
FEEDBACK?
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb13waystoimprove.html[2/21/2011 10:26:13 ]
MTAD: A New Intracanal Irrigant
Young Bui, D.D.S.
Young Bui
MTAD seems to
HE SUCCESS OR FAILURE of root canal therapy
be an excellent
depends upon the ability to remove all or most of the
intracanal irrigant
debris in the canal during instrumentation. Sodium
hypochlorite (NaOCl) is the solution most commonly used to if used according
to clinical
irrigate the canal. NaOCl used in dentistry has a 5.25 percent
protocol.
concentration, which can be diluted to 2.60 percent, 1.3
percent, or .66 percent concentration. As pulp solubilizers,
the 5.25 percent and 2.60 percent concentrations of NaOCl
were equally effective (greater than 90 percent), and 5.25
percent NaOCl was capable of dissolving virtually the entire
organic component of dentin (Beltz et al 2003). NaOCl
alone, however, does not remove the smear layer left behind
from the instrumentation process. Ethylene diamine tetraacetic acid (EDTA) is commonly used to remove this smear
layer. Studies have shown the effectiveness of EDTA in
removing up to 70 percent of the inorganic material in
dentin.
Recently, a new intracanal irrigant has come on the market
to compete with EDTA. MTAD is a mixture of tetracycline
isomer (doxycycline), an acid (citric acid), and a detergent
(Tween 80). The protocol for clinical use of MTAD is 20
minutes with 1.3 percent NaOCl followed by 5 minutes of
MTAD. The solubilizing effects of MTAD on pulp and
dentin are somewhat similar to those of EDTA. The major
difference between the actions of these solutions is a high
binding affinity of the doxycycline present in MTAD for the
dentin. (Beltz et al J Endod 2003) The benefit of the
doxycycline in MTAD can be seen in the study by
Torabinejad et al comparing it to NaOCl and EDTA in the
ability to kill E. faecalis. MTAD is found to be as effective
as 5.25 percent NaOCl and significantly more effective than
EDTA. Furthermore, MTAD is significantly more effective
in killing E. faecalis than NaOCl when the solutions are
diluted. MTAD is still effective in killing E. faecalis at 200x
dilution, but NaOCl ceases to be effective at 32x dilution.
EDTA did not exhibit any antibacterial activity. Shabahang
et al conducted a study to compare the abilities of MTAD
and NaOCl in disinfecting human root canals that had been
contaminated with whole saliva. Twenty-three of sixty teeth
treated with NaOCl remained infected. Only one of sixty
teeth treated with MTAD remained infected.
With every new product we are always concerned about
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb14mtad.html[2/21/2011 10:26:14 ]
the cytotoxicity to the underlying tissue and the effect it may

have on the strength of dentin. MTAD was compared with
commonly used irrigants and medications in a study by
Zhang et al in 2003. The results showed MTAD to be less
cytotoxic than eugenol, 3 percent H2O2, Ca(OH)2 paste, 5.25
percent NaOCl, Peridex, and EDTA. It is more cytotoxic
than NaOCl at 2.63 percent, 1.31 percent, and 0.66 percent
concentrations. Machnick et al conducted a study to evaluate
the effect of MTAD on the flexural strength and modulus of
elasticity of dentin. The result showed no significant
difference in flexural strength and modulus of elasticity
between the dentin bars exposed to saline or MTAD when
applied according to clinical protocol as stated above.
According to all these studies, MTAD seems to be an
excellent intracanal irrigant if used according to clinical
protocol. It is better than EDTA in killing bacteria and less
cytotoxic than most irrigants. This new irrigant may help
increase the success rate of root canal therapy in infected root
canals.
Winter 2004
If you are using liquid EDTA as an
end irrigation during final
instrumentation to clean out the
smear layer in the canal, be sure to
wash it out thoroughly. This can be
accomplished with chlorhexidine in a
syringe with a 30 gauge irrigating
needle. Fill the canals with
chlorhexidine and agitate with an
instrument in the reciprocating
handpiece and then re-irrigate with
the same.
FEEDBACK?
We welcome your
responses and
questions.
the Endo Forum and
add your comments
in Endo-Mail.
Do not irrigate the canal with

Chlorhexidine without rinsing the
canal of NaOCl first. The mixture of
NaOCl and Chlorhexidine will cause a
rust color precipitation and result in a
stain of the internal tooth structure.
Doug Kase
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb14mtad.html[2/21/2011 10:26:14 ]
Three Interesting Cases
Young Bui, D.D.S.
Young Bui
OLLOWING are three interesting cases that I would like

to share with all of you.
The first case was a strip perforation of the distal root of
tooth #19 on the furcation side that occurred when the post
space was prepared (Figure 1). Normally, with a perforation
this big, the tooth would be deemed hopeless. However, with
the invention of the miracle cement MTA, this tooth still had
a chance of success. The first step was to remove the long
Flexi-Post without damaging the root further. I created an
access opening wide enough to expose the head of the post.
Then I used a CPR1 ultrasonic tip to vibrate the post loose
from the cement. Once loosened, the post could easily be
unwound using the wrench that comes in the post kit. After
the post was removed, I went in and instrumented the canal,
removing any gutta percha left in the canal. You should not
try to seal the perforation until the canal has been cleaned
and shaped. The reason is that, once mixed, MTA is a wet
putty. You cannot irrigate and clean the canal after the MTA
has been applied because the material will be dissolved by
the irrigant. Instead, you should apply the MTA when the
canal is ready to be filled. Mix the MTA into a putty
consistency on the dry side then place it into the chamber.
Take a large gutta-percha point or x-coarse paper point and
use it as a plugger to push the MTA down the canal. Next
use the SafeSiders 25/.08 NiTi file to spread the the MTA
along the wall that has the perforation. Spreading the MTA
in this way will help seal the perforation and create a tapered
canal space to place the gutta percha in. Figure 2 shows the
completed case with MTA extruded out along the length of
the furcation wall. Figure 3 shows healing of the furcation
and periapical area eight months later.
Figure 1
FIGURE 1: Strip perforation of the

distal root of tooth #19.
Figure 2
FIGURE 2: The completed

case with MTA extruded
out along the length of the
furcation wall.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb15threecases.html[2/21/2011 10:26:14 ]
Figure 3
FIGURE 3: Healing of the furcation

and periapical area eight months
later.
The cause of failure in the next case was missed canals.

The patient presented to the office with pain and swelling
over #14. The pre-op x-ray showed thinly filled buccal
canals with a large area in the furcation (Figure 4). Access
was made and the post was removed as in the case above.
Next I used a #8 slow-speed round bur to clean the floor of
decay and stain. This procedure allows you to have better
lighting so that you can locate canals better. Most upper
molar failure is caused by missing MB2. Thatand more
was the case with this tooth. After I had cleaned and shaped
all the old canals, I found not only the MB2 but also a second
palatal canal. You can see five separate filled canals in
Figure 5. The key to locating extra canals is to take a #2
round slow-speed and sweep along any groove you find in
the floor of the tooth. This will expose any ditch along the
groove. MB2 is there at least 70 percent of the time in first
and second upper molars.
Figure 4
FIGURE 4: Pre-op x-ray

showed thinly filled buccal
canals with a large area in the
furcation.
Figure 5
FIGURE 5: Showing five

separate filled canals.
The last case is pretty much a straightforward root-canal

case. The only interesting part of this case is the curvature of
the mesial root and the lateral canal near the apex of the
distal root (Figures 6 and 7). Upon encountering a curve like
this one, the first thing that should come to your mind is to
reduce the amount of curvature. By using a #2 Peeso reamer
and leaning it against the outer wall, you will turn a Ccurvature into a J-curvature. This will reduce the stress on
your file or reamer. My suggestion is to use the SafeSiders
reamers with the reciprocating handpiece. The SafeSiders
reamer is flexible and less binding due to the flat side. This
will allow you to instrument the canal without causing any
distortion. The bi-directional spiral is a great instrument to
apply cement with. The flutes on the spiral force the cement
to converge on itself, creating a force that spreads the cement
against the wall. This will disperse the cement into the lateral
canal.
Figure 6
Figure 7
FIGURES 6 AND 7: Showing

curvature of the mesial root
and the lateral canal near the
apex of the distal root.
January-March 2005
FEEDBACK?
Endo-Mail.
Young Bui, D.D.S.

M SURE that most of you have stumbled upon
difficulties while doing root canals. Some of the
problems are easy to fix; others are not. I will bring up
several difficult situations and then explain how to resolve
them.
Diagnosis
Young Bui
A patient presents with generalized pain and cannot
pinpoint a specific tooth. There is no pain to percussion,
chewing, or palpation. The x-ray shows no indication of
pathology on any of the teeth in the quadrant. Rinsing with
hot water increases the pain, but the patient still cannot point
to a specific tooth. In a case like this, you need to isolate
each individual tooth with a rubber dam and run hot water
from an irrigating syringe over the buccal side of the tooth.
Do this for all the teeth in the upper and lower quadrant to
make sure that the pain is not radiating. The culprit tooth will
show itself as hot water is poured over it.
A patient experiencing acute pulpitis enters your office and
has to constantly drink cold water to calm down the pain.
Apply Endo Ice on a piece of cotton pellet. Wait for the pain
to come back and apply the pellet to each of the teeth in the
quadrant until the pain calms down. Wait for the pain to
reappear and apply the cold pellet to that tooth again to make
sure that it is the cause of the pain.
Proper Isolation
There are times when the coronal tooth structure has
decayed out and there is not enough tooth structure above the
gingiva to properly place the clamp on. The first step is to
use a #8 slow-speed round bur to remove all the remaining
decay. Then prepare a mixture of Ti-Core and inject it onto
the tooth using a Centrix needle to rebuild the coronal
structure. Wait for it to set and then clamp it like a normal
tooth. You can also do this using Ketac cement. The only
drawback with Ketac is that it is weaker than Ti-Core so it
can crack under the force of a clamp over time.
If the tooth has decayed out underneath a crown, make
sure you remove all the decayed materials. Never start the
root canal process until all the decay has been removed. If
file:///D|/...TH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb16problemsolving.html[2/21/2011 10:26:15 ]
there is a leakage in the margin between the crown and the

tooth, seal it up by injecting Ketac cement into the crown.
The Ketac cement will flow into the margin area and seal it
up temporarily so that you can do the root canal without
saliva contamination.
Access Preparation
Creating an access opening can be difficult in certain
situations. If you go down too deep in calcified cases on
molars, you can perforate the floor. By using the PulpOut
bur you can prevent this from happening. The stopper on the
bur will prevent you from hitting the chamber floor. The
diamond shaping bur will help you create a perfect straightline access without scratching the floor.
Some pre-molars have large crowns and thin roots. Others
are angulated due to spacing. Do not place the rubber dam
on these teeth before access preparation. The dam can
obstruct your view or give you a false angulation of the root.
You can perforate out to the side if you are not careful.
Locating Canals
The first thing you want is to create an access opening large
enough to allow light to get in. Next, make sure that the
chamber is clean of all decay and calcified pulp stone. This
will illuminate the chamber, allowing you to better locate the
canals. Remember to smooth out the groove along the floor
of the upper molars to locate the MB2.
Weeping Canal
Im sure that every one of you has encountered an infected
canal that refused to be dried. You cleaned it out well and
medicated it with Ca(OH)2 and hoped that it would dry up by
the next visit. When you opened it back up, the canal was as
wet as on the previous visit. You continued this process of
cleaning and closing for a few visits without results. The
reason for this is that the apex has been widened due to
resorption from the infection. What you want to do is clean
out the canal really well to the anatomic apex by using the
apex locator. After that, mix a little MTA and plug it down
the canal to the apex using an extra coarse paper point. This
will absorb the moisture and create a tight plug at the apex.
Now you have a dry canal to fill.
Removing Excess EZ-Fill Cement

After the canals have been filled, you find the chamber
filled with EZ-Fill cement. Removing this cement is easy by
using cotton pellet soaked with alcohol. The alcohol seems
to remove the cement very well and leave a clean chamber to
be restored with composite or amalgam.
Post Hole Preparation

Do not use force when creating a post space with a flexi
drill. Always use a gentle pecking motion so that you can
feel the resistance of the gutta percha. If you feel the drill
against hard surface, do not push any further. Move the drill
in different angles until you feel the gutta percha being
removed.
When using a Flexi-Flange countersink drill, run it with
water. It will cut a lot smoother than it will when running
dry.
I hope that these suggestions will be of help to you when
you encounter such problems. Feel free to visit the Endo
Forum if you have any other problems pertaining to endo that
you need answered.
April-June 2005
FEEDBACK?
Endo-Mail.
The Effect of Aesthetics in Endodontics
Young Bui, D.D.S.
Young Bui
OTARY NiTi and the endodontic microscope have revolutionized the

way we do root canal therapy. We are able to find MB2 in upper
molars and third canals in the mesial of lower molars much more easily
than before due to the introduction of the dental microscope. The NiTi
files have helped us to create the almost perfect taper in canals in a shorter
time. The end result is a nice, densely filled root canal that is aesthetically
pleasing to the eye. However, in our zeal to create a beautiful root canal
treatment, we tend to forget the most basic fundamental rule in
endodontics, and that is cleaning the canal down to the anatomical apex.
Most of us clean and fill our root canal to the radiographic apex. We tend
to doubt ourselves when the gutta-percha point is short of the radiographic
apex. We are letting aesthetics influence our judgment. When we see a
failed root canal case with the filling 1 mm short of the radiographic apex,
we attribute the failure to the short-filled canal. How do we know whether
the filling is short or not?
What are the anatomical and radiographic apexes? The radiographic
apex is the tip of the root as seen on any given x-ray. However, the
anatomical apex is different from one tooth to another. It can be located at
the tip of the root on one tooth and a couple of millimeters away from the
tip on another. The only way to know for sure where the anatomical apex
is located is to measure the length of the root using an apex locator. The
two good apex locators are Endex by Osada (which has a needle gauge) or
Root ZX by J Morita (which is digital).
When you start using the apex locator, you will notice a number of cases
in which the anatomical apex is about .5 mm to 1 mm away from the
radiographic apex. The reason for this difference is that the canal tends to
take a curve at the apical end of the root before it exits the root, as seen in
Figure 1. Figure 2 shows the radiographic apex and the anatomical apex as
seen from the path of the radiation hitting the tooth at a right angle. If you
fill the canal to the radiographic apex of this root, it will be 1 mm
overfilled even though it is aesthetically pleasing.
FIGURE 1
FIGURE 2
Figure 3 shows an x-ray taken from the buccal view of a premolar with a
file in the canal to the radiographic apex. Figure 4 shows the same tooth in
a mesio-distal view with the file overextending the anatomical apex of the
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb17aesthetics.html[2/21/2011 10:26:15 ]
premolar.
FIGURE 3
FIGURE 4
A good example of a misunderstanding of the difference between a

tooths anatomical apex and radiographic apex can be found in a bulletin
board thread on the Dentaltown website at www.dentaltown.com, entitled
by the endodontist who started the thread Pretendodontist vs.
Endodontist. This endodontist from Colorado took a couple of
radiographs from our website and criticized the RCT on the grounds that
the fillings are short on the two radiographs. One of the cases (the
bicuspid), which was done by Dr. Deutsch (pre-op, see Figure 5), has the
final filling 2?3 mm short of the radiographic apex (see Figure 6.)
FIGURE 5
FIGURE 6
However, the apex locator indicates that the length is correct. The
follow-up x-ray, Figure 6, shows healing of the large radiolucency, which
the endodontist from Colorado failed to disclose. He also criticized my
filling on a lower molar because the fill is 1 mm short of the radiographic
apex. He seems to be more concerned with the aesthetic look of the root
canal than the result. Maybe he is a cosmetic dentist who is a
pretendodontist.
July-September 2005
FEEDBACK?
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb17aesthetics.html[2/21/2011 10:26:15 ]
Pain Management in Endodontics
Young Bui, D.D.S.
Young Bui
AIN MANAGEMENT is the key to success in root

canal therapy. Every patient who walks through the
door with a toothache expects the pain to go away once
he or she leaves the office. This expectation puts a lot of
stress on the dentist as he or she tries to relieve the patient of
the tooth pain. Patients should be informed prior to any
treatment that they will feel some discomfort to mild pain
after the procedure for two to three days on average due to
the trauma exerted on the tooth during the procedure. In
certain instances, the pain can be moderate to severe,
depending on the condition of the tooth prior to treatment.
They should also be aware that flare-ups may occur,
especially in cases with multiple appointments, retreatment
cases, periradicular pain prior to treatment, and the presence
of a radiolucent lesion. By informing patients, you will take
away their worries and anxieties that something may have
gone wrong or the treatment was not successful when they
experience some pain that night.
Make sure that the patient is really anaesthetized and
comfortable before starting any treatment. It is better to overanaesthetize patients than to have them jump while you are
instrumenting the canals. Pain will place them in a tension
state and make them feel nervous with every sensation they
may experience afterward. When giving a local injection to
the upper molars, remember to also give a palatal injection.
First molars and sometimes the second molars tend to have
innervation from the palatal nerve to the palatal root. You
will realize this when drilling into the molar and the patient
starts to experience pain or when you place the reamer into
the palatal canal and the patient jumps. The palatal nerve
exits at the level of the 2nd molar about 56 mm from the
midline.
Inferior and mental blocks tend to be a lot more difficult to
achieve than local infiltrations. It can be frustrating for both
the dentist and the patient when the entire side of the
patients face is completely numb but the tooth is still
sensitive. There are three secondary methods to achieve
anaesthesia in these teeth. The first is interligamentary
injection by which a pressure gun is used to administer the
solution into the ligament. This quick and forceful injection
can sometimes cause PDL necrosis and a lot of postoperative
pain for the patient. By using the regular syringe and
Make sure that

the patient is
really
anaesthetized
and
comfortable
before starting
any treatment.
file:///D|/HEALTH/DENTISTRY/L%20E%20C%20T%20U%20R%20E%20S/E%20N%20D%20O/endomail/articles/yb18pain.html[2/21/2011 10:26:16 ]
applying gentle force for a couple of minutes, you will

achieve the same result but with less damage to the PDL.
You will see the tissue blanch as the anaesthetic solution is
working its way down to the apex. The second method is
intraosseous by which a small hole is drilled into the cortical
plate and the solution is administered directly into the jaw
bone. This is done by using the Stabident system. The third is
pulpal injectionand the most painful injection. You have to
get access to the pulp and then inject directly into it with
back pressure. The trick is getting access to the pulp with the
least amount of pain. Look for the area with the highest pulp
horn and do a quick pecking motion with the high speed drill
with water to minimize the pain. Sometimes using the slow
speed round drill can be helpful because the heat generated
from the slow speed is not much and is more comfortable for
the patient.
The worst time to give an injection is when a patient
presents with severe pain from an indurated swelling. Do not
inject directly into the area. Start with a shallow injection at
the outer edge of the swelling and then go deeper as the area
is starting to get numb. Once you are able to touch bone with
little pain, then start moving inward toward the center of the
swelling. Again start with a shallow injection and continue to
go deeper as the area is getting anaesthetized. The entire
injection will take about 1015 minutes to accomplish.
By using the apex locator, we are able to determine the
apical constriction to prevent over-instrumenting the apex. If
the apex is violated in a vital tooth, the PDL will be
traumatized and the patient will experience post-operative
pain. Over-instrumenting the canal will lead to overfilling of
the canal. The extruded gutta percha point will irritate the
periapical ligament, resulting in chronic inflammation. The
patient will experience tenderness in the tooth for a long
time. The other reason not to violate the apical constriction is
that debris can be pushed beyond the opened apex resulting
in flare-ups.
We can control and manage the pre-operative pain with
local anaesthesia. However, post-operative pain is more
difficult to manage. Each patient reacts differently due to
different pain thresholds and different pre-operative
symptoms. One way to help prevent post-operative pain is to
reduce the occlusion so that there is no contact with the
opposing teeth. Use an articulating paper to minimize tooth
removal. This is the most important step in preventing postoperative pain. I like to prescribe a combination of pain killer
and anti-inflammatory and have them alternate between the
two every four to five hours as needed for pain. Patients who
are allergic to codeine can take a combination of 600 mg of
ibuprofen and 1000 mg of acetaminophen together every six
hours for pain control. Studies show that this combination is
more effective than ibuprofen alone. For teeth with active
infection or with PAR, I prescribe Augmentin 875 mg BID
and for Pen-allergic patients, Clindamycin 150 mg QID.
These are the two best antibiotics for necrotic cases or
retreating failed RCT because they kill E. faecalis bacteria

which are the toughest bugs to get rid of. Dr. Deutsch found
that a cardiac dose of antibiotic right after the procedure
reduces the number of flare-ups in his patients. Remember to
inform the patient not to chew on the treated tooth for at least
a week to allow it to heal properly.
September October 2005
FEEDBACK?
Endo-Mail.
Three Cases to Share
Young Bui, D.D.S.
Young Bui
T WAS TAUGHT in school that a necrotic tooth with

Today, canals
periapical lesions should be cleaned out and medicated
are cleaned out
with Ca(OH)2 for at least a week before filling it. Some
using greater
still believe in that teaching while others believe in the onevisit root canal treatment. The reason for the teaching of a
tapered files,
two-visit treatment is because the technology back then was
thus allowing
not as advanced as today. Most of the root canals in the study
the removal of
done by Bender and Seltzer were performed using a .02 taper
more infected
file to do the cleaning. This method does not allow proper
cleaning of the canals wall. Today, canals are cleaned out
dentinal wall of
using greater tapered files, thus allowing the removal of more
the root canal
infected dentinal wall of the root canal system. I do most of
system.
my cases in one visit using the SafeSiders technique. This
technique allows you to clean and shape the canals to a .06 or
.08 taper as in any rotary NiTi system. The canals are
constantly flooded with NaOCl during the instrumentation
process. Once the canals have been cleaned and shaped, rinse
them thoroughly with liquid EDTA to remove the smear layer.
Next soak the canals with a 2 percent chlorhexidine solution
and let it sit for about two minutes. By shaping the wall to a
.06 or .08 taper and then using the EDTA and 2 percent
chlorhexidine, you eliminate bacteria that are embedded in the
dentinal wall. This will ensure a clean canal and eliminate the
use of Ca(OH)2 between visits. By the way, Ca(OH)2 does
not kill enterococci such as E. feacalis; 2 percent chlorhexidine
does. The molar in Figures 1 and 2 was done in one visit. As
you can see in the six-month recall, the root canal was a
success.
Figure 1
Figure 2
FIGURE 1: Molar x-ray showing FIGURE 2: The same tooth as in

finished root canal and periapical Figure 1, six months later, with
area at the apices.
the apices healed.
Im sure everyone reading our newsletter has read about the

SafeSiders reamers. The reason for the flat side on these
instruments is threefold. First, the flat side reduces the amount

of binding along the length of the canal. This allows the
SafeSiders reamer to negotiate even tight and curved canals
with ease. Second, due to the flat side, the reamer is more
flexible than regular reamers thus preventing distortion in
sharply curved canals. Lastly, the flat side acts as a failsafe
system. If you happen to separate a SafeSiders reamer, you
can bypass the reamer along the flat side because it is not
binding to the canals wall. I used rotary NiTi in my early
years, and I was constantly worried about separating the file.
Rotary NiTi can shape straight canals easily, but when it
comes to curved ones, that is where the stomach wrenching
begins. I find the SafeSiders technique to be better due to the
fact that Im not worried at all when it comes to negotiating
tight and curved canals as seen in Figures 3 and 4. The mesial
and distal roots in this molar have sharp curves that end up
touching each other. I call this the kiss of death. I had to
use the SafeSiders reamers with the reciprocating handpiece to
instrument these canals. The #2 Peeso widens the upper
portion of the canal to reduce the amount of stress on the
reamer at the curve. The reciprocating motion also aids in the
instrumentation with no distortion at the curve. I was able to
instrument to a 30/.02 stainless steel SafeSiders reamer and
end with a 30/.04 SafeSiders NiTi file. The canals were filled
using a single cone with EZ-Fill cement.
Figure 3
Figure 4
FIGURE 3: Molar with curved

roots.
FIGURE 4: Finished root canal

on the molar in Figure 3.
When we perform root canal treatment on lower premolars,

we assume that the tooth has only one canal unless we see that
there are two roots on the x-ray. Sometimes, there is an extra
canal midway down the main canal. Im never satisfied with
the cleaning of a lower bicuspid with one canal unless I have
run up and down the length of the wall with a bent #10
reamer. The reamer will get a catch along the wall if there is
another canal present. Figure 5 shows the pre-op x-ray of a
lower bicuspid with two roots. The case was referred to me
after the general dentist had a difficult time filling the canal.
After I cleaned and irrigated the two canals, I ran a #10 reamer
up and down the canal and found another canal along the wall.
The other two canals are straightforward, but in the case of the
third, the instrument must be pre-bent in order to engage the
canal. I cleaned and shaped it using the SafeSiders technique
and filled it using a single cone with EZ-Fill cement (Figure
6).
Figure 5
Figure 6
FIGURE 5: Pre-op x-ray of a

lower bicuspid with, apparently,
two roots.
FIGURE 6: The bicuspid from

Figure 5 with three roots filled.
FEEDBACK?
your comments about any of the articles in EndoMail.

Endo Mail

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Endo Mail

Uploaded by

Copyright:

Available Formats

Review of Ruddle on Retreatment

Amy Beth Dukoff, D.M.D.

Management of Blocks, Ledges, Transportation, and

r. Cliff Ruddle is the founder and director of

You can reach Dr. Ruddle at:

Review of Ruddle on Retreatment

Vicoprofen Product Review

Amy Beth Dukoff, D.M.D.

Vicoprofen: Effective Pain Relief?

icoprofen combines two widely used analgesics. It

Vicoprofen Product Review

Review of Pro Root Instructional Video

Amy Beth Dukoff, D.M.D.

Pro Root Instructional Video

RO ROOT is an instructional video by Densply and

Review of Celebrex and COX-2

Amy Beth Dukoff, D.M.D.

Celebrex and COX-2

ELEBREX IS A COX-2, nonsteroidal, antiinflammatory drug. Celebrex is made by Searle/Pfizer

The Importance of Diagnosis

Amy Beth Dukoff, D.M.D.

The Importance of Diagnosis

IAGNOSIS IS ESSENTIAL before initiating root

The Importance of Diagnosis

Beware of the Groove

Amy Beth Dukoff, D.M.D.

Beware of the Groove

HE TOOTHS ROOT SHAPE is sometimes

Beware of the Groove

How Trauma Affects the Nerve

Amy Beth Dukoff, D.M.D.

How Trauma Affects the Nerve

EETH REACT to trauma in various ways. Their

How Trauma Affects the Nerve

Amy Beth Dukoff, D.M.D.

OOTH RESORPTION may go unnoticed for many

partial removal of the pulp

comments about any of the articles in Endo-Mail.

Amy Beth Dukoff, D.M.D.

ROPER endodontic access is crucial to the success of

initiating the treatment.

Amy Beth Dukoff, D.M.D.

reakage of instruments is a common problem for all

In the final post-operative radiograph , the separated

FIGURE 2: An MB2 was found that

FIGURE 3: In the postoperative radiograph, the

Breakage or separation of instruments are problems that all

Orthodontics and the Root

Amy Beth Dukoff, D.M.D.

Orthodontics and the Root

RACES ARE A FACT OF LIFE for many adolescents.

Orthodontics and the Root

Amy Beth Dukoff, D.M.D.

ISSED APPOINTMENTS can play havoc with a

Did You Know Where Rx Came From?

Amy Beth Dukoff, D.M.D.

Did You Know Where Rx Came From?

for Jupiter, and the Rx

Did You Know Where Rx Came From?

Amy Beth Dukoff, D.M.D.

HE ACRONYM HIPAA stands for Health Insurance

Access to Medical Records

Notice of Privacy Practices

received this notice.