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The EndoFiles Fax

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The EndoFiles Fax
June/July 2002: Volume 3 Issue VI-VII

A Periodic Review of Current Clinically Related Endodontic Topics
Tips and hints for the practicing Dentist

With editorial comment provided by:
Robert M. Kaufmann DMD MS (Endo)

Instant Online referrals or Call 783–2971

Pearls of wisdom from ROOTS Summit II - San Diego June 2002

During the first week of June, I attended a historic seminar in San Diego California - ROOTS Summit II. The Summit represented the continuation of a concept that was originated by Dr. Ken Serota, a Toronto Endodontist of extraordinary vision. Several years ago he undertook a project to unleash the potential of combining the Internet with dentistry. He created ROOTS, an Internet based Endodontic interest group, established to bring clinicians of similar interest together over the Internet in order to exchange ideas, opinions and techniques without the constraints of time or distance. The digitization of photos and x-ray images allowed subscribers to exchange information with literally hundreds of dentists at a time on a daily basis, a concept that could only be dreamt about in the days of regular mail. The convergence of the technology, the people and the ideas is what ROOTS calls "the Nexus". Serota has since extended it to many Dental specialties and topics. The logical next step of this "virtual" daily gathering was an actual meeting, the ROOTS Summit, the first of which was in Toronto in 2001 and again in San Diego in 2002.

Why was the ROOTS Summit II so special? Because it was only advertised on the Internet. Although the attendance was "only" about 230 people from 16 countries (up from 75 in 2001), the entire 3 days of continuing education (7:30 am to 5 pm lectures including prepaid daily "lunch with learning") was only $300 USD. I also enrolled in the full day Microscope pre-Summit course ($150 USD), sponsored by Global Surgical Corp., who shipped 25 fully functional surgical microscopes to San Diego specifically for the demonstration. Participants at each of the 25 scope equipped stations found the latest Ni-Ti file systems, engines, Ultrasonics, electric handpieces and mounted teeth. It was incredible. General Dentist instructors already using the SOM for General Dentistry predicted that its use would become more widespread. Dr. Glen Van As (Oral Health June 2002) GP, showed how he uses it for all of his procedures. During the Summit, I obtained a total of 28 hours of C.E. for $475 USD.

The 3 days of lectures featured some of the biggest names in Endodontics. Ruddle, Buchanan, McSpadden, West, Stropko, Castellucci and many more had all VOLUNTEERED their services at no fee. Clinicians from all over the world lectured to us on their techniques for optimizing treatment. The presentations were absolutely first rate. Illustrations were crystal clear because most photos were obtained via microscope. Presentations were projected on a large screen using MS PowerPoint. The seminar ran like clockwork and our only regret was that 1 or 2-hour time constraints on presenters did not allow for extended discussions and long question periods. That was OK because with only 230 attendees, you could actually come up to presenters during breaks or cocktails and ask the questions that you needed answers for. You could also feel the camaraderie of those who understood how important this meeting was. OK but what did we learn? Some pretty cool stuff. Here are some hi-lites:

1. MTA (Mineral Trioxide Aggregate) ProRoot by Tulsa Dental
This stuff is amazing. Although it technically has the exact same formula as "Portland Cement", it continues to produce phenomenal results for treating perforations, mid root resorption and open apices. The newer white formulation has solved the problem of tooth discoloration that occurred with the regular formula. Drs. John Stropko and Arnaldo Castellucci showed some impressive results in seemingly impossibly involved cases. General Dentists need to become familiar with it. This material is here to stay.

2. Rotary Ni-Ti.
Dr. John McSpadden Dr. Cliff Ruddle, Dr. Joe Maggio
, and Dr. Steve Buchanan made presentations. Some of you may remember Dr. McSpadden's original invention, the McSpadden compactor. Dr. McSpadden must be acknowledged as one of the world's authorities on rotary Ni-Ti instrumentation and testing. He showed us pictures from his laboratory, reviewed his findings and explained the factors that contribute to instrument breakage. He examined several manufacturers' file systems and compared them. I have a summary of his findings for those who are interested. ( E mail me at )They make for interesting reading and are important in understanding why these instruments break.

3. ProTaper File System -Dr. Cliff Ruddle
Here is a brief synopsis of his technique as I understood it:

a. Establish straight line access to the canals by determining that the "scouter' files "stand up straight" in the access. This will determine whether the case is considered "On-Axis" or "Off-Axis". There should be no "preconceived exact mm length" for the canal prior to this point i.e./ a length to which you MUST get your instruments. Scouter files are used short of the apex initially. Do the Scouter file work on the "outstroke" only. Protaper S1 placed to Scouter file length (short). Look for debris at the top of the file (not the tip!).

b. Protaper SX used in a brush stroke if "Off Axis." NO PECKING !

c. Now go to estimated length with a #15 file/ EAL. (This is important because the initial straightening of the canal may have reduced the working length by as much as 1 mm. (If take a working length before you remove the coronal dentin, your rotaries may end up working 1 mm long in molars. This can result in tearing of the apex.) With this method you are more likely to maintain true working length.

d. ProTaper S1 to same length. THIS may be MINIMALLY "Long"! Check patency with #10 file. Irrigate.

e. ProTaper S2. This cuts in the MIDDLE 1/3rd of the root.

f. Maintain patency and NOW confirm working length with EAL and film. This is the final working length you want.

g. ProTaper F1. This blends the apical 1/3rd with the middle third. When it is ½ to 1mm short, remove it. If it does not go to length, recapitulate and irrigate again.

h. In Big, thick canals and when shape dictates - use F2 and F3 short of the apex. (Rare)

There were some interesting exchanges between Dr. Ruddle and Dr. McSpadden. Dr. Ruddle felt that some of the "lab findings" did not represent situations encountered during clinical application. This presentation was immediately followed by a discussion of Kerr Sybron's new K3 system presented by Dr. Joe Maggio.

4. The Profile GT System by Tulsa Dental - Dr. Steve Buchanan
This was Dr. Buchanan's standard presentation of his Profile System, which I currently use. The most significant quote? " If you use instruments more than one time, DO NOT USE MY SYSTEM." Dr. Buchanan believes that the increase in efficiency and decreased treatment time more than make up for the extra cost. Whether dentists in less affluent locations are willing to "toss" these instruments after a single use remains to be seen. It is much harder to recoup costs when you are worried about the fee guide, insurance benefits and practice overhead. (Things not often considered in places like Santa Barbara, Palm Beach or Phoenix).

5. Discussion of Canal Shapes and the "Capture Zone".
This discussion compared the cases of clinicians from different parts of the world who used different Ni-Ti shaping systems (GT Profiles, K3, ProTaper, LightSpeed, Brasseler Race, GGs etc). It offered a glimpse of what cases looked like when prepared with different instruments and techniques. Interesting!

6. Retreatment using the Surgical Operating Microscope
With greater magnification comes greater awareness of missed canals, the ability to remove broken instruments even in the deepest portions of canals and the benefits of focused illumination. You cannot treat what you cannot see.

7. The Endo-Perio Continuum
One of the biggest problems that we face as endodontists in the challenge of the periodontally challenged tooth that appears to be endodontically involved. The Periodontist prays for endodontic involvement so that he has a decent chance of having the endodontist fill that portal of exit and help him to repair the attachment apparatus. In other cases the situation may require a combined or coordinated approach. Dr. Rick Schwartz gave us an overview of the diagnosis and discussed different treatment scenarios. He emphasized working closely with his Periodontist colleagues and asking for their assistance when the procedures involved areas where their expertise was greater. (Proper treatment coordination and/or referral at the right time are the hallmark of a quality clinician!) It was an excellent presentation of some of the more difficult situations that we face when treating a compromised tooth.

8. Dr. Jim Simon - Success and Failure
Dr. Simon's lecture took me completely by surprise. I was expecting another "let me show you why this failed" lecture. Instead, he had some shocking news for us: Not all lesions heal, even when you do the endo perfectly. (This is not what I was led to believe in Grad school.) Dr. Simon discussed such interesting concepts as "apical plaque", "pseudomonas and actinomycetes in apical infections and their relation to failure of apparently perfect endodontic cases". He concluded with a discussion of possible viral involvement in periapical lesions. Although I now feel a little less guilty when one of those perfectly packed cases fails to heal, it does make me wonder about what we can do with these cases in the future. Dr. Simon believes that in order to get healing some cases just have to be surgerized to remove the infected tissue. That was both comforting and alarming at the same time. Just when I thought I had a handle on success and failure after 16 years of Specialty practice!

9. Drs. Carlos Boveda and Liviu Steier - The Endodontic Restorative Continuum
With the increase in endodontic clinical success in the apical sections of the tooth, greater attention has begun to be focused on the coronal seal and its effects on long-term success. Sealing the coronal access with flowable composites, greater attention to proper marginal seal and bonding of restorations to prevent leakage into canal spaces was discussed. Again, there was general consensus that the restorative philosophies of the past have not kept up with the advances in material technology when in comes to seal of the entire canal space from apex to access. We can no longer think of the endodontic treatment as being a separate entity from the restoration. With this realization comes a greater need for both the Endodontist and the restoring dentist to work together as a team ensure that the post endodontic restoration adequately seals the canal space thereby decreasing the chances for long term endodontic failure.

It is impossible to condense almost 4 days of quality Continuing Education into a small 2 page bulletin. Other topics discussed included Trauma, Endodontic Diagnosis, Pain Control and Intra-Coronal Bleaching. There were about a dozen exhibitors present and several thousand dollars worth of raffled prizes were given out. (I was lucky enough to win almost $1000 worth of specialized endo products!) Should you be interested in finding out more or attending the next Summit in Salt Lake City, UT in June 2003, please contact me ( E mail me at ) or check into

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