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Practice Profile

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Brett E. Gilbert, DDS

Brett E. Gilbert, DDS

Combining clinical excellence and compassion What can you tell us about your background? I was born and raised in Baltimore, Maryland. I attended college, dental school, and my postgraduate endodontic residency at the University...

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Randy Garland, DDS

Randy Garland, DDS

Exceeding expectations What can you tell us about your background?
I grew up in southern Orange County and earned a bachelor’s degree in biology at San Diego State University in 1983. There I met my future wife, Kim, at the...

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Scott A. Norton, DMD, MSD

Scott A. Norton, DMD, MSD

Focus on family, patients, friends, growth, and community What can you tell us about your background? For as long as I can remember, I wanted to make people smile. I always loved getting the class laughing in grade school. Looking back, I am sure...

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Clinical Articles

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Management of a tooth with a large internal resorption defect

Management of a tooth with a large internal resorption defect

Dr. Robert Slosberg facilitates accurate mapping and obturation of the resportive defect with CBCT imaging Abstract
A patient presented with advanced internal root resorption of tooth No. 9. The prominent location of this tooth...

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Pulpal diagnosis of teeth presenting with condensing osteitis prior to endodontic treatment — a retrospective study

Pulpal diagnosis of teeth presenting with condensing osteitis prior to endodontic treatment — a retrospective study

Drs. Brian Shaughnessy, Margaret Jones, Ricardo Caicedo, Joseph Morelli, Stephen Clark, and Ms. Jennifer Osborne review the occurrence of teeth presenting with condensing osteitis and their associated pulpal diagnosis over a 2-year period. Introduction Read More...

GuttaCore® system: a step forward in the evolution of endodontics

GuttaCore® system: a step forward in the evolution of endodontics

Dr. Andrei Zoryan dispels some of the common myths surrounding carrier-based obturation Carrier-based gutta percha Carrier-based obturation (such as Thermafil®, GT® obturator, ProTaper® obturator [Dentsply Tulsa Dental Specialties]) is one...

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Practice Management

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Effortless, fun, and profitable endodontics

Effortless, fun, and profitable endodontics

In part 2 of his series, Dr. Ace Goerig suggests ways to reduce stress in the practice Almost all endodontists could be completely out of debt and on the way to financial freedom within 5 to 7 years if they only knew the secret. But the secret is...

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Life after root canal — it’s not just about having enough money

Life after root canal — it’s not just about having enough money

Dr. Robert Fleisher ruminates on how to prepare for retirement There are so many articles about everything that you become pretty much overwhelmed and can never expect to read them all. So you pick and choose. You like to learn about the latest and...

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Superior customer service

Superior customer service

Dr. Roger Levin presents the 10 top ways to help create a perfect dental team With the changes brought on by the economy, top companies are bringing in the best resources they can find to evaluate where their organizations stand. They want to know...

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Dr. Raphael Bellamy emphasizes the importance of the five biological objectives of cleaning and shaping to enhance endodontic success and patient comfort during treatment



When I consider all the literature and lectures on the subject of pain control, postoperative pain control, flare-ups, phoenix abscesses, etc., and the amount of endodontic surgery that is carried out in the field, then I wonder whether it is naïve of me to assume that they are all common practice.

The developments in endodontic technology over the last 10 years have been phenomenal. More developments have occurred in both endodontic technique and endodontic technology in the last decade than the previous century. However, much as in restorative dentistry, it is easy to fall into the trap of thinking purely in mechanical terms when treating an active disease process. While the mechanics of endodontics is important, critical in fact, that alone will not meet the biological criteria for the healing of lesions of endodontic origin (LEO).

It took a long time to discover that the cause of postoperative sensitivity from a simple filling was bacterial and not simply a result of thermal transfer of a recently placed amalgam. It is easy to become complacent, to go “by the book” and forget the biology.

Capacity to heal
There is no doubt that the capacity of lesions of endodontic origin is 100% (100% – X actually, where X is the operator!). Extraction of teeth with periapical pathosis results in prompt healing of bone lesions because extraction totally eliminates the root canal system, the necrotic tissue and, regrettably, the tooth itself.

Where cleaning and shaping are practical, with equal thoroughness, equivalent healing of periapical tissues may be anticipated with healthful retention of the treated tooth. A precondition of any dentist or endodontist embarking upon root canal therapy in practice is the real belief in this fact. To believe this fact is to acknowledge the enormity of the challenge. To acknowledge the challenge creates, if we are true professionals, an obligation to meet that challenge. That is: anything short of excellence is failure.

Knowledge, skill, and desire
Three major elements determine the predictability of successful endodontics. The first is knowledge, the second is skill, and the third is desire. The endodontic disease process has been identified; the treatment developed. Discipline and skills, our levels of acuity as mentioned before, need to be developed, but the critical factor is desire. It can be done if we want to do it. Successful endodontics is a decision.

The biological objectives
The geometric aspects of cleaning and shaping root canal systems, as laid down in Schilder’s five mechanical objectives, are explained in his seminal article “Cleaning and shaping the root canal” (1974), and are enhanced by the biological objectives, clearly in recognition of the human body. The biological objectives are often overlooked, and we do so at our peril.
We should never forget that the tooth that we treat is attached to a human being with a highly developed immune system. This factor is all too often forgotten in conservative dentistry, and endodontics is merely an extension of that. The five biological objectives of cleaning and shaping enhance both endodontic success and patient comfort during treatment.

Irrespective of whatever technique is employed in cleaning and shaping, these principles will apply. There is no doubt at all that the rise in popularity of the “crown-down” technique has helped immensely in the reduction of many of the infamous traps of cleaning and shaping. Also, the utilization of rotary instrumentation has facilitated the removal of inflamed and necrotic tissue as well as substrate by efficient auguring of material up and out of the root canal system.

1 Confine instrumentation to the root canal
Routinely instrumenting either bone or periapical lesions may needlessly enlarge and deform the apical foramen, violating mechanical objectives. It may cause perforation of the maxillary sinus, the floor of the nose, or the mandibular canal. It is prevented by the use of instrument stops on files, the rigid employment of radiographic control and/or electronic apex locators during canal preparation, and understanding on the part of the operator. The practice of patency is not a violation of this objective.

2 Beware of forcing necrotic material beyond the foramen
Many instances of post-treatment flare-up have been caused by necrotic tissue and micro-organisms being seeded into the periapical tissues during canal preparation. Instrumentation beyond the apices of infected teeth will produce demonstrative bacteraemia in blood cultures while if kept within the confines of the canal it will not.
It would seem that flare-ups associated with necrotic debris insertion into the periapical tissues is directly related to the quantity of material deposited beyond the foramen and inversely related to the thoroughness of cleaning and shaping the canal.

3 Remove all tissue debris from the root canal system
This material is the single cause of periapical lesions, and its elimination is critical for success. There is no doubt that the most effective solution to aid removal of tissue remnants and to disinfect the canal is 3%-5% sodium hypochlorite.

4 Complete cleaning and shaping of single canals in one visit
Early practitioners of endodontics feared approaching the apical foramen of infected canals before several treatments of antiseptic drugs and caustic chemicals. On sealing these teeth between appointments, they set themselves up for the very flare-ups they sought to avoid. The drugs did little to sterilize the infectious debris in the system.

Today, it is still commonplace among the profession to endodontically treat teeth over four or even five visits with the use of highly potent, volatile phenolic agents that do nothing but harm the periapical tissues. Leaving substrate in necrotic canals predisposes to post-treatment complications. The sooner, more thoroughly, and more intelligently substrate is removed, the more uneventfully and quickly the canals will be disinfected and obturated, resulting in a more effective RCT. In a multi-rooted tooth, do not enter a canal unless you can completely clean and shape that canal.

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5 Create sufficient space during canal enlargement for intracanal medication and for potential exudates reception
There is only one intracanal medicament to consider today, and that is calcium hydroxide. For many years, canal enlargement was specifically for the placement of medicaments. Depositing drugs in root canals that have been inadequately or insufficiently enlarged encourages percolation of medicament apically. The emphasis now has shifted from a primary reliance upon medicaments to that of primary reliance on cleaning and shaping. That is the way it should be. Leaving space in the body of well-shaped root canals to receive small amounts of periapical exudates that may accumulate between visits relieves apical pressure and prevents percolation of medicaments beyond the apex. The benefits to the patient and the operator are obvious.

Conclusion
So what is Schilder saying in the biological objectives? He is reminding us of the fact that this business is not just mechanical but biological.

We must understand and respect the biology as much as the anatomy, and it is clear that both sets of objectives are inextricably linked. Cleaning and shaping without disinfection is useless. Scrupulous attention to detail is the order of the day. It is more relevant today than ever before as modern instrumentation has allowed the clinician to shape canals in less time than ever before. Less time equals less irrigation and less disinfection of the deeper parts of the system. If an upper molar root canal is completed in 1 hour, then one must question how much disinfection has occurred in the apical extent of the MB2 if it is the last canal to be shaped (if indeed the MB2 was found in that amount of time).

There are no x-rays, no graphs, no drawings, nor pictures to show how these objectives are attained. We can only rely on ourselves. I spoke of knowledge, skill, and desire. The greatest of these is desire. Adherence to these objectives is the difference between endodontic success and failure, postoperative pain or no pain and, ultimately, having a patient who is appreciative of your skills, and values your judgement, your attention to detail, and your work.

It is only by adherence to these basic uncompromising principles that ask so much of us that we can truly place confidence in our work. Then, and only then, can we stand up and say “I believe!”

Bio
Raphael Bellamy, BDS (NUI) Cert. Endo, is a graduate of University College Cork and the Goldman School of Dental Medicine in Boston, Massachusetts, where he completed his postgraduate studies in endodontics under Dr. Herbert Schilder. Dr. Bellamy is a Diplomate of the American Board of Endodontics. He is currently in private practice limited to endodontics in Dublin, Ireland. He can be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it. .

Reference
Schilder H (1974) Cleaning and shaping the root canal. Dent Clin North Am 18(2):269-296.

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Research has shown that irrigants are more effective when they are electro-mechanically activated.

Acoustic streaming and cavitation have been proven to significantly enhance cleaning of difficult anatomy. Studies have shown that low frequency (Sonic) oscillation (160-190Hz) was not sufficient to create acoustic streaming or cavitation within the canal space.

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