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Practice Profile

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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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Dr. Fleur A. Blethen

Dr. Fleur A. Blethen

Empathy, tenacity, and perseverance are keys to this clinician’s flourishing practice  What can you tell us about your background? I was born and raised in Seattle, Washington, and lived there until I was 13 years old. My family relocated...

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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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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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Office Matters: Hard-piped filtered water system vs. self-contained bottled water system

John Bednar helps avert problems coming down the pipe If your office currently has a hard-piped filtered water system, now is a good time to consider if and when you should change to a self-contained bottled water system. A hard-piped filtered water...

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Figure-2

By Drs. G. John Schoeffel and Richard Rubinstein



Safety defines the raison d’être of the EndoVac® endodontic irrigation system because the omnipresent danger of extruding aScreen_shot_2012-01-06_at_2.12.58_PM hydrolytic irrigant into the periradicular tissue during endodontic treatment has been associated with permanent facial disfigurement and nerve damage.1,2 On the other hand, failure to use a hydrolytic irrigant, like sodium hypochlorite, to debride and disinfect the root canal system perpetuates the biological and physical factors responsible for endodontic failure.3 Specifically, pulpal debris and microbiota in the form of biofilm can flourish and escape the confines of the root canal system via lateral canals and apical ramifications, thus causing a constant periapical inflammation and/or infection (Figure 1).

Although several nonhydrolytic root canal irrigants have been and are still used today during the irrigation process, including hydrogen peroxide and chlorhexidine, none has the ability to totally hydrolyze intracanal organic debris to ammonia and carbon dioxide as can sodium hypochlorite.4 In addition, sodium hypochlorite has the ability to destroy vegetative microorganisms, including spores.5 However, the hydrolytic process itself presents an unusual and, until recently, unrecognized problem—the formation of an apical vapor lock.6 This apical vapor lock creates a gas column that isolates the apical third from irrigant exchange,7 thus totally blocking further chemical action of sodium hypochlorite. Senia first described this phenomenon in 1971,8 an example of which can be seen in Figure 2.

The apical vapor lock forms during instrumentation and irrigation as sodium hypochlorite reacts with organic material forming ammonia and carbon dioxide. Due to the buoyancy factor of these gases and the contact angle of NaOCl to dentin, the ammonia and carbon dioxide become trapped in the apical portion regardless of arch or patient position. In 1983, Chow explained that it was virtually impossible to bypass a column of gas in a simulated root canal space unless the irrigation needle was placed in very close proximity to the apical termination. Boutsioukis,9 in 2010, demonstrated that using a side-ported needle a few millimeters from the apical termination at a normal clinical extrusion rate produces 75 mm of Hg pressure at the apical foramen. These two findings, combined with Bradford’s10 findings in 2002 that intracanal pressures should not exceed capillary pressure of 27 mm Hg, creates a serious clinical problem of balancing safety and efficacy. In his discussion section, Boutsioukis warns: “From a clinical point of view, the prevention of extrusion should precede the requirement for adequate irrigant replacement and wall shear stress.”9

The logical answer to this problem is to safely “pull” the irrigants down through the root canal system and all of its irregularities via a small aspirator. Such a device is commercially available under the trade name EndoVac® (Discus Dental) (Figure 3). The clinical safety of the EndoVac® has been proven and reported,11,12 and its significant ability to remove canal debris and smear layer (Figures 4 and 5) has been demonstrated.13,14 Hockett15 reported 100% biological control in vitro when using the EndoVac® compared to side-ported needle irrigation (p value = 0.004). In a clinical study by Gondim,16 significant reduction in postoperative pain was demonstrated when comparing EndoVac® to Max-i-Probe® (Dentsply Rinn) irrigation, leading him to confirm EndoVac’s® ability to prevent apical irrigant extrusion.

Screen_shot_2012-01-06_at_2.15.06_PM

The following case illustrates a serendipitous use of the MacroCannula. The patient was a 48-year-old woman who had just finished chemotherapy for breast cancer. All other medical findings were negative. She presented to her family dentist with a history of chewing pain on her mandibular left first molar. Radiographic examination (Figure 6) revealed a previous root canal attempt performed more than 10 years before with periapical radiolucencies on both the mesial and distal roots. In addition, a separated instrument was identified in the distal root canal system. The patient was not aware of the procedural accident and was informed that in addition to re-treating the case, we would try to remove the separated file as well. After anesthesia was achieved, an access cavity was made, and the post and gutta percha were removed (Figure 7). During the procedure, copious irrigation was introduced into the access cavity and root canal system by using the Master Delivery Tip of the EndoVac® irrigating system according to manufacturer’s recommendations. Apical patency and working lengths (WLs) were established in the distal lingual canal (Figure 8). After careful instrumentation of the distal- buccal canal, the separated instrument was bypassed and freed up (Figure 9). The mobility of the separated instrument was assessed by moving it with a DG-16 endodontic explorer while observing it under 10× magnification. The MacroCannula was inserted into each canal, and irrigation with 6% NaOCl continued for 30 seconds as suggested by the manufacturer. Upon removal of the MacroCannula from the distal-buccal canal, the separated instrument could be seen captured in the opening of the MacroCannula, a serendipitous happening indeed (Figure 10). WL was then established in the distal buccal canal (Figure 11). The case was obturated with warm vertical compaction of Resilon® (Figure 12). Of particular note is that this was the second time the author had the experience of removing a separated instrument with the MacroCannula.

Screen_shot_2012-01-06_at_2.17.26_PM

The authors point out that it is extremely important to follow the manufacturer’s directions with regard to sequence during allScreen_shot_2012-01-06_at_2.18.12_PM phases of EndoVac® irrigation. Thorough evacuation and removal of large debris particles must be removed by using the MacroCannula prior to the introduction of the MicroCannula, or premature clogging will occur (Figure 13).

Bios

G. John Schoeffel, DDS, MMS, obtained his dental degree from UCLA in 1971 and opened his private practice in general dentistry the next year. In 1977, he applied to the Harvard University School of Dental Medicine’s program and completed his clinical certification in 1980. Again, he established a private practice, this time limited to endodontics in the Los Angeles area.
Before attending dental school, Dr. Schoeffel was an aircraft machinist for Northrop Aviation where he learned invaluable skills that enabled him to subsequently develop several key products in the area of endodontics including NiTi files, the Obtura, and now the EndoVac®. Currently, he holds three US patents in the area of endodontics. He has lectured globally, including the United States, South America, and virtually most of Western and Eastern Europe on the Apical Negative Pressure Endodontic Irrigation system.

Richard Rubinstein, DDS, MS, FACD, is in full-time private practice and also serves as an Adjunct Clinical Professor at the University of Michigan School of Dentistry in the department of Cariology, Restorative Sciences, and Endodontics. He is an internationally renowned speaker and a pioneer in the use of the operating microscope in endodontics. Dr. Rubinstein is a contributing author to Endodontics, 4th and 5th editions, edited by Ingle and Bakland, and a contributing author of an article in Dental Clinics of North America, entitled “Microscopes in Endodontics.” He is a principal author of Practical Lessons in Endodontic Surgery, published by Quintessence, and a principal author of A Color Atlas of Microsurgery in Endodontics, published by WB Saunders. Dr. Rubinstein has been using the EndoVac® system since its introduction in 2005 in over 6,000 cases.

References

1. Markose G, Cotter CJ, Hislop WS (2009) Facial atrophy following accidental subcutaneous extrusion of sodium hypochlorite. Br Dent J 206(5):263-264.

2. Pelka M, Petschelt A (2008) Permanent mimic musculature and nerve damage caused by sodium hypochlorite: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106(3):e80-83.

3. Ercan E, Ozekinci T, Atakul F, et al (2004) Antibacterial activity of 2% chlorhexidine gluconate and 5.25% sodium hypochlorite in infected root canal: in vivo study. J Endod 30(2):84-87.

4. Hand RE, Smith ME, Harrison JW (1978) Analysis of the effect of dilution on the necrotic tissue dissolution property of sodium hypochlorite. J Endod 4(2):60-64.

5. Senia ES, Marraro RV, Mitchell JL, et al (1975) Rapid sterilization of gutta-percha cones with 5.25% sodium hypochlorite. J Endod 1(4):136-140.

6. Tay FR, Gu LS, Schoeffel GJ, et al (2010) Effect of vapor lock on root canal debridement by using a side-vented needle for positive-pressure irrigant delivery. J Endod 36(4):745-750.

7. Chow TW (1983) Mechanical effectiveness of root canal irrigation. J Endod 9(11):475-479.

8. Senia ES, Marshall FJ, Rosen S (1971) The solvent action of sodium hypochlorite on pulp tissue of extracted teeth. Oral Surg Oral Med Oral Pathol 31(1):96-103.

9. Boutsioukis C, Verhaagen B, Versluis M, et al (2010) Evaluation of irrigant flow in the root canal using different needle types by an unsteady computational fluid dynamics model. J Endod 36(5):875-879.

10. Bradford CE, Eleazer PD, Downs KE, et al (2002) Apical pressures developed by needles for canal irrigation. J Endod 28(4):333-335.

11. Desai P, Himel V (2009) Comparative safety of various intracanal irrigation systems. J Endod 35(4):545-549.

12. Mitchell RP, Yang SE, Baumgartner JC (2010) Comparison of apical extrusion of NaOCl using the EndoVac or needle irrigation of root canals. J Endod 36(2):338-341.

13. Parente JM, Loushine RJ, Susin L, et al (2010) Root canal debridement using manual dynamic agitation or the EndoVac for final irrigation in a closed system and an open system. Int Endod 43(11):1001-1012.

14. Gomez A (2009) Scanning electron microscope evaluation of smear layer removal using two different delivery systems for root canal irrigation. Master’s Thesis in Endodontics. San Luis Potosie, Mexico.  

15. Hockett JL, Dommisch JK, Johnson JD, et al (2008) Antimicrobial efficacy of two irrigation techniques in tapered and nontapered canal preparations: an in vitro study.
J Endod 34(11):1374-1377.

16. Gondim E, Setzer FC, Bertelli dos Carmo, et al (2010) Postoperative pain after the application of two different irrigation devices in a prospective randomized clinical trial.
J Endod 36(8):1295-1301.

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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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