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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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tech

Dr. Michael Sultan reflects on the technological advances that have revolutionized endodontics since the 1990s

For me, the greatest advances in endodontic technology came between 1990 and 2000. I think these two decades can be neatly bisected into a period of astonishing innovation and growth and one that was less exciting.
Understandably, the pace of change has slowed down as we have adopted and refined the technology we use, so the last decade has been much more about consolidation and less about paradigm shifts in endodontics.

Seeing is believing
Back in the 1990s, my favorite instrument was a Lustra™ DG16 (Dentsply), a sharp double-ended endodontic probe. We were totally reliant on probes because we couldn’t really see what we were doing; so much was by “feel” alone.
There were a few lucky dentists using loupes, some even had loupes and lights, but microscopes were a rarity and weren’t to become commonplace for another 10 years.
I remember going to meetings and seminars where a show of hands indicated who had a microscope and who didn’t, and it felt as though there was a two-tier system—the small minority who had the new technology and the rest trailing behind with just a probe.  
Finding an MB2 was always a bonus—there were even articles in the press about the geometry of locating this elusive canal, or looking out for a stream of bubbles, but even this was less than helpful.
Now, of course, it is impossible to imagine how we managed without microscopes, and I am disappointed if I cannot locate this canal and other additional canals. The microscope—and actually being able to see—was a steep learning curve but has utterly transformed endodontics.
Another area of technological advancement that has had a huge impact on the way we work is digital radiography, which means we are able to get images very quickly with a much lower radiation dosage. Digital images are easier to archive and have minimized the environmental impact of chemical fluids disposal.
In the past, I had arcane formulae for comparing the ratio of the file to the file on the radiograph, but paralleled radiographs coupled with an apex locator again removed the guesswork. I cannot do without the new generation of sophisticated apex locators, which are much smaller, more reliable and, most importantly, can work with various fluids in the canal.
First-generation apex locators were pretty crude and could only really be used in a completely dry canal, such that in a vital case, the tooth was pretty much prepared by the time it was dry. The new generation of apex locators is increasingly sophisticated, and I would trust them more than a radiograph with a file in a canal.

A total eclipse
However, digital radiography will ultimately be eclipsed by the latest advance in imaging—the CBCT scan. The first machines cost around $195,000. Now, they are less than half that price but still out of the reach of most, except for implant specialists.
In fact, there are but a handful of CBCT scanners in non-implant specialist practices, but I believe that will change, and they will follow the trend of microscopes and become the next defining change in endodontics.
While there will always be the radiation dosage to consider, the phenomenal 3-D images of the canal and complex root anatomy will have a major impact on diagnosis and treatment decisions.     

Broken files and broken hearts
In the dim and distant past of the 1990s, all preparation was by hand, carefully manipulating and rotating files. Eye strain and calloused fingers were an occupational hazard, but skills gained from the tactile feel of the files were invaluable.
The arrival of nickel-titanium files (NiTi) has been a mixed blessing. In the early days, protocols were vague, and new files broke straight out of the box, breaking our hearts at the same time. Now the file systems are safe, reliable, and predictable. And although every couple of years a new system comes out that is more resistant to fracture and more efficient, it is still simply a variation on a theme.
NiTi may be smoother and faster, but I firmly believe we are deluding ourselves if we think we are preparing a canal thoroughly when in reality we are pushing debris laterally, and our instruments are not even touching the walls. Okay, we may get a nice shape, but the canal might not even be clean.
The next paradigm shift in shaping will be the self-adjusting files (SAF Endo System®, Henry Schein Dental), which are made up of hollow, flexible lattice that allows continuous irrigation. This can adjust into grooves and noncircular canals giving real 3-D shaping, matching the canal system; this absolutely clean canal has to be the basis for successful endodontics.

Gold standards
I’ve seen changes in irrigants and filling techniques, too. While bleach, or sodium hypochlorite, has always been the gold standard, in the last decade there has been a move to using iodine as an adjunct, especially in re-treatment cases contaminated with E. faecalis, and the increasing use of chlorhexidine (2%) because it gives longer immunity.
In obturation, we have moved from the old-fashioned lateral-condensation filling technique, which was cheap but slow and difficult, to new systems where the obturation system material matches the preparation devices. The results look good radiographically, but lateral condensation is still the gold standard to which all else is compared.
Another much-researched material is mineral trioxide aggregate (MTA), which is a great biocompatible material for perforation repairs and surgery but is like packing wet sand, so it is not that easy to use. There has been a recent launch of a new material, and the scientific data is still awaited.
Interestingly, despite these incredible technological innovations, which have totally revolutionized the way we work, success rates in modern endodontics are not improving. That is due in part to the fact that we are able to take on far more complex treatments, which a few years ago we would not have even considered. We have excellent preparation techniques, but the real challenge is still cleanliness, because irregular, inaccessible portions of the root canal system and coronal leakage will always exist.

The big ouch
Of course, there is disappointment that so much rapid progress is not universal. We are no nearer to getting a reliable pulp test and still rely on patients to say “ouch” as we pulp test teeth to assess which ones are vital (ouch) and which ones are inflamed (big ouch). And, we are still using needles for our injections. Although I’m a dedicated Wand™ (Milestone Scientific) user, which cuts down on discomfort and stress, ultimately there must be something better. So, the next decade or two of discovery and innovation will be fascinating.

 

Michael Sultan, BDS, MSc, DFOd, FICD, is a specialist in endodontics and the clinical director of EndoCare. Dr. Sultan qualified at Bristol University in 1986 and worked as a general dental practitioner for 5 years before commencing specialist studies at Guy’s hospital, London, where he completed his MSc in endodontics in 1993. For more information about EndoCare, please visit www.endocare.co.uk.

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Latest News

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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