April 2018 Bacteria and the Root Canal System Cone Beam CT and Endodontic Treatment Prospects of Regrowing Pulps JournaCALIFORNIA DENTAL ASSOCIATION

EVOLVING ASPECTS OF ENDODONTIC

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DEPARTMENTS

209 The Editor/The TDSC Marketplace and You

213 Letter to the Editor

215 Impressions

269 RM Matters/Spring Cleaning Isn’t Limited to the Offi ce: Update Patient Records To Mitigate Risks

273 Regulatory Compliance/Managing Emergency Patients 278 Tech Trends 215

FEATURES 221 Evolving Aspects of Endodontic Treatment An introduction to the issue. Leif K. Bakland, DDS

227 Can We Eliminate Microorganisms From the Root Canal System? This article discusses the current status of irrigation effectiveness and progress. Markus Haapasalo, DDS, PhD

237 Can Use of Cone Beam Computed Tomography Have an Effect on Endodontic Treatment? This paper reviews the most updated guidelines for use of CBCT to illustrate the effects this has on clinical endodontic practice. Robert S. Roda, DDS, MS

249 Can We Regrow Pulps? This manuscript discusses techniques for managing teeth that will allow continued root development in young patients. Paul V. Abbott, BDS, MDS

260 Implant Dentistry and Endodontics: Can There Be a Mutually Beneficial Relationship? This article reports on the value of dental implants when indicated and the coexistence of endodontics and implant dentistry. Tory Silvestrin, DDS, MSD, and Charles J. Goodacre, DDS, MSD

APRIL 2018 207 CDA JOURNAL, VOL 46, Nº4

Volume 46, Number 4 JournaCALIFORNIA DENTAL ASSOCIATION April 2018 CDA Classifieds.

Free postings. published by the Editorial Production Manuscript California Kerry K. Carney, DDS, CDE Val B. Mina Submissions EDITOR-IN-CHIEF SENIOR GRAPHIC DESIGNER Priceless results. Dental Association www.editorialmanager. 1201 K St., 14th Floor [email protected] com/jcaldentassoc Sacramento, CA 95814 Randi Taylor SENIOR GRAPHIC DESIGNER 800.232.7645 Ruchi K. Sahota, DDS, CDE ASSOCIATE EDITOR cda.org Letters to the Editor Upcoming Topics www.editorialmanager. Brian K. Shue, DDS, CDE May/General Topics com/jcaldentassoc CDA Offi cers ASSOCIATE EDITOR Natasha A. Lee, DDS June/Millennial Dentists PRESIDENT Gayle Mathe, RDH July/Student Research Subscriptions SENIOR EDITOR [email protected] Subscriptions are available only to active members of R. Del Brunner, DDS Leif K. Bakland, DDS Advertising the Association. The PRESIDENT-ELECT GUEST EDITOR Sue Gardner subscription rate is $18 and [email protected] ADVERTISING SALES is included in membership Andrea LaMattina, CDE [email protected] dues. Nonmembers can PUBLICATIONS MANAGER Richard J. Nagy, DDS 916.554.4952 view the publication online VICE PRESIDENT at cda.org/journal. [email protected] Kristi Parker Johnson EDITORIAL SPECIALIST Permission and Manage your subscription Judee Tippett-Whyte, DDS Reprints online: go to cda.org, log in SECRETARY Blake Ellington Andrea LaMattina, CDE and update any changes to TECH TRENDS EDITOR [email protected] PUBLICATIONS MANAGER your mailing information. [email protected] Email questions or other Steven J. Kend, DDS Jack F. Conley, DDS 916.554.5950 changes to membership@ TREASURER EDITOR EMERITUS cda.org. [email protected] CDA classifiedsclassifieds wworkork harder to Robert E. Horseman, DDS HUMORIST EMERITUS bbringring you resuresults.lts. SeSellinglling a practice Craig S. Yarborough, DDS, MBA or a piece ooff equipment? Now you SPEAKER OF THE HOUSE [email protected] can include photos to help buyers Stay Connected cda.org/journal Clelan G. Ehrler, DDS see the potential. IMMEDIATE PAST PRESIDENT [email protected] And if you’re hiring, candidates Management Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the anywhere can apply right from California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Peter A. DuBois Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal the site. Looking for a job? You can EXECUTIVE DIRECTOR of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. post that, too. And the best part— Jennifer George The California Dental Association holds the copyright for all articles and artwork published it’s free to all CDA members. CHIEF MARKETING OFFICER herein. The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for Carrie E. Gordon any expression of opinion or statement of fact, all of which are published solely on the authority All of these features are designed to CHIEF STRATEGY OFFICER of the author whose name is indicated. The association reserves the right to illustrate, reduce, help you get the results you need, revise or reject any manuscript submitted. Articles are considered for publication on condition Alicia Malaby that they are contributed solely to the Journal. faster than ever. Check it out for COMMUNICATIONS DIRECTOR Copyright 2018 by the California Dental Association. All rights reserved. yourself at cda.org/classifieds.

208 APRIL 2018 Editor CDA JOURNAL, VOL 46, Nº4

The TDSC Marketplace and You Kerry K. Carney, DDS, CDE

hen I was a child, we would order our shoes from the For the Marketplace to succeed and support Sears, Roebuck and our members, CDA members need to support Company catalog. I the Marketplace by using it to buy supplies. Wcan remember my mother tracing around my foot to record my footprint on a piece of paper that she would then send to the mail- order company. After some weeks, the box would arrive with my new penny loafers. It The Dentists Service Company is The staff member who does the ordering was easy and convenient. We did not have striving to recreate that experience for will have to change the way she or he has to drive into a big city to purchase shoes. our CDA members when we order dental ordered for years. This can be diffi cult. Sears and Roebuck began as a watch supplies through the TDSC Marketplace. There are issues of friendship, trust, loyalty, and jewelry mail-order company in 1893. The Marketplace was established to provide ease and familiarity. They may have had Rural areas at that time offered a limited CDA members with the same advantage the same dental supply representative for variety of items at prices that varied that large group practices enjoy in securing years. It can feel like a betrayal of a friend. according to the vendor’s inclination. favorable pricing. The price-negotiating Also, in some offi ces the dental supply rep The mail-order company expanded and power of CDA’s 27,000 members can does the inventory and restocking, thereby became successful because it offered a wide translate into reductions in overhead and saving the staff member the physical effort. selection of products at set, listed prices. In overall cost of providing patient care. But though this cooperation on the part 1906, Sears went public and was the fi rst For the Marketplace to succeed and of the rep may seem like it is free, we all major retail IPO in American fi nancial support our members, CDA members know the cost is part of the calculus that history. In the three decades between 1925 need to support the Marketplace by determines the supply prices. Sometimes and 1955, Sears expanded into brick-and- using it to buy supplies. This sounds the supply ordering may be the job of a staff mortar stores and the sales from those easy. The pricing is very good and the member who does not feel comfortable stores eventually exceeded the mail-order shipping is free. If they do not have the with the computer. This can make it revenue. In 1993, Sears discontinued its item you are looking for, they will try to hard to switch over to the online site. catalog. The company continued to expand source it for you so it will be available Therefore, it may be necessary to assign and its profi ts peaked at $1.5 billion in in the future. They are eager for your the job to another more computer-savvy 2006. However, just four years later, their feedback and will adapt to your needs and member of the offi ce team. Sometimes profi ts plummeted to virtually nothing. suggestions. It is easy to reach a human the hard job of changing gets in the way. The irony here is that in 1994, just to speak to for customer support and they In my offi ce, I was very excited about one year after Sears discontinued its strive for excellence in every customer the Marketplace. I introduced my staff catalog business, Jeff Bezos incorporated interaction. But I want to advise you of to it and said, “This is where we want to the company that would eventually one hurdle that you must overcome. place our orders.” I checked in a few days be known as Amazon. The mail-order When I talk with colleagues about later and asked, “Did you order this from business that had been abandoned by Sears the Marketplace, they “get it” right away. TDSC?” The answer was no. I explained was reinvented and became the online They understand how it can help their again that we wanted to support TDSC immediate-gratifi cation machine and the practices and they want to support an and place our orders there. I checked e-commerce gargantua that it is today. endeavor designed by CDA to benefi t again a few days later and found they And now for my confession: I love to CDA members. They sign in and take a were still using the familiar suppliers. shop online. It is easy and convenient. I look at the site. They see the advantageous So I had to crack down and say, “From can compare prices before buying. I can pricing and they are sold. Then comes now on, you must fi rst check the price shop at any hour and free shipping and the hurdle: Usually, the dentist is not the of the item we need on the Marketplace easy returns make me a loyal customer. team member who does the ordering. site and if it is lower, order it there.”

APRIL 2018 209 APRIL 2018 EDITOR

CDA JOURNAL, VOL 46, Nº4

Finally, because my staff loves to staff members investigate the site The Journal welcomes letters fl aunt a retail bargain, they started specials and popular alternatives to the We reserve the right to edit all communica- coming to me to brag about how much items we usually order and take great tions. Letters should discuss an item published in money they had saved by ordering a pleasure in racking up the savings. the Journal within the last two months or certain item through TDSC. When Your role in the success of matters of general interest to our readership. they fi nally became familiar with the TDSC is as clear as Newton’s First Letters must be no more than 500 words and process, they were sold. They now Law of Motion. A body at rest will cite no more than fi ve references. No illustra- have their favorite customer service remain at rest unless acted upon tions will be accepted. Letters should be representatives at TDSC. They by an external force. Each of us submitted at editorialmanager.com/jcaldentas- know them by name. They do not needs to be that external force. soc. By sending the letter, the author certifi es hesitate to tell TDSC reps what our We need to give our staff members that neither the letter nor one with substantially offi ce needs. If a product is not yet that little persistent push to make similar content under the writer’s authorship has available through the Marketplace, sure that we support TDSC’s group been published or is being considered for our customer service rep will add it buying site, the Marketplace. The publication elsewhere, and the author acknowl- to their acquisition list and let us more successful TDSC is, the more edges and agrees that the letter and all rights with know when it becomes available. My TDSC can help us succeed. ■ regard to the letter become the property of CDA.

THERE’S NO BETTER TIME for a member SHARE to get a new member. Our newest benefit? MEMBER Group purchasing savings on dental supplies BENEFITS. through the TDSC Marketplace. GET Refer your colleagues and be rewarded. 1. RECEIVE A $100 AMERICAN EXPRESS® REWARDED GIFT CARD from ADA.1 THREE 2. RECEIVE $100 TO SHOP THE TDSC WAYS. MARKETPLACE from CDA.1

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THE MORE NEW MEMBERS YOU REFER, Offer subject to change. See official guidelines at cda.org/mgm. 1 Rewards issued to referring member once referral joins and pays THE MORE REWARDS! required dues. Total rewards possible per calendar year are limited to $500 in gift cards from ADA and $500 in value from CDA. 2 Rewards issued to referring member once referral joins, pays required dues and Get started at cda.org/mgm. spends $250+ in the TDSC Marketplace by December 31, 2018.

210 APRIL 2018 QUESTIONS MOST OFTEN ASKED BY SELLERS:

1. Can I get all cash for the sale of my practice?

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4. How can I most successfully transfer my patients to the new dentist?

5. What if I have some reservation about a prospective Buyer of my practice?

6. How can I be certain my Broker will demonstrate absolute discretion in handling the transaction in all aspects, including dealing with personnel and patients?

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7. What are the tax consequences for the Buyer when purchasing a practice? 2IÀFHV Lee Skarin & Associates have been successfully assisting Sellers and Buyers of Dental Practices for nearly 30 years in providing the answers to these and other 805.777.7707 questions that have been of concern to Dentists. 818.991.6552 Call at anytime for a no obligation response to any or all of your questions Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 CA DRE #00863149

Letter CDA JOURNAL, VOL 46, Nº4

Bacteria Live Under Treated Caries

our readers may be fascinated recent visit to TRAC Research, I was sterile samples at the very end, after the by a set of experiments spellbound by the measures they took. thousands of bacteria in each step prior. recently described by Dr. Christensen and her colleague Dr. Christensen’s study shows that Rella Christensen, RDH, Brad Ploeger generously showed me there is work left to do. For now, if no PhD, and her colleagues their clinical laboratory and walked me treatment of caries actually arrests all Yat Technologies in Restoratives and through each excruciating step. This bacterial growth (neither Gordon J. Caries (TRAC) Research in a study was the most careful microbiological Christensen-quality fi llings or SDF), published in Clinicians Report. They study I have ever seen — and coming then what do our treatments actually have shown beyond a reasonable doubt from someone in a world-class infectious accomplish? The caring dentist would that living bacteria reside under all disease lab at the University of California, hope that operative or topical approaches manner of treated carious lesions. San Francisco, that means something. debulk the bacterial infection of a carious For a couple of years, TRAC Research Through physical isolation, lesion and limit access to nutrients for the has documented numerous vital microbes decontamination, upward negative remaining microbes, such that bacterial under fi llings. They harvested loads of bugs pressure and putting the microbiology growth and therefore the progression of after fresh cavity preparation performed workstations at the foot of the dental lesions is slowed so much that it would with the most aseptic techniques. Now they chair, they made possible the cultivation rarely be clinically relevant. Until announce the same following treatment and quantifi cation of live bacteria from we have more effective treatments, it with silver diamine fl uoride (SDF). These microgram samples taken in progressive seems that all dentistry may rely upon results pry open a question that would excavations — each from one turn of a a race against time, for the tooth to be easier for us dentists to ignore: What new quarter-round bur. Moreover, they exfoliate or the patient to pass before the are our treatments actually doing? identifi ed each isolate genetically. Each bacteria overcome the pulpal defenses. Dr. Christensen and colleagues went tooth contained its own positive and JEREMY HORST, DDS, PHD to extraordinary means to confi dently negative control. All studied lesions Postdoctoral Fellow reach their conclusions. During my they showed me had several completely UCSF DeRisi Lab

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APRIL 2018 213 Innovative education.

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TOOGEGETHT ER WEW ARER LIL MIM TLT ESSS Impressions CDA JOURNAL, VOL 46, Nº4

Alt-Logic David W. Chambers, EdM, MBA, PhD

Frankly, I have had enough of alt-truths. In the end, the facts are not determinative: It is the interpretation that counts. Most of us know where to get the facts we want, conveniently packaged in our favorite interpretations. And as for the other guy’s supposed facts, here are some convenient defenses: “It might be premature to comment,” “probability is not certainty,” “the sample size is too small” and “beware of overgeneralizing.” Information is a combination of the facts and the assumptions we make about what they would mean for us if true. When we witness a car accident or get an exposure, we say “Oh, no.” It is instinct to deny unwanted facts. The evaluation is instantaneous as though we were shielding ourselves from something we do not acknowledge as the case. If we don’t like the facts, we can make adjustments for the source. It is easy enough to say the radiograph is not diagnostic. Insurance will not cover this. Dentists do not choose a staff member or associate exclusively on the information about the candidate or they would all be after the same ones. Dentists typically diagnose the condition of a tooth by combining what they see with their years of clinical wisdom regarding “these kinds of teeth.” It is human nature to combine real, particular data The nub: with information about cases of a general nature. The sophisticated name for this is evidence-based dentistry. 1. All facts are alt-facts; it is the The critical question is how much weight should be interpretation that matters. placed on the facts and how much on generalizations about where the facts came from and what they mean. Typically, 2. If dentistry were reducible decisions that are based on an honest combination of to objective reality, staff or facts and their sources are better than decisions that undervalue either. There are formal techniques for this. computers would replace dentists. So it may be correct to say “beware of generalizations,” 3. Agreement with others is a but it is incorrect to say we can get rid of them. Better by far to say “be aware of generalizations.” It is unethical matter of perspective; unless we to use logic that misleads others by protecting our can see as others do, we are generalizations at the expense of inconvenient facts. pretty certain to disagree. What makes this an ethical matter is picking only the facts we want or distorting them to match our generalizations. The patient who declines the obvious best health options does so either because he or she has not been given David W. Chambers, EdM, MBA, PhD, is a professor full informed consent or because the common facts of dental education at the University of the Pacifi c, Arthur are placed in different contexts. Change the context A. Dugoni School of Dentistry, San Francisco, and the editor of the American College of Dentists. rather than the facts. A colleague who engages in what you may consider to be questionable treatment may have diagnosed the case exactly as you have. What is needed before judgment is comparing the contexts. ■

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CDA JOURNAL, VOL 46, Nº4

Hot Tea, Smoking and Alcohol: A Cancer Cocktail Drinking hot tea, when combined with heavy alcohol and tobacco use, increases the risk of esophageal cancer by fivefold, according to a China-based study published recently in the journal Annals of Internal Medicine. The study followed tea-drinking habits of more than 450,000 people Bacterial Fats Not aged 30 to 79 over the course of about nine years. Researchers asked Dietary Fats May Cause participants about their tea-drinking habits, along with other lifestyle choices, through a questionnaire. Heart Disease Research findings suggest that those who reported drinking hot or burning-hot New evidence suggests that fatty tea regularly in addition to excessively drinking alcohol or smoking (two already molecules might come not only from known causes of cancer) increased their chances of developing esophageal eating fatty, cholesterol-rich food but cancer. Excessive drinking was defined as having 15 grams of pure alcohol from bacteria in the mouth, which may (slightly more than a 12-ounce glass of beer or 5-ounce glass of wine) every day. explain why gum disease is associated Researchers noted that more studies are needed to confirm these findings with heart trouble, according to a and tea’s possible link to cancer. report in the Journal of Lipid Research. In response to the study, the Tea Association of the USA released a statement For decades, doctors and researchers pointing to the health benefits of tea, including research suggesting it could assumed that the lipids that can lead actually prevent cancer, and stating that “alcohol and tobacco appear to remain to heart attacks and strokes came from risk factors for esophageal cancer.” eating fatty food. But the research The International Agency for Research on Cancer (IARC), which is part of hasn’t borne this out. Some people who the World Health Organization, and the National Toxicology Program do not eat large amounts of fatty food don’t recognize tea as a carcinogen. But the necessarily develop heart disease. IARC did find that hot beverages (at least However, University of Connecticut 149 degrees) “probably” cause cancer researchers believe they may have solved of the esophagus. part of this puzzle. Using careful chemical analysis of atheromas — growths that form Learn more about this study in the in the walls of blood vessels — collected Annals of Internal Medicine (2018); from patients, they found lipids with a doi: 10.7326/M17-2000. chemical signature unlike those from animals. Instead, these strange lipids come from a specifi c family of bacteria called Bacteroides, which make distinctive fats. by an enzyme that processes lipids into the The next step in the research is The chemical differences between starting material to make infl ammation- to analyze thin slices of atheroma to bacterial and human lipids result in enhancing molecules. So the Bacteroidetes localize where the bacterial lipids are subtle weight differences between the lipids have a double whammy on the accumulating. If they are found within molecules, which might be the reason blood vessels: The immune system sees the atheroma but not in the normal they cause disease, according to the study. them as a signal of bacterial invasion and artery wall, that would be convincing The immune cells that initially stick to then enzymes break them down and super- evidence that these lipids are associated the blood vessel walls and collect the charge the infl ammation. Usually the specifi cally with atheroma formation and lipids recognize them as foreign, react Bacteroidetes bacteria stay in the mouth therefore contribute to heart disease. to the lipids and set off alarm bells. and gastrointestinal tract. If conditions are Learn more about this study in The research team showed that the right, they can cause gum disease in the the Journal of Lipid Research (2017); Bacteroidetes lipids could be broken down mouth but not infect the blood vessels. doi: 10.1194/jlr.M077792.

216 APRIL 2018 CDA JOURNAL, VOL 46, Nº4

Research Finds Markers for Early Diagnosis of Tongue Cancer Squamous cell carcinoma of the are signifi cantly reduced in tumor tissue tongue is an aggressive form of cancer compared to their matched nontumor that generally affects older people. tissues. This raises the prospect that Patients with the disease often fi nd certain bacteria and fungi, in suffi cient Cleveland Clinic and the University it diffi cult to eat, swallow food or amounts and in possibly interactive ways, Hospitals Cleveland Medical Center. speak. Reasons for its generally poor may play a part in the development of While the bacteriome is increasingly prognosis include late detection. oral tongue cancer, according to the recognized as playing an active role in But a new study published in the study conducted by a team of researchers health, the role of the mycobiome has journal Oncotarget found that bacterial from the Case Western Reserve never before been studied in the case of diversity and richness and fungal richness University School of Medicine, the oral tongue cancer. In the new study, the researchers extracted tissue DNA from 39 paired tumor and adjacent normal tissues from patients with the cancer. Analyses showed that Firmicutes was the Tooth Enamel Determines Sex of Human Remains most abundant bacterial phylum and was signifi cantly increased in tumors A new method for determining the sex of human remains using tooth compared to nontumor tissue (48 enamel has been discovered by researchers in the United Kingdom and Brazil, percent versus 40 percent, respectively). according to a study published in the journal Proceedings of the National In total, the abundance of 22 bacterial Academy of Science in December 2017. and seven fungal genera types was Determining the sex of human remains has applications in archaeological signifi cantly different between the tumor and legal contexts, among others. DNA sequencing can be used for sex and adjacent normal tissue, including determination, but the approach is often expensive, time-consuming and Streptococcus, which was signifi cantly depends on the quality of the DNA sample. In the study, researchers used increased in the tumor group (34 percent peptides from tooth enamel, a durable human body tissue, to develop a versus 22 percent in normal tissue.) method for determining the sex of human remains. “Our fi ndings mean that it may To extract peptides from tooth enamel, the method uses a minimally be possible to perform precautionary destructive acid-etch procedure. Sex chromosome-linked isoforms of amelogenin testing in patients at high risk for oral — an enamel-forming protein — are identified from the acid-etch sample using tongue cancer,” said the study’s co- nanoflow liquid chromatography mass spectrometry, according to the study. senior author Mahmoud A. Ghannoum, The authors tested the method on the remains of seven adult individuals from PhD, professor at the Case Western the late 19th century as well as male and female pairs from three archaeological Reserve School of Medicine and the University Hospitals Cleveland Medical sites ranging from 5,700 years ago to the 16th century in the United Kingdom. In Center. “If the patterns that we found each context, the method successfully determined the sex of the individuals, as are present in people who are not yet confirmed by comparison with coffin plates or standard osteological analyses. showing signs of lesions, we could According to the authors, the method mightht help improve begin treatment early, offering the techniques for sex determination of humann rremainsemains with possibility of better patient outcomes.” potential applications in bioarcheology Researchers say additional and medical-legal science. research is needed to understand how Read more of this study in the these two communities infl uence Proceedings of the National Academy off or are infl uenced in disease settings Science (2017); doi: 10.1073/ such as oral tongue cancer. pnas.1714926115. Learn more about this study in Oncotarget (2017); doi. org/10.18632/oncotarget.21921.

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‘Smart’ Material Could Help Fight Tooth Decay A study conducted by the University of Toronto has resulted in a novel way to minimize recurrent caries, according to research published recently in the journal Scientific Reports. Researchers in the university’s department of materials science and The researchers used a nozzle to engineering, faculty of dentistry and the Institute of Biomaterials and create the cavitation bubbles that Biomedical Engineering tackled the issue and proposed a novel solution — removed the plaque when they a filling material with tiny particles made by self-assembly of antimicrobial collapsed. (Credit: Hitoshi Soyama) drugs designed to stop bacteria in its tracks. The study shows that these particles may solve one of the biggest problems with antibacterial filling materials: How do you store enough drug within the material to be effective Blasting Dental Plaque for someone’s entire life? With Microbubbles “Adding particles packed with antimicrobial drugs to a filling creates a line of defense against cavity-causing bacteria,” said Professor Ben Hatton, PhD. A research team from Tohoku “But traditionally there’s only been enough drug to last a few weeks. Through University and Showa University in this research we discovered a combination of drugs and silica glass that Japan discovered that using a cavitating organize themselves on a molecule-by-molecule basis to maximize drug density jet to clean dental implants was more with enough supply to last years.” This discovery means the team can pack 50 effi cient and thorough than a water jet, which has been used for a long time to times as much of the bacteria-fighting drugs into the particles. remove plaque from dental implants “We know very well that bacteria specifically attack the margins between to keep them clean, according to a fillings and the remaining tooth to create cavities,” said Professor Yoav Finer, study published in the journal Implant DMD, PhD. “Giving these materials an Dentistry. A cavitating jet uses a nozzle antimicrobial supply that will last for years could to inject high-speed fl uid through greatly reduce this problem.” water to create very tiny bubbles of The research team plans to test these vapor. When these bubbles collapse, drug-storing particles in dental fillings. they produce strong shockwaves that Read more of this study in Scientific Reports are able to remove contaminants. (2018); doi: 10.1038/s41598-018-19166-8. Researchers conducted the study to look for better ways for dentists to remove the plaque that builds up on the screws that hold dental implants in place. While the plaque sticks mainly between the amounts of dental plaque that water fl ow exerts shear stress to to the crown, it also adheres to the removed by both methods after one remove the biofi lm. In addition to microgrooves of the exposed parts of the minute of cleaning, that changed after this shear effect, the cavitating jet screws and are much harder to clean. longer exposure. After three minutes, also produces a considerable force To compare the cleaning effect the cavitating jet had removed about when the bubbles collapse that is able of a cavitating jet to that of a water a third more plaque than the water jet to remove particles from the biofi lm jet, the team grew a biofi lm within did, leaving little plaque stuck to the and carry them away. The researchers the mouths of four volunteers. implant at the end of the experiment. suggest that the two processes probably After three days, they used the two The cavitating jet was also able to work in synergy to make the cavitating different methods to clean the mouths, remove the plaque not only from the jet superior to the water jet. measuring the amount of plaque root section of the screws, but also from Read more of this study in remaining at several time intervals. the harder-to-reach crest section. Implant Dentistry (2017); doi: While there was little difference Previous research has shown 10.1097/ID.0000000000000681.

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Scotland Launches Oral Health Improvement Plan The Scottish government recently preventive treatment for children. This launched a nationwide Oral Health system will include oral health risk Improvement Plan (OHIP) to provide a assessments (OHRA). Patients will be framework for improving the oral health of seen according to their OHRA results, “the next generation,” according to a news meaning they may be recommended to article on the website fl uoridealert.org. visit the dentist once every 24 months. As part of the OHIP, the government The OHIR will also implement ways will introduce a system of monitoring to to meet the needs of Scotland’s aging ensure that all dental practices provide population. The Scottish government predicts that the number of people aged over 65 will increase by 53 percent by 2039 and has therefore decided to introduce arrangements to accredited general dental practitioners to provide Wine Polyphenols Could Benefi t Oral Health care in elderly care homes. Additionally, Abundant and structurally diverse polyphenols have been attributed dental practices will be required to display to the healthy effects of wine on the colon and heart, but new research the government oral health information reported in the American Chemical Society’s Journal of Agricultural and on self-care, treatments available, costs Food Chemistry in February 2018 shows that wine polyphenols might also and services and to communicate be good for oral health. this information clearly to patients. Polyphenols are antioxidants, meaning they likely protect the body from In response to the 46 percent increase harm caused by free radicals. However, recent work indicates polyphenols might in the number of dentists working under Scotland’s national health system — from also promote health by actively interacting with bacteria in the gut. That makes 2,474 in March 2007 to 3,613 in March sense because plants and fruits produce polyphenols to ward off infection by 2017 — the OHIP will establish a dental harmful bacteria and other pathogens, according to research. workforce planning forum, which will M. Victoria Moreno-Arribasm, who studies wine chemistry, and research make recommendations for workforce colleagues from the University of Madrid in Spain wanted to know whether requirements, morale and issues affecting wine and grape polyphenols would also protect teeth and gums, and if so, dental teams. Promotional programs will how this could work on a molecular level. The researchers checked out the also be developed to encourage dentists effect of two red wine polyphenols, as well as commercially available grape to work in rural areas of Scotland, and a seed and red wine extracts, on bacteria that stick to teeth and gums and European Union (EU) dentists’ network cause dental plaque, cavities and periodontal disease. will be established for after Brexit, providing Working with cells that model gum tissue, they found that the two wine an opportunity for dentists from the EU to polyphenols in isolation — caffeic and p-coumaric acids — were generally engage with Scotland’s chief dental offi cer. better than the total wine extracts at cutting back on the bacteria’s ability to While the government admits OHIP stick to the cells. When combined with the Streptococcus dentisani, which is is an ambitious program of work, it has believed to be an oral probiotic, the polyphenols were even better at fending pushed on to establish a number of off the pathogenic bacteria. The researchers also showed that metabolites short-term working groups to take it that formed when digestion of the polyphenols forward. In the meantime, a biannual begin in the mouth might be responsible for some newsletter will be produced to provide of these effects. updates on the progress that is being made Learn more about this study in the Journal toward implementation and a number of of Agricultural and Food Chemistry (2018); doi: “roadshow” events will be held to discuss 10.1021/acs.jafc.7b05466. the implementation arrangements. Read more about Scotland’s Oral Health Improvement Plan at fl uoridealert.org/news/30322.

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Evolving Aspects of Endodontic Treatment

Leif K. Bakland, DDS

GUEST EDITOR

Leif K. Bakland, DDS, urrent evolving aspects Root Canal Disinfection is a distinguished emeritus of endodontic treatment The pulp spaces in human teeth professor of endodontics at are connected to many are complex. That notion is not new the Loma Linda University historical efforts to save — a century ago Hess3 examined 2,800 School of Dentistry. His professional career has and preserve teeth. An extracted teeth and described the been devoted to teaching, Coft-quoted recommendation in Miguel anatomy of the root canal system; his research and patient care. de Cervantes’ novel, Don Quixote, is still images show pulp spaces with numerous He is the author and co- good advice 400 years later: “Because I’ll variations in shapes and sizes. In recent author of more than 100 have you know, Sancho, that a mouth without years, the advent of microcomputed scientifi c abstracts, articles and book chapters and was teeth is like a mill without its stone, and you tomography (microCT) has allowed 1 co-editor with John Ingle, must value a tooth more than a diamond.” an even more detailed examination DDS, of the fourth, fi fth To appreciate the treatment advances of the complexity of the root canal and sixth editions of Ingle’s that have been and continue to be made system4 (FIGURE 1). From such micro- Endodontics. in patients with endodontic problems, one CT images one can only wonder how Confl ict of Interest Disclosure: None reported. may look at the evolving understanding root canal treatment can be done and of the etiology and diagnosis of pulpal and how such treatment can succeed. periapical disease. That understanding From the beginning of human history has led to improvements in treatment and through subsequent millennia until outcomes making endodontic treatment the last couple of centuries, dental a quite predictable treatment modality.2 pulp infections from caries and trauma This issue of the Journal contains have been major medical problems. reports on current advances in endodontic Bacteria are for the most part prevented treatment procedures in four areas: from penetrating through the skin and Management of bacterial contamination mucous membranes into underlying in the root canal system; improvement in tissues. But when they gain access to visualization of the tooth-bone complex the dental pulp, they can grow in a through cone beam computed tomography; protected environment not accessible to replacement of necrotic pulpal tissue the body’s defense system and stimulate in developing immature teeth; and infl ammatory reaction in tissues enhanced understanding of the balance surrounding the tooth and even invade between endodontics and dental implants these tissues and the bloodstream. The in a patient-centered environment. result can be disastrous (FIGURE 2).

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FIGURE 1. MicroCT of a maxillary molar FIGURE 2A. FIGURE 2B. showing the complex anatomy of the root canal system. (Courtesy Gina D. Roque-Torres, DDS, FIGURES 2. During excavation in 2005 at the Jamestown settlement near Williamsburg, Va., by the Jamestown PhD, MSD, Center for Dental Research at the Rediscovery and the Smithsonian Institution, the skeletal remains of a 15-year-old boy were exhumed. According Loma Linda University School of Dentistry) to historical records, he died in an American Indian attack in 1607. Martin D. Levin, DMD, adjunct professor of endodontics at the University of Pennsylvania, and Barry Pass, BSc, MSc, DDS, PhD, professor of oral diagnosis and radiology at Howard University, assisted in the analysis of the traumatic fracture of the mandibular left central incisor in early childhood, leading to food impaction, bacterial infection of the pulp and extensive alveolar bone Until modern times, the most destruction. The skull of JR1225B showing a missing buccal plate and missing mandibular incisors (2A). The common treatment for infected, painful fractured margins of the mandibular buccal plate appear to fl are anteriorly and the lingual cortical plate is intact. teeth was usually extraction, often a The anterior mandible shows radiographic features consistent with buccal and lingual expansion with a large area of crude and painful procedure. There were, bone destruction. An intraoral radiographic image of the mandibular left central incisor showing an immature tooth however, according to Ingle et al.1 some with a complicated crown fracture with pulp exposure (2B). The canal contained cotton fi bers indicating that an innovative approaches to treatment based eff ort had been made to prevent food impaction. (Courtesy Martin D. Levin, DMD, Washington, D.C.) on the notion that “tooth worms” were responsible for the dental problems — an idea that fi rst seemed to have originated of diseased pulp tissue, a procedure who had studied microbiology under in China perhaps as long as two millennia that sometimes was accomplished by Dr. Robert Koch (of Koch’s postulate ago. The Chinese then started applying cauterization with red-hot wires.1 It is not fame) in Berlin. Dr. Miller laid the arsenicals to carious lesions, a procedure known when the fi rst root canal fi lling foundation for modern endodontics that much later was also adopted in was placed, but McQuillen7 reported with the publication of his classic 1890 Europe and subsequently in the U.S.5 seeing a patient who had a root-fi lled textbook Microorganisms of the Human A more invasive approach was tooth that likely was treated in the early Mouth.8 Thus, the technical and the reported by Zias and Numeroff.6 They part of the 1800s. The root canal fi lling biological concepts were coming together discovered, in a mass grave in the Negev material apparently was gold foil. Later to help form a sound basis for saving Desert, a skeleton from 200 BCE with in the 19th century, further progress in teeth through root canal therapy. a maxillary lateral incisor that had a endodontics saw the introduction of the Recognizing that bacteria play 2.5 mm bronze wire inserted in the root rubber dam for dental procedures, root an important role in many diseases, canal. Radiographically, the tooth apex canal instruments, intracanal antiseptics, including dental disease, researchers was associated with a large bony lesion, gutta-percha and local anesthesia.1 began to speculate that bacteria had likely of endodontic origin, and the By the end of the 19th century, the a special selective affi nity for certain wire was inserted in a way suggesting technical aspects of cleaning, preparing tissues and organs. That concept became some learned skills on the part of and fi lling root canal spaces were the basis for the focal infection theory,9 the person performing this ancient aided by the innovations described. which led to physicians blaming dental root canal treatment (FIGURE 3). Of equal importance was the growing diseases for such diverse conditions as More recent efforts to address pulpal understanding of the biological basis for rheumatism, appendicitis and ulcers. disease probably began about 250 years root canal treatment. Contributing to Contributing to this concept was a ago when the father of modern dentistry, this understanding was the work done seminal event in the history of dentistry Pierre Fauchard, recommended removal by Willoughby D. Miller, MD, DDS, that took place in 1910 when a physician

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Pulp Space Visualization Medical radiology was introduced in the 1890s on both the European and the American continents. In 1895 in Germany, Dr. Wilhelm Conrad Röntgen (FIGURE 4) discovered what he termed X-rays. At the same time in the U.S., Nikola Tesla and Thomas A. Edison made the same discovery and adopted 14 FIGURE 3. Oldest known root canal FIGURE 4. Dr. Wilhelm Conrad Röntgen, Dr. Röntgen’s term for the cathode rays. fi lling. Radiograph of a maxillary 1845–1923. (www.nobelprize.org/nobel_ German dentist Friedrich Otto von lateral incisor from skeletal remains prizes/physics/laureates/1901/rontgen-bio.html) Walkhoff made the fi rst dental image in an excavation site in the Negev with X-rays shortly thereafter.15 In the Desert from about 200 BCE. A U.S., Morton16 was probably the fi rst to bronze wire was implanted in the describe its use in dentistry, when in 1896 root canal perhaps to prevent food he addressed the New York Odontological impaction. (Used with permission Ingle et al. ENDODONTICS, 5th ed. thus leading to what Dr. Louis I. Society and demonstrated radiographs of 12 BC Decker, 2002, Chapter 1, fi gure Grossman later described as a national teeth. Interestingly, he also noted “that the 1. First published: Zias J, Numeroff furor that resulted in people running pulp-chamber is beautifully outlined …” K. Operative dentistry in the second to their physicians to inquire whether Being able to visualize the root century BCE. J Am Dent Assoc 1987; illnesses they had were the result of canal system became an important 114:665–6.) bad teeth and then to their dentists to modality in the treatment of teeth have the teeth taken out. Dr. Grossman with pulpal problems. The fi rst summarized the problem by observing: dentist to use radiography for root from the United Kingdom, Dr. William “The focal infection theory that canal therapy was Dr. C. Edmund Hunter, gave a stirring speech at McGill’s created dissensions among dentists, and Kells in New Orleans in 1899.17 The University in Montreal entitled “The role between dentists and physicians, was obvious benefi ts included the ability of sepsis and antisepsis in medicine.”10 Dr. destined to die a slow, reluctant death, to visualize the canals and to monitor Hunter had observed in the U.K. a dismal but leaving many people edentulous.” treatment outcomes (FIGURES 5). state of dental health in the population There were, however, many pioneers in Advances in radiographic equipment at large — patients with rampant caries endodontics, including Dr. Grossman, and X-ray fi lms proceeded over the and periodontal disease, a condition he who were able to demonstrate that following decades with the next major called “oral sepsis.” What made it worse endodontic treatment was safe and progress being the development of was that in many cases patients had valid.12 Sadly, the false concept of digital radiography.18 Again, endodontic gold crowns and bridges sitting on top focal infection appears occasionally treatment benefi tted from this technical of rotting teeth. Incidentally, in Europe even in modern times.13 advance with the ability to get instant this type of dentistry — that is gold While concerns about focal infection imaging of a tooth and convenient crowns and bridges — was often called are not the driving force, eliminating enhancement of the image quality. “American dentistry”! His description bacteria from the root canal system The latest development in dental was graphic as he painted a picture has been a goal for a long time. Many imaging is the application of cone of gold crowns as “… mausoleums approaches, from disinfectants and beam computed tomography (CBCT). of gold over a mass of sepsis.”11 irrigants to ultrasonic stimulation, Endodontists were quick to recognize the Dr. Hunter’s speech contributed to have been tested and new innovations benefi ts of three-dimensional imaging and the notion that foci of infection could are on the horizon. In this issue, have adopted its use extensively.19,20 The disseminate bacteria to tissues and author Markus Haapasalo, DDS, increasing role of CBCT in endodontic organs all over the body. It apparently PhD, discusses the current status of treatment is explored by author Robert made sense in the medical community, irrigation effectiveness and progress. S. Roda, DDS, MS, in this issue.

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FIGURE 5A. FIGURE 5B. FIGURE 5C.

FIGURES 5. Root canal treatment by Dr. G. Mitchell in 1920. Preoperative fi lm (5A). Completed treatment — note chloroform softened gutta-percha extending past apical foramen. This was done on purpose to allow for shrinkage of the softened gutta-percha (5B). Two-year follow-up (5C). Nearly complete bony healing and absorption of the excess fi lling material. Note that the complexity of the root canal system could be readily visualized radiographically.

Treatment Options for Diseased Pulps A new era in pulp treatment and allowing a blood clot to form in the The specialty of endodontics is began when the fi rst bioceramic space where the infected pulp tissue had involved with the physiology and material, mineral trioxide aggregate been removed. They sealed the occlusal pathology of the dental pulp.21 Historically (MTA), was shown to be useful for access and monitored the outcome, that meant recognizing pulps that were pulp capping in traumatically exposed which was continued root formation diseased and needed to be removed and teeth.28 It was subsequently shown along with healing of the apical abscess. replaced with a fi lling material such as that it could also be successfully used The Iwaya report generated an silver points or gutta-percha. Preserving in teeth with carious pulp exposures29 immense interest among endodontists. pulp tissue, however, was promoted by (FIGURES 6). Further, a recent study Could diseased pulp tissue be replaced some dentists; the fi rst to recommend that showed MTA to be more predictable with new pulp tissue — pulp regeneration? idea was probably Dr. B.W. Hermann22 than CH in treatment of teeth with While that question stimulated case nearly a century ago when he published carious exposures.30 Preserving vital reports, professional lectures and his report on the use of calcium hydroxide pulps has now become an important research projects, it is reasonable (CH). Dr. Grossman15 paid tribute to Dr. component of general dentistry as well to conclude that at this time “pulp Hermann by pointing out that his purpose as pediatric dentistry and endodontics.31 regeneration” is not clinically feasible.34,35 for suggesting CH as a medicament was A new era of pulp therapy arrived But techniques for managing teeth in “not to destroy but to heal the pulp.” with the clinical report published in young patients to allow continued root In subsequent decades, CH became 2001 by Iwaya et al.32 They demonstrated development continue to be developed. a much relied-upon medicament for that teeth with dens evaginatus could Author Paul V. Abbott, BDS, MDS, treatment of the pulp.23–25 For the most be treated in a way that would preserve discusses the topic in this issue. part, however, treatment with CH was uninfected pulp tissue in the root canal confi ned to immature, developing teeth and permit continued root formation. Endodontics and Dental Implants with traumatic crown fractures; the Dens evaginatus is an anomaly of Dental implants have a long procedure became knowns as a Cvek-type odontogenesis in which a central cusp history. The ancient Mayans apparently pulpotomy. It was rarely used in teeth with develops on the occlusal surface of successfully placed dental implants.36 carious pulp exposures.26 The expected a crown, and during eruption, when In 1913, Dr. E.J. Greenfi eld from response to exposing pulp tissue to CH was contact is made with the opposing tooth, Kansas presented a lecture on the “… development of a hard tissue barrier (dentin the cusp can fracture and expose the implantation of artifi cial roots …” made bridge) to protect the underlying pulp tissue. underlying pulp providing a pathway from irridio-platinum to which crowns One of the problems with the use of CH in for bacteria to enter.33 In the case could be attached.37 But it was not until these cases is that CH gradually neutralizes presented by Iwaya et al.,32 the bacteria the 1970s that root-formed implants, as and loses its ability to kill bacteria. If had stimulated a periapical response developed by Per-Ingvar Brånemark in microleakage of the coronal restorations resulting in an apical abscess. The authors Sweden, again appeared.38 During the occurs, bacteria may then penetrate through decided to attempt to preserve as much preceding years, other types of implants, the CH-generated dentin bridge through pulpal tissue as possible and limited the such as the blade and the subperiosteal which they can cause pulpal disease.27 treatment to removal of infected tissue implants, had gained prominence.39

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Recognizing the value of dental implants when indicated, endodontists also began placing them.48,49 In this FIGURE 6B. issue, authors Tory Silvestrin, DDS, MSD, and Charles J. Goodacre, DDS, FIGURE 6A. MSD, report on the coexistence of endodontics and implant dentistry. Root canal therapy has evolved over the past two centuries to where treatment outcomes are highly favorable.2 In this issue, we describe evolving aspects of endodontic treatment that may further promote efforts to preserve natural dentition. ■

REFERENCES 1. Ingle JI, Bakland LK, Beveridge EE, Glick DH, Hoskinson AE. FIGURE 6C. FIGURE 6D. Modern endodontic therapy. In Ingle’s ENDODONTICS, Ingle JI, Bakland LK, eds. 5th ed. Chapter 1, BC Decker, Hamilton, FIGURES 6. Vital pulp therapy with bioceramic cement (MTA). The patient responded normally to cold test. Canada, 2002. Radiograph of a fi rst mandibular molar with deep distal caries (6A). Caries excavation resulted in two pulp 2. Friedman S. Endodontic treatment outcome: The potential for exposures (6B). Sodium hypochlorite on a cotton pellet was used for hemostasis. Postoperative radiograph MTA healing and retained function. In Ingle’s ENDODONTICS 6th covering the pulp exposers; the MTA was covered with a temporary fi lling, which subsequently was replaced with ed. Ingle JI, Bakland LK, Baumgartner JC, eds. Chapter 32. BC Decker Inc. Hamilton, 2008. a bonded composite resin fi lling (6C). Control radiograph taken eight years later. The tooth was comfortable, 3. Hess W. Formation of root-canals in human teeth. J National responded to pulp tests and no radiographic lesions were noted (6D). (Courtesy George Bogen, DDS, Los Angeles) Dent Assoc 1921;8:704–34. 4. Cleghorn BM, Goodacre CJ, Christie WH. Morphology of teeth and their root canal systems. In Ingle’s ENDODONTICS 6th ed, Ingle JI, Bakland LK, Baumgartner JC, eds. Chapter 6. FIGURE 7. root ratios. For a while the procedure BC Decker Inc. Hamilton, 2008. Endodontic gained some popularity and reported 5. White JD. Sensitive dentin — arsenic, and the treatment of the endosseous success39,42 (FIGURE 7). But reports dental pulp. Editorial. The Dental Cosmos 1864;6:27–8. 6. Zias J, Numeroff K. Operative dentistry in the second century implant on implant corrosion43,44 probably providing BCE. J Am Dent Assoc 1987;114:665-6. 7. McQuillen JR. Editorial. Who fi lled the fi rst nerve cavities? stabilization contributed to a reduced interest in endodontic implants over time. The Dental Cosmos 1862;3:556–7. of maxillary 8. Miller WD. The microorganisms of the human mouth. The S. lateral incisor As Brånemark’s root-formed S. White Dental Mfg. Co. Philadelphia, 1890. for 32 years. implants gained in popularity, 9. Rosenow EC. The relation of dental infection to systemic (Courtesy endodontists began to worry that disease. The Dental Cosmos 1917;59:485–91. Dr. Pabla 10. Hunter W. The role of sepsis and antisepsis in medicine and placement of dental implants would the importance of oral sepsis as its chief cause. Dent Register Barrientos, obviate the choice of endodontic 1911;44:579–611. Santiago, treatment for teeth with pulpal disease. 11. Hunter W. The role of sepsis and antisepsis in medicine. Chile) The Dental Cosmos 1918;60:585–602. But clinical data began to accumulate 12. Grossman LI. Focal infection: Are oral foci of infection related showing that endodontically treated to systemic disease? Dent Clin North Am 1960;4:749–63. teeth held up well in comparison 13. Pallasch TJ, Wahl MJ. Focal infection: new age or ancient 45,46 history? Endod Topics 2003;4:32–45. Endodontists became interested in with implants with the added 14. Abramovitch K. The 120th anniversary of the discovery endodontic endosseous implants when advantage of delaying the need of X radiation and dental radiology. LLUSD Articulator Orlay40 suggested their use in splinting for replacing a tooth. A pertinent 2016;27:38–44. 15. Grossman LI. Pioneers in endodontics. J Endod mobile teeth with periodontal disease. question was asked by Giannobile 1987;13:409–15. Frank41 soon after reported on six cases and Lang47 in a recent editorial, “Are 16. Morton WJ. The X-ray and its application in dentistry. The in which endodontic implants were dental implants a panacea or should Dental Cosmos 1896;38:478–86. 17. Langland OE, Langlais RP. Early pioneers of oral and used to stabilize teeth with poor crown- we better strive to save teeth?” maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral

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Radiol Endod 1995;80:496–511. 25. Cvek M. A clinical report on partial pulpotomy and 2014;30:440–50. 18. Farman AG, Ramamurthy R, Hollender LG. Digital imaging capping with calcium hydroxide in permanent incisors with 32. Iwaya S, Ikawa M, Kubota M. Revascularization of an for endodontics. In Ingle’s ENDODONTICS 6 ed, Ingle JI, complicated crown fracture. J Endod 1978;4:232–7. immature permanent tooth with apical periodontitis and a sinus Bakland LK, Baumgartner JC, eds. Chapter 15B. BC Decker 26. Cvek M. Partial pulpotomy in crown-fractured incisors — tract. Dent Traumatol 2001;17:185–7. Inc. Hamilton, 2008. results three to 15 years after treatment. Acta Stomatologica 33. Geist JR. Dens evaginatus. Oral Surg Oral Med Oral Oral 19. Fayad MI. Contemporary endodontic technology: Cone Croatica 1993;27:167–73. Pathol Oral Radiol Endod 1989;67:628–631. beam imaging in treatment planning. AAE Communiqué, 27. Bakland LK, Andreasen JO. Will mineral trioxide aggregate 34. Andreasen JO, Bakland LK. Pulp regeneration after non- January 2014, pp 3–7. replace calcium hydroxide in treating pulpal and periodontal infected and infected necrosis, what type of tissue do we want? 20. Setzer FC, Hinckley N, Kohli MR, Karabucak B. A survey healing complications subsequent to dental trauma? A review. A review. Dent Traumatol 2012;28:13–18. of cone-beam computed tomographic use among endodontic Dent Traumatol 2012;28:25–32. 35. Huang GT, Garcia-Godoy F. Missing concepts in de novo practitioners in the United States. J Endod 2017;43:699–704. 28. Pitt Ford TR, Torabinejad M, Abedi HR, Bakland LK. Using pulp regeneration. J Dent Res 2014;93:717–224. 21. Gutmann JL. History of endodontics. In Ingle’s mineral trioxide aggregate as a pulp-capping material. J Am 36. Ring ME. Dentistry: An Illustrated History. The CV Mosby ENDODONTICS 6th ed. Ingle JI, Bakland LK, Baumgartner JC, Dent Assoc 1996;127:1491–4. Company, St. Louis, 1985, p 17. eds. Chapter 2. BC Decker Inc. Hamilton, 2008. 29. Bogen G, Kim JS, Bakland LK. Direct pulp capping with 37. Greenfi eld EJ. Implantation of artifi cial crown and bridge 22. Dammaschke T. The history of direct pulp capping. J Hist mineral trioxide aggregate. An observational study. J Am Dent abutments. The Dental Cosmos 1913;55:364–9. Dent 2008;56:9–23. Assoc 2008;139:305–15. 38. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year 23. Berk H. The eff ect of calcium hydroxide methyl cellulose 30. Kundzina R, Stangvaltaite L, Eriksen HM, Kerosuo E. study of osseointegrated implants in the treatment of the paste on the dental pulp. J Dent Child 1950;17:65–8. Capping carious exposures in adults: A randomized controlled edentulous jaw. Int J Oral Surg 1981;10:387–416. 24. Cox CF, Bergenholtz G, Heys DR, Syed SA, Fitzgerald M, trial investigating MTA versus calcium hydroxide. Int Endod J 39. Lozada JL, Kleinman A. Osseointegrated dental implants. Heys RJ. Pulp capping of the dental pulp mechanically exposed 2016; doi: 10.1111/iej.12719. In Ingle’s ENDODONTICS 6th ed. Ingle JI, Bakland LK, to oral microfl ora: A one to two year observation of wound 31. Bakland LK, Andreasen JO. Biological considerations in Baumgartner JC, eds. Chapter 33. BC Decker Inc. Hamilton, healing in the monkey. J Oral Path 1985;14:156–68. the management of traumatic dental injuries. Endod Topics 2008. 40. Orlay HG. Endodontic splinting treatment in periodontal disease. Br Dent J 1960;108:118–21. 41. Frank AL. Improvement in the crown-root ratio by endodontic endosseous implants. J Am Dent Assoc 1967;74:451–62. 42. Wolff J, Sándor GK, Forouzanfar T, Schulten EAJM, Weekly Sterilizer Monitoring is Required by Law Oikarinen KS. A 22-year follow-up of an endodontic implant. Dent Traumatol 2015;31:409–12. 43. Seltzer S, Maggio J, Wollard R, Green D. Titanium endodontic implants: A scanning electron microscope, electron microprobe, and histologic investigation. J Endod 1976;2:267–76. 44. Simon JH and Frank AL. The endodontic stabilizer: Additional histologic evaluation. J Endod 1980;6:450–5. 45. Holm-Pedersen P, Lang NP, Müller F. What are the longevities of teeth and oral implants? Clin Oral Impl Res 2007;18:15–9. 46. Pjetursson BE, Brägger U, Lang NP, Zwahlen M. Comparison of survival and complication rates of tooth- supported fi xed dental prostheses (FDPs) and implant- supported FDPs and single crowns (SCs). Clin Oral Implants Res 2007;18:97–113. Proudly owned 47. Giannobile Wv, Lang NP. Are dental implants a panacea or should we better strive to save teeth? Editorial J Dent Res and operated in 2016;95:5–6. 48. Pecora G, Andreana S, Covani U, De Leonardis D, California. Schiff erle RE. New directions in surgical endodontics: immediate implantation into an extraction socket. J Endod 1996;22:135–9. 49. Silvestrin T. The role of implant dentistry in the specialty of endodontics. Endod Topics 2014;30:66–74.

THE AUTHOR, Leif K. Bakland, DDS, can be reached at Judy, did we run the spore test this week? [email protected].

LEBRA E T C I

N G 11306 Sunco Drive, Suite 7, Rancho Cordova, CA 95742 S www.oshareview.com • 800-555-6248 Y E A R

226 APRIL 2018 microbes

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Can We Eliminate Microorganisms From the Root Canal System?

Markus Haapasalo, DDS, PhD

ABSTRACT Bacteria in the root canal system are the causative factor of apical periodontitis (AP). Therefore, removing and killing these bacteria is the goal of endodontic treatment of AP. So far, none of the materials, methods and strategies employed has allowed elimination of all microbes in the root canal system. Emerging materials and equipment are moving us closer to predictable elimination of all root canal microbes.

AUTHOR

Markus Haapasalo, icrobial invasion through When the pulp has become necrotic, DDS, PhD, is a professor the protective layers of there are no defense mechanisms left in of endodontics at the the tooth, enamel, root the root canal. The newcomers, microbes, University of British Columbia in Vancouver, surface cement and dentin quickly develop biofi lm ecosystems Canada. He has published into the pulp is the most throughout the root canal system, attached extensively on endodontic Mcommon cause of pulpal and periapical to the root canal wall and to the necrotized topics, including biofi lm, infl ammation and infection. Other pulp tissue (FIGURE 4). Periapical disinfection, microbiology pathways for the microbes include leaking infl ammation starts when antigens start and endodontic materials. Confl ict of Interest fi llings, exposed dentin, trauma, cracks, spreading through the apical foramina Disclosure: Dr. Haapasalo lateral canals and even invaginations and into the periapical tissue (FIGURES 5A has commercial interest evaginations (FIGURE 1). Pulp infl ammation and 5B), similar to what happened when in two products named starts before the invading bacteria enter the bacteria in carious dentin sent antigens in the article: QMiX pulp from penetration of bacterial antigens (e.g., bacterial surface structures) toward (Dentsply Tulsa Dental) and 4 GentleWave (Sonendo). released from the carious lesion through the the pulp. There is strong consensus dentinal tubules toward the pulp (FIGURE 2). based on classical studies that apical These antigens are recognized by the periodontitis is caused by microbes in the defense system of the pulp, fi rst by antigen necrotic root canal, not by necrotic tissue presenting dendritic cells, followed by a per se (FIGURE 6).5,6 The pathogenesis wider participation of the immune system of pulpitis and apical periodontitis differ, and infl ammatory apparatus.1–3 Infection however, in one very important aspect: starts when bacterial cells enter the pulp. If The pulp has no collateral circulation left untreated, caries and bacterial invasion and is therefore vulnerable to irreversible thus lead to pulp infl ammation, infection infl ammation and necrosis to occur. The and eventually necrosis and apical periapical area is different; collateral periodontitis (FIGURE 3). circulation secures continuing presence

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of the host defense system, with a variety of different defense cell populations and active angiogenesis (FIGURE 7), which in most cases successfully fi ghts the invading bacteria and prevents them from establishing biofi lm communities outside the root canal system. Therefore, the goal FIGURE 2. Histological section showing bacteria of root canal treatment is to eliminate halfway in dentin and early pulpal reaction by infl ammation and a tiny micro abscess. the microbes from the root canal system, ending the continuous feeding of antigens into the periapical area. Following this, FIGURE 1. Pathways for bacteria to enter the pulp: normal wound healing mechanisms will 1) deep caries lesion, 2) enamel caries, 3) leaking usually take over and the periapical soft fi lling, 4) cracks in tooth structure, 5) lateral canal, tissue infl ammatory lesion is gradually 6) opened dentin canals, 7) deep pocket to the apex, 8) bacteremia and 9) trauma exposing the pulp. replaced again by healthy bone tissue. Other pathways: cracked tooth, vertical root fracture, The key questions are: How predictably invagination and evagination. (All fi gures courtesy and with what methods can we eliminate Artendo Enterprises Inc. if not otherwise stated) the microbes from the root canal system? If not all microbes can be eradicated, is there some threshold limit or other of apical periodontitis the root canal is specifi c conditions under which complete occupied dominantly by strictly anaerobic healing can be obtained? Is prevention of bacteria (FIGURE 8).8–10 Typically, a few to reinfection of the root canal system different several dozen different species are found, from prevention of the primary infection? and combining different cases together, In this review, the nature of root several hundred different microbial species canal infection is discussed, together with of which > 99 percent are bacteria can be FIGURE 3. Maxillary lateral incisor with existing and potential future strategies found in infected, necrotic root canals of apical periodontitis. Bacteria may have to maximally reduce or even completely teeth with apical periodontitis.11,12 The entered the root canal e.g., via a lateral eliminate microbes from the root canal fl ora of root canals that have become canal, dentin canals or a microfracture system. Extraradicular infections, where reinfected has shifted to a more facultative caused by trauma. biofi lms have established their presence microbiota (“semi-aerobic,” facultative on root surface or in the periapical bacteria tolerate both lack and presence lesion requiring endodontic surgery for of oxygen) instead of the strong anaerobic successful completion of the treatment, dominance typical of primary infections. will not be discussed in this review. Treatment Strategy Part I Infection Part I From a clinical point of view, should Before the development of anaerobic the composition of the fl ora be refl ected culturing techniques for bacteria in the in the treatment strategy? Since the late 1960s and 1970s, many necrotic 1960s and even before, there have teeth with apical periodontitis were been numerous reports of the different thought to be sterile.7 Developments in virulence potential of various bacteria anaerobic microbiology eventually led found in necrotic root canals,13–15 FIGURE 4. A scanning electron microscope (SEM) image of necrotic pulp shows a mixture of necrotic to the current understanding that every and frequently, new studies suggest tissue and bacteria of many diff erent morphotypes. tooth with necrotic pulp and periapical that certain species can be regarded lesion has microbes (mostly bacteria) in as “important pathogens.”16 There is the root canal space and that in most cases probably much unnecessary confusion

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FIGURE 5A. FIGURE 5B.

FIGURES 5. Schematic illustration of bacteria in the apical canal of a necrotic tooth facing a zone of defense cells (5A). Interaction between the root canal microbes and host defense cells initiates a variety of FIGURE 6. Classical studies have shown that sterile immunological chain reactions (5B). One result of this is activation of osteoclast cells, which remove the bone necrosis (tooth with necrotic pulp but with no bacteria) around the apical foramen. does not create a periapical lesion (left). Only when the necrotic canal contains microbes will a lesion will appear.

FIGURE 8. related to pathogenicity and virulence. A cultured Pathogenicity is the ability to cause a sample from disease while virulence is related to the the tooth in severity of the infection. Virulent bacteria fi gure 3 shows a mixed fl ora cause more serious, symptomatic, even of mostly spreading infections. Less virulent bacteria anaerobic more often cause symptom-free local bacteria, infections. Bacteria with both low and including high virulence are pathogenic, but they at least two can all cause periapical infl ammation. diff erent Critical analysis of studies on FIGURE 7. Histological specimen from a “black periapical lesion shows a small arteriole and great pigmented” endodontic microbiology shows that numbers of defense cells. species. whenever bacteria survive the ecological conditions of the root canal, a periapical lesion will develop. In other words, development of the lesion (pathogenesis) is not dependent on the presence of certain specifi c, more pathogenic or virulent microbial species. Rather, the lesion develops as a response to any microbiota established in the canal space.5,6 It seems therefore that the endodontic infection (and the “pathogenic” lesion) differs from some other common host-parasite interactions in the oral cavity: Tooth surface plaque may or may not cause disease (caries) on the enamel and gingival crevice plaque FIGURE 9. An SEM image of the surface of a FIGURE 10. A special FIB-SEM image of a biofi lm may or may not cause gingivitis. Microbiota multispecies oral biofi lm. Many diff erent types of shows structures not seen in a conventional SEM in the necrotic root canal, however, will bacteria can be seen. However, extracellular polymeric image: blue arrows: EPS between cells; yellow arrows always cause apical periodontitis. Therefore, substance (EP) between cells is not visible in a — microscopic water channels; green arrows — debris the target in endodontic treatment is conventional SEM image. (waste) on biofi lm surface. the elimination of any microbes in the root canal system, with no specifi c focus on certain microbial groups or species.

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FIGURE 11. An SEM image of a root tip, from FIGURE 12. Cross section of a microCT FIGURE 13. An SEM image of a root outside. Three major apical foramina can be seen, scan of a mandibular molar reveals several canal shows numerous small dentinal tubule together with at least two lateral canal openings. hard-to-reach areas and also dentin debris openings, an attached pulp stone and a packed into the fi ns. lateral canal opening in the canal wall.

Infection Part II: Biofi lm Bacteria in nature and in infections exist either as planktonic, i.e., individual, single cells fl oating in a liquid medium, or as biofi lms, which are complex ecological structures usually attached to solid surfaces.17 It has been estimated that approximately 80 percent of human infections are biofi lm infections.18 Most oral infections are also biofi lm infections: caries, gingivitis, periodontitis, implantitis and FIGURE 14. An SEM view to instrumented root FIGURE 15. Enterococcus faecalis bacteria deep apical periodontitis.19 The two states, canal wall after NaOCl and EDTA irrigation. There inside a dentinal tubulus, beyond the reach of instruments. planktonic and biofi lm, have great are 10.000 — 25.000 dentinal tubules per square and clinically important differences: millimeter in root canal dentin. These are large Planktonic bacteria are sensitive to enough to harbor bacteria. common antimicrobial substances, whereas biofi lm bacteria are much Anatomy, Advantages and only rarely do large volumes of liquid more resistant. In other words, in Disadvantages escape to the exterior. However, even endodontics the dentist is treating The root canal system in a tooth is though the chance of an NaOCl a resistant biofi lm infection.20 where the effort to eliminate endodontic accident is small, the mere possibility The key characteristics of a biofi lm biofi lms takes place. This environment may result in excessive caution for fear are as follows: The biofi lm is attached is a very special area of the human body, of the dramatic, negative consequences (often fi rmly) to a solid surface, the cells which can be both good and bad. The of an NaOCl extrusion accident.21,22 inside biofi lm are surrounded by a gel big advantage from the treatment point Disadvantages of the root canal anatomy consisting of different organic molecules of view is that the root canal offers include the frequent presence of and extracellular polymeric substance, and a space surrounded by hard, mainly narrow, deep fi ns, tiny anastomoses and the metabolic activity of the microbial inorganic walls of dentin. This allows connecting isthmuses,23 which cannot cells in the biofi lm is low and some may use of harsh, even caustic disinfecting be reached with instruments and are even be in a dormant state (viable but solutions such as concentrated sodium also diffi cult to access by conventional nonculturable). FIGURES 9 and 10 were hypochlorite (NaOCl). Although the irrigation (FIGURES 11–13). Further, the taken with a regular scanning electron root canal system is not completely microanatomy of dentin, the 1–2.5 μm microscope (SEM) and a specialized isolated from the surrounding soft tissues wide dentinal tubules (FIGURE 14), allows focused ion beam SEM technique and bone, the limited connections via bacterial penetration deep into dentin shows some key structural features of small apical foramina usually allow (FIGURE 15) and renders them beyond a multispecies bacterial biofi lm. solutions to be kept inside the tooth; the reach of endodontic instruments.24

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Treatment Strategy Part II: Sterilization vs. Disinfection Effective sterilization methods include the use of autoclave or dry heat at more than 100 degrees Celsius or high-energy gamma FIGURE 17. Dentin debris packed by rotary fi les into radiation. These methods are not suitable for FIGURE 16. Smear layer on the wall of the main the isthmus area between two canals in the same root. Even after 20 minutes of syringe-needle irrigation the infected root canals. Therefore, sterilization root canal after instrumentation. Several bacteria can be seen embedded in the layer. debris had not been removed. is not a correct word to describe the methods of reducing and eliminating microbes from infected root canal spaces. Instead, Treatment Strategy Part III: Elimination (complete elimination of bacteria) was not disinfection and antisepsis better describe of Root Canal Bacteria achieved even after fi ve appointments of what is done in endodontics. Antisepsis Microorganisms, mostly bacteria, are mechanical instrumentation and irrigation means destruction or prevention of killed or removed from the contaminated with saline.30,31 Newer studies have confi rmed proliferation of (pathogenic) microorganisms root canal system by a combination of these fi ndings.32,33 While these more in order to prevent infection: the state of methods and approaches. These include recent studies confi rmed earlier fi ndings, being free from living pathogenic organisms. mechanical removal of necrotic and they did show that increasing the size of Antiseptic compounds (such as iodine) infected pulp tissue along with some of apical preparation would further reduce are designed to be used in direct contact the root canal wall dentin by hand and the number of bacteria or colony forming with living tissue, therefore their toxicity rotary instruments and the washing action units of bacteria on culture plate counts. level is low.25,26 Disinfecting agents, such as by irrigation solutions. Other methods Many of the above studies have NaOC1, are antimicrobial agents that are are chemical dissolution and fl ushing of indicated that some of the canals can be applied to the surface of nonliving objects to intradental soft tissues and dentin, removal rendered bacteria free by instrumentation. destroy microorganisms that are present.25–27 of soft tissue and biofi lms by NaOCl However, it is generally understood Disinfectants work by destroying the cell and ultrasonic and other sound energies, that the negative cultures refl ect more wall of microbes or interfering with the chemical killing of microbes by disinfecting the lack of sensitivity of the sampling metabolism, but they will not necessarily solutions and interappointment medication and culturing methods rather than true, kill all microorganisms. By defi nition, such as calcium hydroxide, killing by complete absence of bacteria.34 It should disinfecting solutions are not used in contact direct antimicrobial effect from some be emphasized that sampling is usually with living tissue, usually meaning “inside sealers and killing by long-term blocking done in areas of the main canal where the human body.” As mentioned earlier, of nutrients by a high-quality root fi lling instrumentation and irrigation have the the mainly inorganic dentin walls create a and proper restoration of the tooth.20,24 strongest effect. New studies where dentin special exception to the rule by effectively of the whole tooth has been crushed into limiting the spreading of the solutions to Mechanical Instrumentation powder and sensitive molecular biological living tissue where cells, vital connective Instrumentation by hand and rotary methods have been used, much more tissue, nerves and the circulatory system instruments impacts the root canal bacteria/ bacteria are found than with traditional are present. Bacterial spores are often biofi lms mainly in two ways. Firstly, infected paper point and culturing methods.35,36 resistant to disinfectants, but the challenge pulp tissue and dentin is removed and in endodontics to obtain a completely secondly, space is created for effective Irrigation With Antimicrobial and bacteria-free canal is not primarily related irrigation. Together with antibacterial Other Solutions to the presence of bacterial endospores in root canal fi llings, it is expected that most Irrigation of the root canals can reach the root canal. It is more a matter of the of the microbes will be eliminated. It is areas that instruments cannot.21,27 The microanatomical conditions in the root recognized that mechanical instrumentation “fl exibility” of liquids allows them, in theory, canal system, the chemical nature of the cannot remove all microbes from the to penetrate into all areas in the canal tooth structures (in activation of disinfecting root canals.30,31 The classic studies in system, many of which had not been touched agents)28,29 and to some extent the necessary Sweden in the 1970s showed that while by metallic fi les. Also, in the instrumented caution in the endodontic procedures the number of bacteria in the canal was areas, the fi les have created a smear layer to avoid disinfection complications. reduced even a thousandfold, sterility (FIGURE 16) and debris (FIGURE 17) that

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contains not only dentin but remnants of pulp tissue and bacteria and their antigens in all cases where the canal has been infected. Irrigants with specifi c properties can remove the smear layer and its contaminating microbial material. NaOCl FIGURE 18. Biofi lm grown from a mixture of bacteria FIGURE 19. Same CLSM technique as in followed by ethylene diaminetetraacetic commonly found in infected root canals. The biofi lm was fi gure 18 now used to measure killing of bacteria acid (EDTA) will predictably and usually treated with 3% sodium hypochlorite for fi ve minutes, in dentinal tubules by diff erent endodontic quite easily remove the smear layer; NaOCl stained with “viability” stain and examined under confocal irrigating solutions, sealers or other materials. removes the organic portion and EDTA the laser scanning microscopy (CLSM). Red areas show killed biofi lm microbes; in green areas the microbes are still alive. inorganic portion of the smear layer.21,27,34 Although not conclusively shown by studies, it is likely that if any part of the biofi lms20 have given a very different biofi lms attached to the dentin surface. root canal system is bacteria free after view. The level of killing is concentration With respect to the ability of EDTA to chemomechanical preparation, it would dependent and so far there are no studies kill microbes, most evidence shows it has be the main root canal. However, the few showing complete killing of all biofi lm little if any antimicrobial activity.21,27 The studies that have focused on removal of bacteria (FIGURE 18). In a recent study role of EDTA is important as it helps to dentin debris from fi ns, isthmuses, lateral of dentin biofi lm (bacterial biofi lm in remove the smear layer and at least some canals and apical foramina have shown dentinal tubules), 6% NaOCl used for 30 of the dentin debris with all the microbes that the available methods for cleaning minutes and refreshed every 5 minutes contained in it. EDTA or citric acid root canals with instruments, irrigants killed only > 70 percent of the microbes combination products intend to combine and aids such as ultrasound are not able in dentin. Importantly, there was very smear layer removal with antimicrobial to remove all of the debris.37,38 Debris little additional killing after 10 minutes activity.21,27 So far, the highest documented will always harbor microbes, therefore of exposure, despite refreshed NaOCl.39 antimicrobial effect has been demonstrated the inability to remove all debris gives Other studies have suggested that long- with QMiX (Dentsply Tulsa Dental, Tulsa, a negative answer to the question asked term NaOCl irrigation weakens dentin Okla.), which killed about 65 percent of in the title of this article. However, it is structure,40 therefore it is quite clear that dentinal tubule bacteria in three minutes, important to remember that in the world of long exposure to high-concentration same as 6% NaOCl (FIGURE 19).41,42 infection and disease, the criteria for healing NaOCl will not be the ultimate answer are almost never black and white. In the to obtain bacteria-free root canals. Negative Pressure and Agitation of majority of oral infections, such as caries, However, there are indications that Irrigants gingivitis, periodontitis, peri-implantitis and 5–6% NaOCl can detach biofi lms from Several methods of agitation of the pericoronitis, the question is clearly about the dentin surface, which can then be irrigating solutions in the root canals have threshold and balance, not about sterility. more easily fl ushed out of the canal by been developed.27 It is likely that such NaOC1 is the key irrigant in the continuing irrigation. However, emphasis to improve irrigation will have a the killing of root canal bacteria. In biofi lm detachment by conventional positive effect. However, so far none of the vitro studies done in a test tube using syringe-needle NaOCl irrigation methods have been shown to completely planktonic bacteria (single cells or small works only in the main root canal, not and predictably eliminate microbes from aggregates) have shown that even low in dentinal tubules. Whether it can root canals. One of the newer methods concentration NaOCl kills 100 percent detach biofi lms in isthmus areas or includes the use of negative pressure of various bacteria in seconds. These lateral canals is not currently known. irrigation (EndoVac, Kerr Dental, Orange, tests in the earlier days of endodontic Chlorhexidine (CHX) kills planktonic Calif.), which allows more effective research gave clearly a too optimistic and biofi lm bacteria, but its effectiveness irrigation of the apical canal space than view about the possibility of obtaining is at best the same as that of NaOCl traditional positive pressure syringe- a completely bacteria-free root canal and in many instances CHX is weaker.27 needle irrigation.43 In negative pressure with endodontic disinfectants.21,27 Newer CHX does not dissolve tissue and has irrigation, there is no risk of irrigant studies where bacteria are grown as not been shown to be able to detach extrusion to the periapical area, which

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FIGURE 20. ProUltra PiezoFlow system for FIGURE 21. A cordless, high-energy EndoUltra FIGURE 22. GentleWave (GW) instruments for front continuous fl ow ultrasonic activation. device with optional irrigant canister. teeth and premolars (left) and molars (right).

makes it possible to maximize the chemical cleaning and killing of microbes in this key location of the canal. Comparative studies have shown improvement by EndoVac over positive pressure irrigation in reducing bacteria but complete absence of the microbes remains a challenge. EndoActivator (Dentsply Tulsa Dental) uses sonic vibration to facilitate irrigation. FIGURE 24. Hard tissue section of a molar mesial Again, while any valid method to improve canal after 15/04 instrumentation, cleaning with cleaning is commendable, complete GW and root fi lling with gutta-percha and GuttaFlow disinfection cannot be accomplished with 2 sealer. The deep, microscopic fi n has also been sonic activation of irrigation solutions. cleaned and fi lled completely. Ultrasound uses higher frequency vibration FIGURE 23. A mandibular molar fi lled after than sonic activation, usually in the range minimal instrumentation and GW cleaning. Tiny apical 44,45 of 20.000–35.000 Hz. Ultrasound used lateral canals also fi lled. (Courtesy Dr. T.F. Baker) with an irrigant in the canals and pulp chamber works in two ways, cavitation and acoustic streaming. In cavitation, continuous ultrasonic irrigation because in high fl ow velocity (45 mL/min) of NaOCl high-energy vacuum bubbles are formed, addition to the ultrasonic energy there is a hits an end plate of a nozzle in a treatment which in theory have the ability to release simultaneous fl ow of irrigant through the instrument, just above the pulp chamber a concentrated energy burst at their target needle into the root canal (FIGURE 20).47 fl oor. The liquid then spreads all around the and cause a breakdown such as cell death. Detailed studies on reduction of intracanal pulp chamber and the root canal system.48 The diffi culty in endodontic cavitation bacteria are too few to draw conclusions. Second, the liquids (NaOCl, EDTA and so far has been that the vacuum bubbles EndoUltra (Vista Dental, Racine, Wis.) water) are all degassed to remove micro air, have been estimated to last only for a is another new high-energy ultrasonic which is known to reduce or eliminate the few micrometers from the surface of the device with an optionally attached effects of cavitation. Third, GW irrigant oscillating fi le. Acoustic streaming extends prefi lled irrigant canister (FIGURE 21). fl ow happens under slight negative pressure further in the canal system but many Recently, a new type of endodontic in the canals, eliminating the risk of irrigant studies with equipment using so-called cleaning device was introduced. The extrusion.48 A study on tissue dissolution passive ultrasonic irrigation (PUI) show instrument (FIGURE 22) GentleWave by GW, ultrasound and conventional limited effect on bacterial reduction as (GW, Sonendo, Laguna Hills, Calif.) uses syringe-needle irrigation indicated that compared to syringe-needle irrigation.46 a wide spectrum of sound waves, including cavitation may in fact be contributing to ProUltra PiezoFlow (Dentsply Tulsa ultrasonic frequencies. The GW action is the much faster (8 x) tissue dissolution by Dental) ultrasonic irrigation is active/ based on three main mechanisms. First, GW as compared to all other systems.48

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Other studies have shown the ability of indicated killing of 30–50 percent of Conclusions GW to clean the main canal, isthmuses bacteria in dentinal tubules by sealers None of the materials, equipment and lateral canals from pulp tissue remnants after 30 days of incubation. This is an and strategies currently available for or from calcium hydroxide to allow high- important contribution in the elimination endodontics can predictably create a quality root fi lling.49,50 The latter, complete of residual microbes.56 Follow-up studies completely microbe-free root canal. calcium hydroxide removal, was only using 5% NaOCl and AH+ sealer Although 100 percent sterility is not accomplished by GW but not by PUI or (Dentsply Tulsa Dental) or bioceramic required for complete healing of apical syringe-needle irrigation.50 A recent in sealers reported up to 80 percent killing periodontitis, a high level of bacterial vitro study comparing the effectiveness of of biofi lm bacteria in root canals.57 reduction is desirable. While this can GW and continuous ultrasonic irrigation to often be achieved with currently available reduce bacterial numbers in contaminated Other Emerging Strategies methods and materials, implementation root canals showed that GW predictably Nanoparticles made of a wide variety of emerging new technology seems produced the highest level of cleanliness of materials are particles with a size necessary in order to predictably obtain (FIGURES 23 and 24).51 A 12-month between 1 and 100 nm. Many materials the highest level of cleaning and follow-up study after GW cleaning reported in the size of nanoparticles can have disinfection and thereby healing. ■ approximately 96 percent healing rate, thus properties that are quite different from REFERENCES clinically supporting the results of superior their usual characteristics. The appearance 1. Bergenholtz G. Pathogenic mechanisms in pulpal disease. 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14. Sundqvist G. Pathogenicity and virulence of black- endodontic infection by instrumentation and irrigation solutions. 51. Zhang, D. Evaluation of the eff ectiveness of two irrigation pigmented gram-negative anaerobes. FEMS Immunol Med Endod Topics 2005;10:72–102. systems in reducing bacterial load in root canals in vitro by Microbiol 1993 Mar;6(2–3):125–37. 35. Cook J, Nandakumar R, Fouad AF. Molecular- and quantitative real-time polymerase chain reaction. MSc Thesis, 15. Siqueira JF Jr., Magalhães FA, Lima KC, de Uzeda M. culture-based comparison of the eff ects of antimicrobial agents University of British Columbia, Canada. 2017. Pathogenicity of facultative and obligate anaerobic bacteria in on bacterial survival in infected dentinal tubules. J Endod 52. Sigurdsson A, Garland RW, Le KT, Woo SM. 12-month monoculture and combined with either Prevotella intermedia 2007;33:690–2. healing rates after endodontic therapy using the novel or Prevotella nigrescens. Oral Microbiol Immunol 1998 36. Kho, P, Baumgartner JC. A comparison of the antimicrobial GentleWave System: A prospective multicenter clinical Dec;13(6):368–72. effi cacy of NaOCl/biopure MTAD versus NaOCl/EDTA study. J Endod 2016 Jul;42(7):1040–8. doi: 10.1016/j. 16. Siqueira JF Jr, Rôças IN. Dialister pneumosintes can be a against Enterococcus faecalis. J Endod 2006;32:652–5. joen.2016.04.017. suspected endodontic pathogen. Oral Surg Oral Med Oral 37. Paqué F, Laib A, Gautschi H, Zehnder M. Hard-tissue debris 53. Kawashima N, Wadachi R, Suda H, Yeng T, Parashos P. Pathol Oral Radiol Endod 2002 Oct;94(4):494–8. accumulation analysis by high-resolution computed tomography Root canal medicaments. Int Dent J 2009 Feb;59(1):5–11. 17. Costerton JW, Cheng KJ, Geesey GG, Ladd TI, Nickel scans. J Endod 2009;35:1044–7. 54. Sathorn C, Parashos P, Messer HH. Eff ectiveness of single- JC, Dasgupta M, Marrie TJ. Bacterial biofi lms in nature and 38. Endal U, Shen Y, Årving K, Gao Y, Haapasalo M. A versus multiple-visit endodontic treatment of teeth with apical disease. Annu Rev Microbiol 1987;41:435–64. high-resolution computed tomographic study of changes in root periodontitis: A systematic review and meta-analysis. Int Endod 18. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofi lms: canal isthmus area by instrumentation and root fi lling. J Endod J 2005 Jun;38(6):347–55. A common cause of persistent infections. Science 1999 May 2011;37:223–7. 55. Slutzky-Goldberg I, Slutzky H, Solomonov M, Moshonov 21;284(5418):1318–22. 39. Du T, Wang Z, Shen Y, Ma J, Cao Y, Haapasalo M. The J, Weiss EI, Matalon S. Antibacterial properties of four 19. Larsen T, Fiehn NE. Dental biofi lm infections — an update. eff ect of long-term exposure to endodontic disinfecting solutions endodontic sealers. J Endod 2008 Jun;34(6):735–8. doi: APMIS 2017 Apr;125(4):376–384. doi: 10.1111/ on young and old Enterococcus faecalis biofi lms in dentin 10.1016/j.joen.2008.03.012. apm.12688. canals. J Endod 2014;40:509–14. 56. Wang Z, Shen Y, Haapasalo M. Dentin extends the 20. Haapasalo M, Shen Y. Current therapeutic options for 40. Marending M, Paqué F, Fischer J, Zehnder M. Impact of antibacterial eff ect of endodontic sealers against Enterococcus endodontic biofi lms. Endod Topics 2012;22:79-98. irrigant sequence on mechanical properties of human root faecalis biofi lms. J Endod 2014;40:505–8. 21. Basrani B, Haapasalo M. Update on endodontic irrigating dentin. J Endod 2007;33:1325–8. 57. Du T, Wang Z, Shen Y, Ma J, Cao Y, Haapasalo M. solutions. Endod Topics 2013; 27:74–102. 41. Stojicic S, Shen Y, Qian W, Johnson B, Haapasalo M. Combined antibacterial eff ect of sodium hypochlorite and root 22. Guivarc’h M, Ordioni U, Ahmed HM, Cohen S, Catherine Antibacterial and smear layer removal ability of a novel canal sealers against Enterococcus faecalis biofi lms in dentin JH, Bukiet F. Sodium hypochlorite accident: A systematic irrigant, QMiX. Int Endod J 2012;45:363–71. canals. J Endod 2015 Aug;41:1294–8. review. J Endod 2017 Jan;43(1):16–24. doi: 10.1016/j. 42. Ma J, Wang Z, Shen Y, Haapasalo M. A new noninvasive 58. Del Carpio-Perochena A, Kishen A, Shrestha A, Bramante joen.2016.09.023. model to study the eff ectiveness of dentin disinfection using CM. Antibacterial properties associated with chitosan 23. Vertucci FJ. Root canal morphology and its relationship to confocal laser scanning microscopy. J Endod 2011;37:1380–5. nanoparticle treatment on root dentin and two types of endodontic procedures. Endod Topics 2005;10:3–29. 43. Miller TA, Baumgartner JC. Comparison of the endodontic sealers. J Endod 2015 Aug;41(8):1353–8. doi: 24. Haapasalo M, Shen Y, Ricucci D. Reasons for persistent antimicrobial effi cacy of irrigation using the EndoVac to 10.1016/j.joen.2015.03.020. and emerging posttreatment endodontic disease. Endod Topics endodontic needle delivery. J Endod 2010;36:509–11. 59. Zhang T, Wang Z, Hancock RE, de la Fuente-Núñez C, 2011;18:31–50. 44. Urban K, Donnermeyer D, Schäfer E, Bürklein S. Canal Haapasalo M. Treatment of oral biofi lms by a D-enantiomeric 25. Spångberg L, Engström B, Langeland K. Biologic eff ects cleanliness using diff erent irrigation activation systems: A SEM peptide. PLoS One 2016 Nov 23;11(11):e0166997. doi: of dental materials. 3.Toxicity and antimicrobial eff ect of evaluation. Clin Oral Investig 2017 Feb 9. doi: 10.1007/ 10.1371/journal.pone.0166997. endodontic antiseptics in vitro. Oral Surg Oral Med Oral s00784-017-2070-x. 60. Wang D, Shen Y, DDS, Ma J, Hancock REW, Haapasalo Pathol 1973;36:856–71. 45. Howard RK, Kirkpatrick TC, Rutledge RE, Yaccino JM. M. Antibiofi lm eff ect of D-enantiomeric peptide alone and 26. McDonnell G, Russell D. Antiseptics and disinfectants: Comparison of debris removal with three diff erent irrigation combined with EDTA in vitro. J Endod 2017;in press. activity, action, and resistance. Clin Microbiol Rev techniques. J Endod 2011 Sep;37(9):1301–5. doi: 1999;12:147–79. 10.1016/j.joen.2011.05.008. THE AUTHOR, Markus Haapasalo, DDS, PhD, can be reached at 27. Haapasalo M, Shen Y, Qian W, Gao Y. Irrigation in 46. Paiva SS, Siqueira JF Jr, Rôças IN, Carmo FL, Leite [email protected]. endodontics. Dent Clin North Am 2010;54:291–312. DC, Ferreira DC, Rachid CT, Rosado AS. Molecular 28. Haapasalo H, Sirén E, Waltimo T, Ørstavik D, Haapasalo microbiological evaluation of passive ultrasonic activation as a M. Inactivation of local root canal medicaments by dentin. Int supplementary disinfecting step: A clinical study. J Endod 2013 Endod J 2000; 33:126–31. Feb;39(2):190–4. doi: 10.1016/j.joen.2012.09.014. 29. Portenier I, Haapasalo H, Rye A, Waltimo T, Ørstavik D, 47. Malentacca A, Uccioli U, Zangari D, Lajolo C, Fabiani C. Haapasalo M. Inactivation of root canal medicaments by Effi cacy and safety of various active irrigation devices when dentine, hydroxyapatite and bovine serum albumin. Int Endod J used with either positive or negative pressure: An in vitro 2001; 34:184–8. study. J Endod 2012 Dec;38(12):1622–6. doi: 10.1016/j. 30. Bystrom A, Sundqvist G. Bacteriological evaluation of the joen.2012.09.009.para 3. effi cacy of mechanical root canal instrumentation in endodontic 48. Haapasalo M, Wang Z, Shen Y, Curtis A, Patel P, therapy. Scand J Dent Res 1981;89:321–8. Khakpour M. Tissue dissolution by a novel multisonic 31. Bystrom A, Sundqvist G. Bacteriologic evaluation of ultracleaning system and sodium hypochlorite. J Endod the eff ect of 0.5 percent sodium hypochlorite in endodontic 2014;40:1178–81. therapy. Oral Surg Oral Med Oral Pathol 1983;55:307–12. 49. Molina B, Glickman G, Vandrangi P, Khakpour M. 32. Dalton BC, Orstavik D, Phillips C, Pettiette M, Trope M. Evaluation of root canal debridement of human molars using Bacterial reduction with nickel-titanium rotary instrumentation. J the GentleWave System. J Endod 2015 Oct;41(10):1701–5. Endod 1998: 24: 763–7. doi: 10.1016/j.joen.2015.06.018. 33. Card SJ, Sigurdsson A, Orstavik D, Trope M. The 50. Ma J, Shen Y, Yang Y, Gao Y, Wan P, Gan Y, Patel P, eff ectiveness of increased apical enlargement in reducing Curtis A, Khakpour M, Haapasalo M. In vitro study of calcium intracanal bacteria. J Endod 2002: 28: 779–83 hydroxide removal from mandibular molar root canals. J Endod 34. Haapasalo M, Endal U, Zandi H, Coil J. Eradication of 2015 Apr;41:553–8.

APRIL 2018 235 Practice Support

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CDA JOURNAL, VOL 46, Nº4

Can Use of Cone Beam Computed Tomography Have an Eff ect on Endodontic Treatment?

Robert S. Roda, DDS, MS

ABSTRACT Cone beam computed tomography (CBCT) has revolutionized endodontic diagnosis and treatment planning over the past decade. It allows the clinician to detect dental anatomy and disease states with much greater accuracy than regular two-dimensional radiography and is recommended as the imaging modality of choice for use in most aspects of endodontics. This paper reviews the most updated guidelines for use of CBCT to illustrate the effects this has on clinical endodontic practice.

AUTHOR

Robert S. Roda, DDS, ver the 122 years since imaging to dentistry was somewhat slow MS, is a board-certifi ed Professor Otto Walkhoff with initial uses being mainly restricted endodontist, past president exposed the fi rst dental to imaging craniofacial abnormalities of the American Association 1 of Endodontists and an radiograph, radiography and to aid in planning very complex oral associate editor of the has become an integral and maxillofacial surgeries. This limited Journal of Endodontics. He Opart of all aspects of dentistry, including use of conventional CT in dentistry was practices in Scottsdale, Ariz. endodontics. Recently, cone beam due to the relatively high X-ray dosages Confl ict of Interest computed tomography (CBCT) has of medical CT scanners and the high Disclosure: None reported. been added to the armamentarium for cost of imaging. The advent of cone endodontic therapy. As with any new beam CT in the late 1980s resulted in technology, there has been a rapid growth dramatically lower radiation exposure to in knowledge along with changes in patients, higher spatial resolution and implementation strategies that require lower costs. The technology soon became clinicians to continually review all aspects widely used in diagnostic imaging for of this new three-dimensional radiography. dental implant placement and complex Three-dimensional radiographic oral surgery procedures. It was the recent imaging began to be widely used in development of restricted or small fi eld the 1980s in medicine, and ongoing of view (FOV) CBCT that brought it developments in imaging have to the fore in endodontics. The much revolutionized the process of medical higher resolution of these smaller-imaged diagnosis. Progress in adapting medical CT volumes allows detection of many of

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FIGURE 1A. FIGURE 1B. FIGURE 1C. FIGURES 1. 2-D periapical image of asymptomatic tooth No. 9 (1A). 3-D medium FOV CBCT image of tooth No. 9 (sagittal plane) (1B). Arrows show suspected PA low-density area consistent with asymptomatic apical periodontitis. 3-D small FOV CBCT image of tooth No. 9 (sagittal plane) showing normal periapical architecture (1C). the fi ne details in tooth structures and incident beam angles, three-dimensionality isotropic units (cubes) that make up surrounding tissues and that information can be inferred but the distortions of the image. Generally, the smaller the can have an impact on clinical decision- the image still make defi nitive diagnosis voxel, the higher the spatial resolution making. The impact of CBCT in diffi cult and sometimes impossible. of the imaged volume.4 Commonly used endodontics is refl ected in the scientifi c Three-dimensional radiography voxel sizes in endodontics range from literature. Each year for the last decade, was developed to overcome these 0.076 to 0.6 mm. Because a computer there have been an increasing number disadvantages. Hounsfi eld introduced in the scanner processes the data, the of articles published regarding CBCT. computed tomography in the 1970s limitations on resolution imposed by A quick search of scientifi c articles and the technology has been advancing larger voxel sizes can often be overcome and case reports in the Journal of ever since. Conventional medical CT with sophisticated algorithms. Endodontics revealed that in 2006 only scanners produce a fan-shaped beam Other parameters that affect image three articles mentioned CBCT. In that rotates around the patient multiple quality include the peak kilovoltage 2011, that number had risen to 39; in times in a helical or spiral motion to (kVp), milliampere seconds (mA-s) and 2016, there were 64 articles. The interest create image slices that are stacked FOV that is imaged. Of these, the FOV in this topic is clearly increasing. one upon the other. This process is is of critical importance. Generally, the time-consuming and results in a large smaller the FOV, the better the resolution What Is Cone Beam Computed radiation exposure to the patient2,3 and of the images produced, which, in Tomography? artifacts induced by patient movement. endodontics, allows for more accurate Traditional 2-D radiography produces CBCT reduces the time of acquisition of diagnosis and treatment planning a fl at image on a fi lm or sensor that is the image and reduces exposure of the decisions because many of the factors made up of the shadows of all of the patient to X-rays by using a cone-shaped leading to better outcomes are too small to structures between the X-ray source and beam that rotates between 180 and 360 detect on larger FOV images (FIGURES 1). the detector (fi lm or digital sensor). These degrees around the patient with the In addition, smaller FOV volumes expose structures appear as overlapped and, while beam hitting a detector on the opposite the patient to less radiation.5 the image resolution is excellent, the side of the patient’s head similar to Rather than the overlapped shadows geometries are distorted and true sizes of panoramic radiography. A third type of in 2-D radiography, CBCT produces a biological structures are not discernible. 3-D radiography is the micro-CT (μCT). 3-D image that is made up of slices. But Superimposed anatomic structures impede It produces 3-D images of exceedingly unlike medical CT devices, these slices visualization of subjacent structures and fi ne detail and clarity, and it is widely are combined into a volume that can be disease-related changes. In dentistry, used in endodontic research but is not inspected in many ways. The structures this renders diagnosis diffi cult especially adaptable to the clinical setting.4 in the imaged area can be seen from any in the maxillary posterior region. By The imaged area is called a volume of the three traditional anatomic planes making multiple 2-D images from differing that is made up of voxels. Voxels are of view (sagittal, coronal and axial)

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FIGURE 2B.

FIGURE 2A. FIGURE 2C.

FIGURES 2. 2-D periapical radiograph of tooth No. 9 with a silver point endodontic fi lling (2A). 3-D CBCT slice from the axial plane showing beam hardening as streaks on the image (2B). 3-D CBCT slice from the sagittal plane showing the beam-hardening artifact as a thick black area lingual to the full length of the silver point (2C). 2-D periapical radiograph of tooth No. 20 (2D). 3-D CBCT slice from the sagittal plane showing apparent enlargement of the post (volumetric or “cupping” artifact) (2E).

FIGURE 2D. FIGURE 2E. but also, depending on the rendering few. The resolution of the 3-D image high and most medium FOV units software, the structures can be viewed is still not comparable to conventional can also produce a digital panoramic from any angle because the voxels are radiographs.4 CBCT is prone to the radiograph thus replacing the traditional isotropic. These structures rendered are creation of streaking (beam hardening)6 panoramic machine. The proliferation geometrically accurate and actual sizes and volumetric distortion (cupping)7 of stand-alone imaging centers in of the structures can be measured using artifacts in the presence of very radiodense dentistry provides an alternative to tools available in most of the software materials such as dental restorations, the purchase and maintenance of readers. Therefore, the image is viewed surgically implanted metallic materials and CBCT equipment. These centers can in slices (one layer or sheet of voxels), root canal obturation materials (FIGURE usually provide services with various overlapping of structures does not occur 2). This limits the usefulness of the CBCT units with multiple FOVs, and a true representation of the tissues can technology for assessment of restorative frequently at a lower cost to the patient. be seen, enhancing diagnostic yield. The and postendodontic complications such as Because they produce more volumes, volume data is required to be provided vertical root fractures or strip perforations.8 imaging centers can negotiate better in the recognized DICOM format so Also, the incident radiation doses to fees from radiologists for reading that the volumes can usually be shared the patient, while very small, are still the volumes while making access to and viewed by clinicians using many higher than with 2-D radiography.9,10 professional interpretation much easier. different software readers, although some Finally, the cost of purchasing and Manufacturers are now producing CBCT manufacturers of CBCTs have yet to make maintenance of CBCT equipment is units with FOVs, higher resolution their volumes universally accessible. generally much higher than that for and artifact reduction software making Compared to 2-D radiography, the 2-D radiography. The convenience the decision to purchase a unit or disadvantages of CBCT imaging are of having a CBCT in the offi ce is use an imaging center diffi cult.

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TABLE Comparison of Approximate Radiation Dosages

Source Dosage (μSv) Annual background radiation 3000 4 BW (digital or F-speed, rectangular collimation) 5 AAE/AAOMR Joint Position Statement FMX (digital or F-speed, rectangular collimation) 35 Recently, the American Association FMX (D-speed, round collimation) 388 of Endodontists (AAE) and the American Academy of Oral and Panoramic (digital 2 brands) 14–24 Maxillofacial Radiology (AAOMR) Chest radiograph 100 updated their joint position statement Lower GI tract radiograph 8000 5 on the use of CBCT in endodontics. CT chest 7000 The updated statement provides CT maxillofacial large FOV mean (range) 212 (46–1073) guidance on the use of CBCT in CT maxillofacial medium FOV mean (range) 177 (9–560) various clinical situations where it is applicable. It is not intended to CT maxillofacial small FOV mean (range) 84 (5–652) substitute for a clinician’s independent Source: Adapted from references 3, 9 and 10 judgment regarding the needs of a patient, but the usefulness of this statement is valuable to clinicians tissue susceptibilities in units called Indications performing endodontic diagnosis microsieverts (μSv). Limited FOV The AAE/AAOMR joint position and treatment. It states that CBCT CBCT exposes the patient to reduced statement lists recommendations should only be used when the needs dosages compared to larger FOVs and regarding the clinical use of CBCT in of imaging cannot be met with lower- so, where practical, compliance with the endodontics.5 These recommendations dose conventional 2-D radiography, ALARA principle is best achieved using are a list of the possible clinical so it is not recommended for routine small FOV. It is particularly important in indications for use of CBCT. While use on all patients. After a thorough children (up to and including the age of not all of these situations would evaluation of the patient including the 18) to reduce any exposure to radiation routinely require use of CBCT, there patient’s medical and dental history when the opportunity to use lower- are situations where the use of 3-D and a thorough clinical examination, dose imaging modalities is possible.11 imaging is especially helpful in the the clinician will then decide whether Finally, the AAE/AAOMR statement diagnosis and treatment planning the unique situation of that patient recommends that if a clinician has a of endodontically involved teeth. requires the use of CBCT imaging question regarding image interpretation, Preoperative 2-D radiographs are an to complete the diagnosis. The an oral and maxillofacial radiologist integral part of the initial diagnosis position paper also states that, for should read the volume. With small or of patients and should be used in all most endodontic applications, small limited FOV CBCT, the imaged area cases, and 3-D CBCT should only or limited FOV CBCT is preferred usually contains tissues with which be used in those cases where more although for large or multifocal dentists are familiar, but even in these information is needed to answer any lesions with possible systemic origin familiar areas, unusual or unexpected unanswered diagnostic questions. larger FOV imaging can be selected. fi ndings should trigger consultation with The AAE/AAOMR joint position a radiologist. In a recent study, an oral Diffi cult Diagnosis statement further recommends that radiologist detected more incidental Endodontic disease can present in ALARA principles be followed when fi ndings in more than 200 limited FOV a variety of ways and it can be diffi cult selecting an imaging modality. ALARA scans than endodontic graduate students to interpret confl icting diagnostic means choosing an imaging technology could, suggesting that even small FOV information pointing to a variety that achieves the diagnostic goals scans should be routinely read by a of pathological conditions. It may while using a radiation dose that is radiologist.12 With medium or large FOV be challenging to determine with “as low as reasonably achievable.” volumes and image regions that are conventional diagnostic techniques Selected radiation dosages for some outside the usual areas of expertise for whether a patient is suffering from commonly used radiography modalities dentists (such as the base of the skull or endodontic pain, pain of musculoskeletal are provided in the TABLE and show anterior spine), prudence suggests that origin, pain from sinusitis or even the relative incipient radiation and those scans should be read by a radiologist. neurogenic or atypical facial pain. Even

240 APRIL 2018 CDA JOURNAL, VOL 46, Nº4

FIGURE 3A. FIGURE 3B. FIGURE 3C.

FIGURE 3F.

FIGURE 3D. FIGURE 3E.

FIGURES 3. Patient presented with long-term mild pain and accompanying symptoms of maxillary sinusitis. Clinical examination (including this 2-D periapical image) did not lead to diagnosis (3A). 2-D distal angle periapical radiograph of tooth No. 2 showing no defi nitive evidence of pathosis (3B). 3-D CBCT slice from the sagittal plane showing low-density periapical area consistent with apical periodontitis. Note the thickening of the sinus membrane (3C). 3-D CBCT slice from the coronal plane showing that the low-density area is confi ned to the palatal aspect of the mesial roots (3D). 3-D CBCT slice from the axial plane showing the low-density area (arrows) (3E). 2-D periapical radiograph showing completed nonsurgical re-treatment 79 months postoperatively. The patient’s symptoms had resolved completely (3F). when all non-endodontic etiologies for ability of CBCT to provide information detecting severe curvatures in canals a patient’s symptoms have been ruled that can help identify endodontic disease can lead to separated instruments, canal out, it may still be diffi cult to identify has been demonstrated in several ex vivo transportation and retention of necrotic the tooth that may be the origin of the and clinical studies.13–18 An example of tissue/bacteria in the canals. Lack of patient’s chief complaint. This is related where CBCT was essential in diagnosing healing or posttreatment endodontic to the limitations in current clinical a diffi cult case is shown in FIGURES 3. disease may be the eventual outcome. testing and intraoral 2-D radiography. Use of CBCT can provide a much In many of such diffi cult situations, Anatomic Variations more accurate and detailed image than CBCT can provide information that The success of root canal therapy 2-D radiography and help avoid these can lead to a correct diagnosis. The depends on identifying, cleaning and undesirable outcomes (FIGURES 4). recommendation of the AAE/AAOMR sealing all of the root canal system. Studies have shown a strong correlation position statement is that limited FOV Because of the anatomic variations between anatomic information obtained CBCT should be considered the imaging and complexities of the root canal from CBCT volumes and anatomic modality of choice for diagnosis in system, 2-D radiography frequently is studies using sectioning or histologic patients who present with contradictory inadequate in revealing such things as methods in anatomic studies of or nonspecifi c clinical signs and symptoms the number and the shapes of canals and teeth.19,20 Improvement in detection of associated with untreated or previously roots. The results of leaving untreated second mesiobuccal canals in maxillary endodontically treated teeth. The superior spaces in the canal system or not molars has also been shown.21

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FIGURE 4C. FIGURE 4A. FIGURE 4B.

FIGURES 4. Tooth No. 19 is symptomatic fi ve years after initial endodontic treatment. A mesial PA radiolucency is evident (4A). 3-D CBCT slice from the axial plane showing an untreated fourth canal (DL) (4B). Seven months after nonsurgical re-treatment, the 2-D PA radiograph shows partial shrinkage of the mesial PA radiolucency and the patient is asymptomatic (4C).

Intraoperative Use restorative and endodontic materials. very detailed analysis of factors that may While not as routine, CBCT may Two recent systematic reviews have have led to the posttreatment disease, occasionally be used intraoperatively. If indicated that direct detection of such as untreated canals, (FIGURES 4) the during endodontic therapy it becomes fracture in endodontically treated teeth adequacy of previous instrumentation and apparent that not all of the canals have is unreliable due to these factors.8,22 obturation, root perforations, periodontal been found and no pretreatment CBCT CBCT imaging can, however, be helpful disease, furcation involvements, vertical images are available, the access can be in detecting the patterns of bone loss root fractures and the patterns of bone sealed and a CBCT scan exposed to and alterations in the periodontal loss and locations of periapical lesions. reveal untreated canal spaces. This is ligament space that usually accompany By detecting otherwise hidden factors especially useful when treating teeth a tooth fracture. These changes in affecting prognosis, better treatment with extensively calcifi ed canals, thus the appearance of the periodontium planning choices can be made. reducing the risk of root perforation. surrounding a cracked root are frequently In some instances, CBCT images Absent any questions about not visible on a 2-D radiograph but can can identify factors that would indicate treatment outcomes, the posttreatment be more easily detected in the CBCT that re-treatment (either surgical radiographic image need only be 2-D.5 volume (FIGURES 5). Both laboratory or nonsurgical) would have a poor and clinical studies indicate that CBCT prognosis. Lacking such information Tooth Fracture imaging can show the presence of root could lead to re-treatment procedures Cracks in teeth can be diffi cult to fractures, even if the fracture itself with high likelihood of failure. This may diagnose. Detection of tooth fractures, remains diffi cult to visualize.23–26 be avoided by using CBCT to evaluate while complicated, is important because teeth with posttreatment disease. these fractures often affect the tooth’s Posttreatment Endodontic Disease When planning for surgical re- prognosis. Undiscovered fractures can Millions of endodontically diseased treatment, the use of CBCT has many lead to treatment efforts that are in vain. teeth are treated every year through benefi ts. One will be able to see the spatial Two-dimensional radiography rarely will nonsurgical endodontic therapy. relationships between the affected tooth detect a fracture in a tooth because the While this treatment modality enjoys and adjacent anatomical structures such X-ray beam must be perfectly aligned a very high rate of clinical success,27,28 as the maxillary sinus29,30 (FIGURES 6), with the fracture plane to allow it to be there are some cases that will exhibit adjacent tooth root proximity, buccal seen on the radiograph. CBCT imaging endodontic posttreatment disease. The bone thickness31 and the path of the can help in visualizing fractures, but AAE/AAOMR position paper5 points inferior alveolar nerve32,33 and blood whether the fracture itself can be seen out that limited FOV CBCT may be vessels. By accurately locating these depends on the length and the width the imaging modality of choice when structures, surgical complications such of the fracture, the spatial resolution evaluating cases of nonhealing that as sinus perforation, damage to adjacent of the volume and the presence of may need either surgical or nonsurgical teeth, paresthesia/dysesthesia and severe artifacts due to adjacent radiopaque re-treatment. The CBCT allows for hemorrhage can generally be avoided.

242 APRIL 2018 CDA JOURNAL, VOL 46, Nº4

FIGURE 5A. FIGURE 5B. FIGURE 5C.

FIGURES 5. 2-D periapical radiograph showing a large periapical radiolucency that surrounds the root and extends up toward the cervical one-third of the root on the distal surface (5A). 3-D CBCT slice from the sagittal plane showing that the distal low-density area extends up to the crest of bone (5B). 3-D CBCT slice from the axial plane showing that the low-density area is very narrow mesiodistally. A periodontal probe could reach to the apex. The patient’s tolerance for risk was low and so an extraction was performed whereupon a vertical fracture was found in the root (5C).

Dental Trauma The AAE/AAOMR joint position statement recommends that CBCT be the imaging modality of choice in the diagnosis and management of limited dentoalveolar trauma.5 The 3-D view will aid in the diagnosis of horizontal root fractures, alveolar fractures and luxation injuries. More extensive trauma may also require other imaging modalities. The clinical value of using CBCT FIGURE 6A. FIGURE 6B. must be weighed against the increased radiation dosage especially in young patients. But in general, the benefi ts of using CBCT outweigh the risks such as missed fractures both in teeth and bone. Often the need for multiple 2-D images may result in more radiation than that from taking a CBCT image. Adjusting the exposure parameters of the CBCT can also reduce the radiation exposure while not impacting the diagnostic accuracy.34

FIGURE 6D. Resorption Root resorption presents signifi cant FIGURE 6C. challenges in attempts to retain such teeth. The extent of the resorption and its FIGURES 6. 2-D periapical radiograph showing a symptomatic upper premolar in apparent close proximity to possible effect on the structural integrity the maxillary sinus (6A). 3-D CBCT slice from the sagittal plane showing evident communication between the apical low-density area and the maxillary sinus (6B). Clinical microscopic view of the preexisting perforation into of the tooth posttreatment requires the sinus (6C). Six months after apical microsurgery, the patient is asymptomatic (6D). careful consideration. CBCT imaging has been found to be more accurate than 2-D radiography in detecting and

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FIGURE 7A. FIGURE 7B.

FIGURES 7. 2-D periapical and bitewing radiographs showing a small area of resorption on tooth No. 3 (7A). 2-D periapical radiograph from a distal angulation is not very helpful in assessing the prognosis (7B). 3-D CBCT slice from the axial plane showing the extent of the resorption and that it has opened a communication between the pulp space and the periodontium. The prognosis was unfavorable and the patient elected to extract the tooth (7C). FIGURE 7C.

FIGURE 8C.

FIGURE 8A. FIGURE 8B.

FIGURE 8. 2-D periapical radiograph of tooth No. 6 indicates a radiolucency consistent with external root resorption (arrow) (8A). 2-D periapical radiograph from a distal angulation indicates that it is on the palatal side (since the canal moved most to the mesial) (8B). There was no discontinuity in the structure of the tooth in any view on the CBCT. This axial plane view shows a suspicious notch (arrow) in the bone palatal to the tooth (8C). 3-D CBCT slice from near the sagittal plane indicates that the “lesion” is simply an anatomic variation. It is called the canalis sinuosus (Dr. Bruno Azevedo – OMR, personal communication) and contains the anterior superior alveolar nerve and blood vessels (8D). 3-D rendering showing the palatal view of this variant (arrows). If the CBCT had not been FIGURE 8E. made, this patient would have possibly undergone unnecessary, potentially invasive treatment for a FIGURE 8D. disease that did not exist (8E).

244 APRIL 2018 CDA JOURNAL, VOL 46, Nº4

determining the extent of a resorptive recently,42,43 there is still no consensus. treatment plans for the teeth in question lesion in a tooth35–37 (FIGURES 7). Prior For example, it is common to fi nd and were then presented with the CBCT to the availability of CBCT, invasive that an asymptomatic, endodontically volumes and asked if this information exploratory procedures to determine the treated tooth may exhibit a low-density would change their treatment plans. The extent of lesions were often necessary. periapical area as an incidental fi nding plans were changed in 35 to 62 percent Such exploratory procedures — whether on a CBCT volume. If this is not visible of the cases illustrating the infl uence surgical or nonsurgical — combined on a 2-D radiograph and there are no that CBCT information can have on with treatment efforts would sometimes subjective symptoms or clinical fi ndings, endodontic treatment planning. result in a poor prognosis for long-term it is diffi cult to tell if such a “lesion” retention. With the possibility of obtaining represents disease or simply delayed Conclusion detailed preoperative information using healing. The ability to fi nd suspected As more research is completed CBCT imaging, managing cases of teeth pathosis by using CBCT has exceeded regarding CBCT imaging, specifi c with root resorption has improved. the ability to determine accurately guidelines and clinical best practices will Another advantage of using CBCT what is occurring in such instances. evolve. In the future, one can expect for assessment of suspected resorption The AAE/AAOMR joint position improvements in 3-D imaging technology is that occasionally the imaging will statement5 recommends that absent signs to enhance resolution akin to the micro- reveal that what appeared to be resorption or symptoms, 2-D periapical radiographs CT. Regardless of what the future brings radiographically is, in fact, something else are the imaging modality of choice for in this rapidly growing fi eld, the question (FIGURES 8). In such cases, patients are outcome evaluation following endodontic now is: Can use of CBCT have an effect spared unnecessary treatment and cost. therapy. If, however, CBCT imaging on endodontic treatment? The answer to was used preoperatively, the statement this question, as posed in the title of this Treatment Outcomes and Healing does make the allowance that the same article, appears to be an emphatic yes. ■ Assessment modality may be used postoperatively Treatment outcomes are evaluated to assess the outcome. If there are signs REFERENCES 1. Grossman LI. A brief history of endodontics. J Endod following completion of endodontic and symptoms of posttreatment disease, 1982;8:S36–S40 (special issue). therapy. This may be to determine it refers back to the recommendation to 2. Nardi C, Talamonti C, Pallotta S, Saletti P, Calistri L, improvements or recurrence in patients’ use CBCT for assessment of this. The Cordopatri C, et al. Head and neck eff ective dose and quantitative assessment of image quality: A study to compare subjective symptoms, clinical fi ndings ambiguity of these recommendations cone beam CT and multislice spiral CT. Dentomaxillofac Radiol and radiographic appearances or upon refl ects a lack of consensus that may be 2017;20170030. patients’ requests. The radiographic gained in the future. One can expect 3. Radiological Society of North America. Radiation Dose in X-ray and CT Exams. 2017. www.radiologyinfo.org/en/info. fi ndings that are indicative of healing or research to improve the ability to cfm?pg=safety-xray. Accessed July 15, 2017. nonhealing of endodontic disease have interpret endodontic outcomes using 4. Nair MK, Levin MD, Nair UP. Radiographic Interpretation. been infl uenced by two scientifi cally CBCT technology; for now practitioners In: Hargreaves KMB, Berman LH, Rotstein, I, ed. Cohen’s Pathways of the Pulp. 11th ed. St Louis: Elsevier; 2016:33–70. validated systems to assess two- with minimal experience should be 5. AAE/AAOMR. Use of Cone Beam Computed Tomography dimensional radiographs: the Strindberg encouraged to seek advice from oral in Endodontics — 2015/2016 Update. 2016 www.aae.org/ criteria38 and the periapical index (PAI).39 and maxillofacial radiologists or other uploadedfi les/clinical_resources/guidelines_and_position_ statements/conebeamstatement.pdf. Chicago; 2016. Accessed In light of the superior ability to detect specialists with experience in the area. July 16, 2017. periapical low-density areas and other 6. Helvacioglu-Yigit D, Demirturk Kocasarac H, Bechara B, changes that may indicate endodontic Eff ect on Treatment Planning Noujeim M. Evaluation and Reduction of Artifacts Generated 15 by Four Diff erent Root-End Filling Materials by Using Multiple posttreatment disease using CBCT, The most compelling evidence of Cone Beam Computed Tomography Imaging Settings. J Endod concerns have arisen regarding the the importance of CBCT in endodontic 2016; 42(2):307–314. validity of previous endodontic outcomes diagnosis and treatment planning is 7. Decurcio DA, Bueno MR, de Alencar AH, Porto OC, 40 44–46 Azevedo BC, Estrela C. Eff ect of root canal fi lling materials on studies. Complicating that concern is found in three recent studies where dimensions of cone beam computed tomography images. J the lack of a universally accepted system clinicians were presented with complete Appl Oral Sci 2012; 20(2):260–267. for endodontic outcomes assessment diagnostic information including 2-D 8. Chang E, Lam E, Shah P, Azarpazhooh A. Cone beam 41 computed tomography for detecting vertical root fractures in using CBCT. While some research radiographs but not CBCT volumes. endodontically treated teeth: A systematic review. J Endod has been published addressing this These subjects completed endodontic 2016; 42(2):177–185.

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9. Ludlow JB. Dose and risk in dental diagnostic imaging: With fractures in nonendodontically treated teeth. Int Endod J assessment one year after periapical surgery. Int Endod J emphasis on dosimetry of CBCT. Kor J Oral Maxillofac Radiol 2014;47(8):735–746. 2016;49(10):915–925. 2009;39:175–184. 25. Metska ME, Aartman IH, Wesselink PR, Ozok AR. 42. Estrela C, Bueno MR, Azevedo BC, Azevedo JR, Pecora 10. Ludlow JB, Timothy R, Walker C, Hunter R, Benavides E, Detection of vertical root fractures in vivo in endodontically JD. A new periapical index based on cone beam computed Samuelson DB, et al. Eff ective dose of dental CBCT — a meta treated teeth by cone beam computed tomography scans. J tomography. J Endod 2008;34(11):1325–1331. analysis of published data and additional data for nine CBCT Endod 2012;38(10):1344–1347. 43. von Arx T, Janner SF, Hanni S, Bornstein MM. Evaluation units. Dentomaxillofac Radiol 2015;44(1):20140197. 26. Leader DM. CBCT is valuable for diagnosis of tooth of new cone beam computed tomographic criteria for 11. Abdelkarim AA. Appropriate use of ionizing radiation in fracture. Evid Based Dent 2015;16(1):23–24. radiographic healing evaluation after apical surgery: orthodontic practice and research. Am J Orthod Dentofac 27. Salehrabi R, Rotstein I. Epidemiologic evaluation of the Assessment of repeatability and reproducibility. J Endod Orthopedics 2015;147(2):166–168. outcomes of orthograde endodontic re-treatment. J Endod 2016;42(2):236–242. 12. Oser DG, Henson BR, Shiang EY, Finkelman MD, Amato 2010;36(5):790–792. 44. Ee J, Fayad MI, Johnson BR. Comparison of endodontic RB. Incidental fi ndings in small fi eld of view cone beam 28. Lazarski MP, Walker WA, Flores CM, Schindler WG, diagnosis and treatment planning decisions using cone beam computed tomography scans. J Endod 2017; 43(6):901–904. Hargreaves KM. Epidemiological evaluation of the outcomes volumetric tomography versus periapical radiography. J Endod 13. Patel S, Wilson R, Dawood A, Mannocci F. The detection of nonsurgical root canal treatment in a large cohort of insured 2014;40(7):910–916. of periapical pathosis using periapical radiography and cone dental patients. J Endod 2001;27(12):791–796. 45. Mota de Almeida FJ, Knutsson K, Flygare L. The eff ect beam computed tomography — part 1: Preoperative status. Int 29. Lavasani SA, Tyler C, Roach SH, McClanahan SB, Ahmad of cone beam CT (CBCT) on therapeutic decision-making in Endod J 2012;45(8):702–710. M, Bowles WR. Cone beam computed tomography: Anatomic endodontics. Dentomaxillofac Radiol 2014;43(4):20130137. 14. Abella F, Patel S, Duran-Sindreu F, Mercade M, analysis of maxillary posterior teeth — impact on endodontic 46. Mota de Almeida FJ, Knutsson K, Flygare L. The impact of Bueno R, Roig M. Evaluating the periapical status of teeth microsurgery. J Endod 2016;42(6):890–895. cone beam computed tomography on the choice of endodontic with irreversible pulpitis by using cone beam computed 30. von Arx T, Fodich I, Bornstein MM. Proximity of diagnosis. Int Endod J 2015;48(6):564–572. tomography scanning and periapical radiographs. J Endod premolar roots to maxillary sinus: A radiographic survey 2012;38(12):1588–1591. using cone beam computed tomography. J Endod THE AUTHOR, Robert S. Roda, DDS, MS, can be reached at 15. Cheung GS, Wei WL, McGrath C. Agreement between 2014;40(10):1541–1548. [email protected]. periapical radiographs and cone beam computed tomography 31. Bornstein MM, Lauber R, Sendi P, von Arx T. for assessment of periapical status of root fi lled molar teeth. Int Comparison of periapical radiography and limited cone Endod J 2013;46(10):889–895. beam computed tomography in mandibular molars for 16. Sogur E, Grondahl HG, Baksi BG, Mert A. Does a analysis of anatomical landmarks before apical surgery. J combination of two radiographs increase accuracy in detecting Endod 2011;37(2):151–157. acid-induced periapical lesions and does it approach the 32. Aminoshariae A, Su A, Kulild JC. Determination of the accuracy of cone beam computed tomography scanning? J location of the mental foramen: A critical review. J Endod Endod 2012; 38(2):131–136. 2014;40(4):471–475. 17. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. 33. Koivisto T, Chiona D, Milroy LL, McClanahan SB, Detection of periapical bone defects in human jaws using cone Ahmad M, Bowles WR. Mandibular Canal location: beam computed tomography and intraoral radiography. Int Cone beam computed tomography examination. J Endod Endod J 2009;42(6):507–515. 2016;42(7):1018–1021. 18. Uraba S, Ebihara A, Komatsu K, Ohbayashi N, Okiji 34. Jones D, Mannocci F, Andiappan M, Brown J, Patel S. The T. Ability of cone beam computed tomography to detect eff ect of alteration of the exposure parameters of a cone beam periapical lesions that were not detected by periapical computed tomographic scan on the diagnosis of simulated radiography: A retrospective assessment according to tooth horizontal root fractures. J Endod 2015;41(4):520–525. group. J Endod 2016;42(8):1186–1190. 35. Yi J, Sun Y, Li Y, Li C, Li X, Zhao Z. Cone beam computed 19. Michetti J, Maret D, Mallet JP, Diemer F. Validation of cone tomography versus periapical radiograph for diagnosing beam computed tomography as a tool to explore root canal external root resorption: A systematic review and meta-analysis. anatomy. J Endod 2010;36(7):1187–1190. Angle Orthod 2017;87(2):328–337. 20. Blattner TC, George N, Lee CC, Kumar V, Yelton CD. 36. Durack C, Patel S, Davies J, Wilson R, Mannocci F. Effi cacy of cone beam computed tomography as a modality to Diagnostic accuracy of small volume cone beam computed accurately identify the presence of second mesiobuccal canals tomography and intraoral periapical radiography for the in maxillary fi rst and second molars: A pilot study. J Endod detection of simulated external infl ammatory root resorption. Int 2010;36(5):867–870. Endod J 2011;44(2):136–147. 21. Vizzotto MB, Silveira PF, Arus NA, Montagner F, 37. Estrela C, Bueno MR, De Alencar AH, Mattar R, Valladares Gomes BP, da Silveira HE. CBCT for the assessment of Neto J, Azevedo BC, et al. Method to evaluate infl ammatory second mesiobuccal (MB2) canals in maxillary molar teeth: root resorption by using cone beam computed tomography. J Eff ect of voxel size and presence of root fi lling. Int Endod J Endod 2009;35(11):1491–1497. 2013;46(9):870–876. 38. Strindberg L. The dependence of the results of pulp therapy 22. Talwar S, Utneja S, Nawal RR, Kaushik A, Srivastava D, on certain factors. An analytic study based on radiographic Oberoy SS. Role of cone beam computed tomography in and clinical follow-up examinations. Acta Odontol Scand diagnosis of vertical root fractures: A systematic review and 1956; 14 Suppl 21. meta-analysis. J Endod 2016;42(1):12–24. 39. Orstavik D. Reliability of the periapical index scoring 23. Edlund M, Nair MK, Nair UP. Detection of vertical root system. Scand J Dent Res 1988;96(2):108–111. factures by using cone beam computed tomography: A clinical 40. Wu MK, Shemesh H, Wesselink PR. Limitations of study. J Endod 2011;37(6):768–772. previously published systematic reviews evaluating the outcome 24. Brady E, Mannocci F, Brown J, Wilson R, Patel S. A of endodontic treatment. Int Endod J 2009;42(8):656–666. comparison of cone beam computed tomography and 41. von Arx T, Janner SF, Hanni S, Bornstein MM. periapical radiography for the detection of vertical root Agreement between 2-D and 3-D radiographic outcome

246 APRIL 2018

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CDA JOURNAL, VOL 46, Nº4

Can We Regrow Pulps?

Paul V. Abbott, BDS, MDS

ABSTRACT Interest in regrowing pulps is increasing. Case reports and studies have been published but predictable protocols have not been developed. While periapical healing is predictable because of canal disinfection, clinical fi ndings are variable especially regarding root maturation. Histological studies demonstrate connective tissue and blood vessels rather than pulp and dentin-like or cementum-like tissue but not dentin or cementum. Repair procedures can help retain teeth but currently have no advantages over apexifi cation and apical barrier techniques.

AUTHOR

Paul V. Abbott, BDS, n recent years, dentists have become was that some viable pulp remained MDS, is a professor of excited by the prospect of regrowing in the apical part of the canal and this clinical dentistry at The pulps after they have become necrotic recovered1 or new tissue grew in from University of Western Australia. He is a and infected. This possible new the periapical region with the aid of a 2 specialist endodontist treatment modality became popular blood clot scaffold inside the canal. and also works part time Ifollowing two case reports in the early This concept was not new when these in a private specialist 2000s that described management of cases were treated. The earliest reports of endodontic practice. immature mandibular second premolars attempts to regrow the pulp date back to Confl ict of Interest Disclosure: None reported. with infected root canal systems and 1961 when Nygaard-Östby histologically chronic apical abscesses where a dens analyzed cases and reported that pulps and evaginatus fractured and exposed the dentin were not reliably induced.3 Later, pulp.1,2 Both cases were managed by Hørsted and Nygaard-Östby reported that disinfecting the root canal system prior when canals were intentionally fi lled 2-4 to placing a material in the coronal mm short of the apical foramen, slightly part of the canal without a root canal infl amed connective tissue formed within fi lling to allow tissue to grow into the two months. After six and 10 months, remaining canal space. Radiographs there was a cell-rich fi brous tissue with a showed periapical healing and hard few lymphocytes, but it was not pulp.4 tissue within the canals. In one case,1 With the progress of stem cell root formation appeared to progress research in the last two decades, the normally with a narrow apical foramen desire to regrow pulps has resurfaced. after 30 months while the other case2 The purpose of this paper is to summarize had considerable narrowing of the canal the literature and provide a balanced but not complete narrowing of the apical view of the possible treatment modalities foramen after 24 months. The premise for infected immature teeth.

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FIGURE 1A. FIGURE 1B. FIGURE 1C.

Healing of periapical tissues ? Hard tissue — dentine-like/ cementum-like/ bone-like ? Nil ? Connective tissue/ ? fi brous tissue

FIGURE 1E. Cervical barrier — MTA/bioceramic

Restoration in the access cavity

FIGURE 1D. FIGURE 2. Diagrammatic representation of typical FIGURES 1. Maxillary left lateral incisor in a 9-year-old girl where revascularization occurred after avulsion. It fi ndings following repair procedures to treat infected was placed in milk, then replanted and splinted 45 minutes later. After replantation (1A). Three-month review (1B). immature teeth. These involve inducing a scaff old within It responded to electric pulp testing but not a cold test. Seven-month review — further root development and pulp the canal to encourage tissue ingrowth from the periapical canal calcifi cation are evident. It still responded to electric pulp testing (1C). Fourteen-month review showing further region. The reparative tissue may be various types of soft pulp canal calcifi cation (1D–1E). The tooth continued to respond to electric testing. or hard tissues or the canal may remain empty.

Defi nitions also leads to unrealistic expectations tissues, etc., that have been lost, removed Before reviewing the literature, among practitioners and/or patients. or injured.”5 This implies that new tissue the terminology needs to be defi ned. Regeneration — This term has become in the canal must be pulp and not other Unfortunately, the profession has adopted popular to the extent that it is almost tissues. As outlined below, this does not terms that are ill defi ned and hence used exclusively (although in varying predictably occur in animal studies or in the are not always used appropriately. It is forms — such as regeneration, regenerative few human cases where histological analysis essential that new terms or new procedures endodontic procedures, etc.) when has been performed. Hence, use of this term be clearly defi ned so all practitioners discussing procedures that attempt to should be abandoned until it can be proven and authors understand them. The regrow pulps. However, it has not been that pulp is actually, and reliably, formed. use of inappropriate terminology leads adequately defi ned. “Regeneration” when Interestingly, the term “regeneration” was to misunderstanding and potentially used in a biological sense means “restoration not used in the titles of the early papers; inappropriate clinical procedures. It or new growth by an organism of organs, instead “revascularization” was used.1,2

250 APRIL 2018 CDA JOURNAL, VOL 46, Nº4

FIGURE 3B.

FIGURE 3A. FIGURE 3C.

FIGURE 3E.

FIGURE 3D. FIGURE 3F.

FIGURES 3. Traumatized immature tooth with a pulpless, infected root canal system and a chronic apical abscess treated with a repair procedure. Triple antibiotic paste was used followed by Ca(OH)2 and induction of a blood clot. Preoperative (3A–B). Postoperative with an MTA cervical barrier (3C). Eighteen months (3D–E). Six years (3F). (Courtesy Dr. Eugene Chen)

Revascularization — means “re- there is no bacterial contamination, term. In clinical practice, it is impossible establishment of blood supply to a part pulps can recover and function normally. to determine whether pulps have viable or organ.”6 The American Association Pulp canal calcifi cation typically blood supply because thermal and electric of Endodontists (AAE) defi nes it as “the occurs (FIGURE 1) but this is a normal pulp tests are sensibility tests and not restoration of blood supply.”7 This is physiological response demonstrating vitality tests — that is, they indicate the known to occur after trauma where the pulp survival and normal function. ability of the pulp to respond to a stimulus. pulp’s neurovascular supply is severed by Revitalization — means “to give new Specifi c tests for blood supply (laser luxation or avulsion. In immature teeth life to or to give new vitality or vigor to.”9 Doppler fl owmetry or pulse oximetry) where the apical foramen is “open” — It is not defi ned in the AAE Glossary of are required if claims about vitality are to especially more than 1.1 mm — blood Endodontic Terms. In dentistry, vitality be made, but these tests are not typically vessels can anastomose and re-establish refers to presence of pulp blood supply. used in practice due to cost, time, lack blood supply to the pulp.8 Provided It is a poorly understood and misused of reliability and little research.

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Healing of periapical tissues “Natural” induced hard tissue barrier

Repair — this term can have several this concept using modern approaches, Root canal fi lling — meanings, including “to restore to a especially with a focus on stem cells gutta percha and good or sound condition after decay that may be in the periapical tissues. cement or damage, to restore or renew by any Iwaya et al. assumed that some viable process of making good, strengthening, tissue remained in the apical part of the etc., to remedy and to make good.”10 This root canal.1 This assumption was based on Restoration in the defi nition is appropriate for procedures the patient having pain when instruments access cavity where clinicians treat root canal infections were used in the canal. The authors and attempt to encourage pulp regrowth. stated that visual inspection confi rmed By using this term, the profession the presence of pulp tissue approximately recognizes that a reliable pulp regenerative 5 mm apical to the canal orifi ce. They FIGURE 4. Diagrammatic representation of typical procedure has yet to be developed (and therefore avoided further instrumentation fi ndings following apexifi cation of infected immature proven) and that healing with other tissue to preserve this tissue, and they postulated teeth where an apical hard tissue barrier is induced before root fi lling. may occur (FIGURES 2 and 3). Hence, that it recovered, regrew and continued this term will be used in this review. to function by producing dentin to Apexifi cation — the AAE defi nes this complete the root development. these is a distinctly different condition term as “a method to induce a calcifi ed Banchs and Trope took a different (albeit with a similar cause) so they may barrier in a root with an open apex.”7 approach.2 Following canal disinfection, have different responses to treatment. This usually involves placing intracanal periapical bleeding was induced to form The stage of root development (apical medicaments such as calcium hydroxide a blood clot in the canal to act as a foramen width, canal width, root length) to induce closure of the open apical “scaffold” for ingrowth of new tissue. They varies considerably as do the methods foramen with a natural hard tissue barrier hypothesized that this was “similar to and criteria used to assess outcomes. (FIGURES 4 and 5). This procedure has necrotic pulp after a traumatic injury” in As a result of these variables and the been used in dentistry for many years with immature teeth where revascularization lack of standardization/consensus, the great success and high predictability.11–14 occurs. A triple antibiotic paste was fi ndings are quite variable, which leaves Apical barrier technique — the AAE used as the main disinfecting agent. the profession without true indications defi nes this as “blockage of the apical This paste was based on an in vitro for when repair procedures are indicated foramen; may be an induced hard tissue study that reported it to be highly and how to predictably perform them. or artifi cial materials.”7 Placing hard- effective for infected root dentin.15 A systematic review16 found 214 setting materials such as mineral trioxide Many case reports and studies have studies regarding repair procedures but aggregate (MTA) or other bioceramic now been published. On reviewing the only six satisfi ed the inclusion criteria — materials prior to fi lling the remaining case reports, it is apparent that there is no English, performed in humans with fi ve or canal is an example of an apical barrier standard protocol and the types of cases more teeth, immature infected permanent technique (FIGURES 6 and 7). The vary considerably. There is no consensus teeth. Various outcome measures were barrier formed is artifi cial although a regarding the materials used for canal used in these six studies, including tooth natural hard tissue barrier may form disinfection, the timing and number survival and function, resolution of signs later — however this cannot usually be of appointments, the use of adjunctive of disease and success/failure. Two of assessed radiographically because of the agents (such as blood products) and other the six studies were excluded from parts radiopacity of the barrier material. variables to treat a range of presenting of the analysis due to discrepancies in conditions. Reports have concerned dens their initial assessments. Hence, only Literature Overview evaginatus in mandibular premolars or four studies could be assessed for all Nygaard-Östby was the fi rst to traumatized maxillary incisors. Some criteria, which demonstrates the limited investigate whether pulp could regrow cases have had draining sinus tracts evidence available and highlights the after infection of the root canal system but indicating chronic apical abscesses, wide variation between studies. The four he was unable to predictability induce pulp while others have had chronic apical studies included only 75 teeth treated regrowth.3 Subsequently numerous case periodontitis, acute apical abscesses with repair procedures and 53 treated by reports and research papers have discussed or acute apical periodontitis. Each of apexifi cation or apical barrier techniques.

252 APRIL 2018 CDA JOURNAL, VOL 46, Nº4

respectively.17 These were compared with changes following apexifi cation and barrier techniques but only the length changes should be compared because dentin thickness cannot possibly change with apexifi cation and apical barrier techniques. After apexifi cation, average root length increased by 6.1 percent.17 Another study found average changes following repair procedures were 5 percent FIGURE 5A. FIGURE 5B. for root length and 21 percent for dentin thickness.18 These changes were only detectable and quantifi ed by computer software and could not be detected by visual examination of radiographs.18 Alobaid et al. reported no statistical differences for changes in root length and dentin thickness following repair and apexifi cation/apical barrier procedures.19 They used 20 percent as a clinically meaningful change for each category but only four repair cases and one apexifi cation/apical barrier case met this threshold. Hence, the clinical relevance of these changes is doubtful. The authors concluded that repair and apexifi cation/apical barrier techniques FIGURE 5C. FIGURE 5D. were equivalent with insuffi cient evidence FIGURES 5. An immature tooth with a pulpless, infected root canal system and secondary acute to claim superiority of any technique. apical periodontitis treated by apexifi cation with three monthly calcium hydroxide dressings. The In another systematic review of repair apical hard tissue barrier was noted after 12 months. Preoperative radiograph (5A). After nine procedures,20 the authors reported that months — periapical healing and hard tissue barrier formation are evident (5B). Root canal fi lling the tooth survival rates and resolution of 12 months after commencement of treatment (5C). Five-year review (5D). periapical radiolucencies were excellent. However, they also reported that apical closure and continued root development Unfortunately, the data for these latter 100 percent for apexifi cation/barrier were inconsistent in the reviewed studies. two procedures were combined, which is techniques. Periapical healing based on Furthermore, they commented that inappropriate because they are different radiographs from three studies was 89.7 there are few well-reported randomized clinical procedures. Each procedure percent for repair and 100 percent for prospective clinical studies, plus evidence cannot be assessed individually as apexifi cation/barrier techniques. One regarding long-term outcomes and late the results of one may (positively or study assessed bone density and found effects was sparse. No study evaluated negatively) infl uence results of the other no difference among these procedures. health economic outcomes and whether procedure. Tooth survival was 98.6 percent Quantitative analysis of changes in there were any improvements to quality for repair procedures and 88.6 percent for root length and dentin thickness have of life for the patients. Their conclusions combined apexifi cation/barrier techniques. been performed. Jeeruphan et al. reported stated that there are many gaps in the The combined clinical success from two average increases of 14.9 percent and profession’s knowledge regarding repair studies was 89.7 percent for repair and 28.2 percent in length and thickness, procedures and the published evidence

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Healing of the periapical tissues Apical barrier — with MTA/bioceramic does not provide defi nitive conclusions over time by examining animals at Root canal fi lling — regarding the predictability of treatment appropriate time intervals. They show gutta percha and outcomes following repair procedures. tissue responses within both the canals cement Alobaid et al. compared outcomes and the periradicular tissues. Histological and “adverse events” following repair and studies can rarely be performed on human 19 apexifi cation/apical barrier procedures. teeth. If they can, it is usually due to an Restoration in the Follow-up periods were short and the adverse event that led to tooth extraction access cavity number of teeth was small — 19 teeth so the fi ndings may not be applicable for 15 months average in the repair group to all cases. In addition, histological and 12 teeth for 22 months average in examination of extracted teeth does not the apexifi cation/apical barrier group. usually include the periradicular tissues FIGURE 6. Diagrammatic representation of typical One tooth from the repair group did not and it is an examination at a single time fi ndings following apical barrier techniques to treat survive (further trauma) and four teeth point without showing healing over time. infected immature teeth. A cement is placed to close had unfavorable outcomes (78 percent Hence, histological animal studies are the apical foramen prior to root canal fi lling. clinical success). In the other group, all essential to provide evidence to support teeth survived with favorable outcomes (or not support) new techniques. materials. The overall conclusion of this (100 percent clinical success). There A systematic review of repair review was: “None of the regenerative were more adverse events in the repair procedures in animals where histology protocols resulted in predictable group (eight teeth, 42 percent) than was used to assess tissue responses initially formation of a true pulp-dentin complex.” the other group (one tooth, 8 percent). identifi ed 123 studies but only 13 met This is a very important fi nding that The adverse event in the latter group the inclusion criteria.21 None of these contradicts claims in many reports of was further trauma whereas the repair studies identifi ed pulp tissue in the canals pulp regeneration, revascularization or group had a variety of adverse events, — instead, there were varying degrees revitalization. Furthermore, claims of root including reinfection (three teeth), of connective tissue, fi broblast-like cells strengthening need reconsideration in staining (two), fracture (one), pain (one) and blood vessels. Various types of hard light of this review because a “like tissue” and further trauma (one). Some adverse tissue were found in the canals and none is unlikely to have the same physical events are unavoidable and/or unrelated of the studies reported them as being properties as the tissue it is replacing. to the procedure (e.g., further trauma, dentin, bone, periodontal ligament or It will not necessarily provide the same fracture) so they are not “negative” cementum — instead, they were “like” structural strength as the original tissue. issues or contraindications. However, tissues suggesting similarity but not In addition, different types of “like tissues” other adverse events (e.g., continued replication of these tissues. Dentin-like that would not normally be present in the infection, pain, no healing) may be tissue was reported on canal walls in 4 canal (e.g., bone-like, cementum-like) related to the procedure and must be percent of teeth after blood-clot scaffold are less likely to provide strength because considered whenever contemplating such procedures and 2 percent of teeth where strength relies on having suffi cient dentin. procedures. Patients (and parents) must blood clots plus additional materials were Some further observations from the be informed of these possible problems. used. Periodontal ligament-like tissue literature,1,2,16–23 especially case reports, are: When assessing new techniques, case was reported in 46 percent of teeth. ■ Infected immature mandibular reports and clinical studies have severe Cementum-like tissue was in 64 percent premolars with dens evaginatus limitations because of the variations of teeth with blood-clot scaffolds, 80 generally respond well to repair in techniques and conditions being percent with blood clots and additional procedures. Radiographs suggest treated. Hence, animal studies are materials, 50 percent with alternative resumption of normal root extremely valuable because histology scaffold materials and only 5 percent development, indicating that pulps and scanning electron microscopy can when canals were left empty. Bone-like may have regrown. Radiographs be used to assess healing responses, hard tissue was reported in 10 percent of usually show good periradicular the type/nature of reparative tissue (if cases with blood-clot scaffolds, 2 percent repair, reformation of normal any) and treatment outcomes. Animal with blood clots and additional materials periodontal ligament space, root studies can show progress of healing and 4 percent with alternative scaffold canal narrowing and closure of

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FIGURE 7A. FIGURE 7B. FIGURE 7C.

FIGURES 7. Immature tooth with a pulpless, infected root canal system and chronic apical periodontitis treated with an MTA apical barrier technique. On referral to an endodontist — treatment had been commenced by a general dentist (7A). MTA apical barrier (7B). Canal fi lled with gutta percha and cement (7C). Six months (7D). Four years (7E).

open apical foramina. However, caution is necessary as radiographs do not allow differentiation between dentin and other hard tissue and the tissue within the canal cannot be seen to FIGURE 7D. FIGURE 7E. determine its composition. ■ Maxillary incisors that become root canal rather than just in the even without canal and apical infected following trauma do cervical region (FIGURE 8). In some foramen narrowing. These fi ndings not respond as predictably as cases, material has been placed indicate periapical healing but mandibular premolars discussed almost to the apical foramen, not pulp repair/regeneration. above. Damage to the periapical which leaves little space for repair ■ Some cases have used radiographs stem cell base during trauma is and hard tissue formation — this to assess outcomes while others the likely explanation. The type is more akin to apexogenesis or have used cone beam computed of trauma is probably critical an apical barrier technique. tomography (CBCT). Neither of because some injuries damage ■ Follow-up radiographs usually these can determine the nature of periapical tissues more than show periapical tissue repair. This the soft tissue (if any) that may form others — for example, crown should be an expected outcome if within the canal. These images only fractured teeth may have no the root canal system is adequately show hard tissue changes and not damage while luxated and avulsed disinfected. It is well-known presence (or absence) of soft tissue. teeth have considerable damage. that periapical radiolucencies They cannot be used to distinguish ■ Controlled placement of the can heal without canals being between pulp, connective tissue, cervical barrier is diffi cult and fi lled.24,25 However, many authors fi brous tissue or other soft tissue. radiographs often show the use this as the sole criterion to ■ Radiographs and CBCT cannot be material placed well into the claim pulp has “regenerated,” used to determine the nature of new

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FIGURE 9. Cervical root fracture after apexifi cation. This tooth had three episodes of hard tissue. This may be dentin, trauma after the cementum, bone or a mixture of root fi lling was these. Animal studies have shown completed, with the new hard tissues are “like” these the fi nal episode original tissues but they are not the (three years later) resulting in same when examined histologically. fracture. Radiographs and CBCT images are not discriminating enough FIGURE 8. In repair cases, the cervical barrier placement is diffi cult to control. It may inadvertently be to distinguish between these positioned too apical as in this immature mandibular different hard tissues. premolar with dens evaginatus. ■ Many clinicians report diffi culty in inducing bleeding into the canal to create a scaffold. In such cases, hard tissue does healing.24,25 In these two studies, one result from normal functional loading not appear to form within the group of infected teeth had root canal (especially in very immature teeth). The canal although periradicular fi llings placed while canals in another proportion of fractures was highest (77 healing still occurs because the group were left empty. Periapical healing percent) in the most immature teeth canal has been disinfected. rates were identical for both groups — i.e., Stage 1 development — and in both studies. This clearly indicated lowest in mature teeth (28 percent). Discussion that disinfection is the most important The frequency of fractures was also The literature suggests many teeth contributor to periapical healing. This highly statistically signifi cantly related to can be retained with repair procedures. approach should be identical for immature external infl ammatory resorption defects However, histological studies do not teeth, although instrumentation of canal where tooth structure had been lost.26 support the concept of pulp and dentin walls is minimized to preserve dentin. Unfortunately, Cvek’s data has been regeneration. Hence, the profession needs Advocates for repair procedures employ misrepresented by proponents of repair to reconsider what it is trying to achieve disinfection methods although protocols procedures who claim fractures are very with these procedures. If the intent is to vary between studies and cases. Typically, likely after apexifi cation because some retain teeth, then repair procedures can antibiotics (triple, double or single publications suggest calcium hydroxide be performed but the evidence does not antibiotic pastes), calcium hydroxide or weakens dentin.27,28 However, the show any advantages over apexifi cation other antiseptics are used. These, along methods used do not replicate the clinical and its derivative, the apical barrier with canal irrigation (typically with scenario of trauma as they typically use technique. There are further aspects sodium hypochlorite and ethylenediamine dentin samples rather than intact human that need consideration other than just tetra-acetic acid), are very predictable teeth. In addition, the medicament is periapical healing and whether pulp in achieving bacteria-free root canal not just applied within the root canal and/or hard tissue form in the canal. systems and therefore periapical healing and continuous loading is used rather Periapical healing following should be expected. Hence, periapical than impact forces. Other studies have treatment of infected root canal systems healing following repair procedures is contradicted these fi ndings, suggesting is predictable provided adequate neither surprising nor remarkable. that calcium hydroxide may not be disinfection protocols are followed.24,25 Further consideration is needed the cause of dentin changes.29,30 In a These include using a rubber dam, regarding the aims of repair procedures. systematic review regarding nonsetting thorough instrumentation, antibacterial One aim is to strengthen tooth roots by calcium hydroxide, no clinical studies irrigants and medicaments, plus adequate regrowing pulp that can then produce directly supporting a correlation between tooth restoration during and after root dentin. This is based on Cvek’s fi ndings of calcium hydroxide intracanal dressings canal treatment. Studies have shown cervical root fractures in some teeth after and root fracture could be found in the that it is not necessary to fi ll canals calcium hydroxide apexifi cation.26 The literature. This was despite most of the with materials such as gutta percha fractures usually occurred after further in vitro studies showing some reduction and cement to achieve periapical trauma (FIGURE 9) although some may in the mechanical properties of dentin

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FIGURE 10A. FIGURE 10B. FIGURE 10C.

FIGURE 10D. FIGURE 10E. FIGURE 10F.

FIGURES 10. Example showing how a tooth treated by apexifi cation can be re-treated. Postoperative radiograph after Ca(OH)2 apexifi cation (10A). Eight-year review (10B). Thirteen-year review (10C). Periapical radiolucency indicates an infected root canal system and chronic apical periodontitis. Working length radiograph shows the apical hard tissue barrier (10D). Postoperative radiograph with the new root fi lling (10E). Two-year review (10F). after exposure to calcium hydroxide Increases in root length and dentin a small amount of hard tissue at the root for fi ve weeks or longer. However, thickness are of interest because it has apex seems unlikely to increase resistance to conversely, there was no conclusive data been assumed that they provide greater fracture at the cervical level where fractures concerning calcium hydroxide used for strength to teeth over time. However, this occur. Likewise, a small increase in dentin one month or less had a negative effect is purely an assumption and no studies thickness in the apical two-thirds of the on the properties of dentin.31 Careful have investigated this. Increases are root is also unlikely to increase resistance analysis of Cvek’s paper indicates that usually reported as average percentages to cervical fracture. If any procedure could fractures were directly related to the but if quantifi ed as tooth structure, it is increase resistance to fracture, it would need amount of tooth structure rather than doubtful that they will strengthen teeth. to produce a signifi cant amount of dentin at the effect of calcium hydroxide since As an example, extrapolating data from the critical point where the fractures occur all cases had long-term application Saoud et al.18 suggests the change in root — that is, the cervical level. Unfortunately, of this medicament and the only length averaged only approximately 1.0 current repair protocols cannot achieve this signifi cant variables were the stage of root mm while dentin thickness changed by as barrier materials (MTA or a bioceramic development and the resorptive defects.26 only about 0.54 mm. Production of such material) are placed in the cervical part of

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the root, thus preventing dentin formation demonstrated by one case presented by Conclusions there. The material must be placed there Bukhari et al.23 Sometimes, apical barrier Having treatment procedures that to facilitate access cavity restoration and techniques are used.24 It is somewhat predictably lead to pulp regrowth to avoid staining. Hence, it is impossible ironic that these procedures are only is desirable but currently there is to overcome this fundamental problem used as a “backup” rather than as the insuffi cient evidence to support this of immature teeth being susceptible to fi rst choice of management when they concept as a modality for managing cervical fracture using current techniques are associated with fewer complications infected immature teeth. The best that for managing immature teeth whether and are generally more predictable. can be achieved with current repair they be repair, apexifi cation or apical The potential need for endodontic procedures is periapical healing, but barrier techniques. Furthermore, a study re-treatment if and when the root canal root maturation is unpredictable. In similar to Cvek’s26 needs to be conducted system becomes infected again should some cases, various types of soft and so the incidence of root fractures following always be considered when planning hard tissues may form in the canal. repair and apical barrier procedures treatment. This is a possibility because all Current repair procedures show no can be determined and compared with teeth require a restoration after root canal advantage over apexifi cation and Cvek’s results for apexifi cation. treatment. Over time, restorations break apical barrier techniques. The latter Proponents of repair and apical barrier down, leading to reinfection, because all two procedures tend to be more techniques often discuss the number of restorations have a fi nite life span. Hence, predictable, and they provide more appointments and patient compliance as clinicians and patients should be prepared possibilities for longer-term retention advantages over apexifi cation. However, for possible endodontic re-treatment. The of immature infected teeth. ■ there is little difference apart from overall concept of “what goes in, must come out” time to treat the tooth. Apexifi cation should be followed — that is, materials REFERENCES studies have reported hard tissue barriers must be capable of being removed without 1. Iwaya S, Ikawa M, Kubota M. Revascularization of an 12 immature permanent tooth with apical periodontitis and sinus within 5.1 months (average 2.4 visits), risking damage to the tooth, particularly in tract. Dent Traumatol 2001;17:185–187. 13 2. Banchs F, Trope M. Revascularization of immature 7.8 months (three Ca(OH)2 dressings) immature teeth as they already lack tooth and 9.0 months.14 The time for apical structure. Use of hard cements as apical permanent teeth with apical periodontitis: new treatment protocol? J Endod 2004;30:196–200. closure was signifi cantly related to size or cervical barriers may be problematic. 3. Nygaard-Östby B. The role of the blood clot in endodontic of the apical foramen — average 6.2 No reports have been published regarding therapy: an experimental histological study. Acta Odontol months when the opening was less than barrier removal but it is likely to be diffi cult Scand 1961;79:333–349. 4. Hørsted P, Nygaard-Östby B. Tissue formation in the root 2.0 mm and 11.0 months when more and even impossible in some cases. During canal after total pulpectomy and partial root fi lling. Oral Surg than 2.0 mm.13 Protocols for apical barrier removal, apical barrier materials may be Oral Med Oral Pathol 1978; 46:275–282. and repair procedures vary between extruded into the periapical tissues leading 5. Regeneration. www.dictionary.com/browse/ regeneration?s=t. practitioners but both procedures require to infl ammation or foreign body reactions. 6. Revascularization. www.dictionary.com/browse/ three to four appointments over one If the material cannot be removed, the revascularization. to three months. Hence, there is little apical part of the canal may not be able to 7. American Association of Endodontists — Glossary of Endodontic Terms, 9th ed 2015. difference in the number of appointments. be disinfected, which may lead to treatment 8. Kling M, Cvek M, Mejàre I. Rate and predictability of pulp Therefore, arguments regarding time and failure or the need for periapical surgery. revascularization in therapeutically reimplanted permanent compliance are irrelevant and patients Cervical barriers used for repair procedures incisors. Endod Dent Traumatol 1986;2:83–89. 9. Revitalization. www.dictionary.com/browse/ should be offered the most predictable may be more accessible but still diffi cult revitalization?s=t. treatment with a full discussion of the to remove without damaging the canal 10. Repair. www.dictionary.com/browse/repair?s=t. time and appointment scheduling. Well- walls. In contrast, following apexifi cation 11. Rafter M. Apexifi cation: a review. Dent Traumatol 2005;21:1–8. informed patients are likely to comply to create natural hard tissue barriers it is 12. Mackie IC, Hill E, Worthington HV. Comparison of two in the interest of predictable outcomes. relatively simple to re-treat as the gutta calcium hydroxide pastes used for endodontic treatment Interestingly, although apexifi cation percha can be removed in the usual manner of nonvital immature incisor teeth. Endod Dent Traumatol 1994;10:88–90. has lost favor among some clinicians, with solvents and fi les. The apical hard 13. Mackie IC. Bentley EM, Worthington HV. The closure it remains the “fall-back” procedure tissue barrier is usually still intact and of open apices in nonvital immature teeth. Brit Dent J for repair cases that have not healed the new root fi lling can be easily placed 1988;165:169–173. 14. Yates JA. Barrier formation time in nonvital teeth with open or have become infected again, as after canal disinfection (FIGURE 10). apices. Int Endod J 1988;2I:313–319.

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15. Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato study. J Endod 2014;40:1063–1070. and hardness of root dentin. J Endod 2002;28:828–830. M, Kota K, Iwaku M. In vitro antibacterial susceptibility of 20. Tong HJ, Rajan S, Bhujel N, Kang J, Duggal M, Nazzal H. 27. Hawkins JJ, Torabinejad M, Li Y, Retamozo B, Eff ect of bacteria taken from infected root dentine to a mixture of Regenerative endodontic therapy in the management of non- three calcium hydroxide formulations on fracture resistance of ciprofl oxacin, metronidazole and minocycline. Int Endod J vital immature permanent teeth: a systematic review-outcome dentin over time. Dent Traumatol 2015;31:380–384. 1996;29:125–130. evaluation and meta-analysis. J Endod 2017;43:1453–1464. 28. Hatibović-Kofman S, Raimundo L, Zheng L, Chong 16. Kahler B, Rossi-Fedele G, Chugal N, Lin LM. An evidence- 21. Altaii M, Richards L, Rossi-Fedele G. Histological L, Friedman M, Andreasen JO. Fracture resistance and based review of the effi cacy of treatment approaches for assessment of regenerative endodontic treatment in animal histological fi ndings of immature teeth treated with mineral immature permanent teeth with pulp necrosis. J Endod studies with diff erent scaff olds: A systematic review. Dent trioxide aggregate. Dent Traumatol 2008;24:272–276. 2017;43:1052–1057. Traumatol. 2017;33:235–244. 29. Bukhari S, Kohli MR, Setzer F, Karabucak B. Outcome 17. Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, 22. Klevant FJ, Eggink CO. The eff ect of canal preparation on of revascularization procedure: A retrospective case series. J Khewsawai P, Hargreaves KM. Mahidol study 1: Comparison periapical disease. Int Endod J 1983;16:68–75. Endod 2016;42;1752–1759. of radiographic and survival outcomes of immature teeth treated 23. Sabeti MA, Nekofar M, Motahhary P, Ghandi M, Simon JH. 30. Nagy MM, Tawfi k HE, Hashem AA, Abu-Seida AM. with either regenerative endodontic or apexifi cation methods — Healing of apical periodontitis after endodontic treatment with Regenerative potential of immature permanent teeth with a retrospective study. J Endod 2012;38:1330–1336. and without obturation in dogs. J Endod 2006;32:628–633. necrotic pulps after diff erent regenerative protocols. J Endod 18. Saoud TMA, Zaazou A, Nabil A, Moussa S, Lin LM, 24. Cvek M. Prognosis of luxated nonvital maxillary incisors 2014;40:192–198. Gibbs JL. Clinical and radiographic outcomes of traumatized treated with calcium hydroxide and fi lled with gutta percha. 31. Yassen GH, Platt JA. The eff ect of nonsetting calcium immature permanent necrotic teeth after revascularization/ Endod Dent Traumatol 1992;8:45–55. hydroxide on root fracture and mechanical properties revitalization therapy. J Endod 2014;40:1946–1952. 25. Rosenberg B, Murray PE, Namerow K. The eff ect of of radicular dentine: A systematic review. Int Endod J 19. Alobaid AS, Cortes LM, LO J, Nguyen TT, Albert J, calcium hydroxide root fi lling on dentin fracture strength. Dent 2013;46:112–118. Abu-Melha AS, LIN LM, Gibbs JL. Radiographic and clinical Traumatol 2007;23:26–29. outcomes of the treatment of immature permanent teeth by 26. White JD, Lacefi eld WR, Chavers LS, Eleazer PD. The eff ect THE AUTHOR, Paul V. Abbott, BDS, MDS, can be reached at revascularization or apexifi cation: A pilot retrospective cohort of three commonly used endodontic materials on the strength [email protected].

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Implant Dentistry and Endodontics: Can There Be a Mutually Benefi cial Relationship?

Tory Silvestrin, DDS, MSD, and Charles J. Goodacre, DDS, MSD

ABSTRACT Endodontics focuses on preservation of teeth with pulpal and periapical disease. Implant dentistry provides replacement of missing or nonsalvageable teeth with implant-supported restorations. Arguments have been made that teeth are sometimes treated endodontically but instead should be replaced with implants. Opposing arguments suggest that teeth have been needlessly replaced with implants. Data show that endodontics and implant dentistry play important roles in patient-centered dentistry.

AUTHORS

Tory Silvestrin, DDS, Charles J. Goodacre, ndodontics as a specialty has implant dentistry in their practices. MSD, attended the DDS, MSD, graduated promoted the preservation of They have begun to recognize the value University of Washington with a doctor of dental teeth that can be properly restored of adding this treatment modality in School of Dentistry and surgery degree in 1971 earned his endodontic and subsequently earned and function satisfactorily after cases where teeth cannot be treated certifi cate and master a master of science treatment of pulpal and periapical endodontically or have a questionable of science in dentistry in dentistry degree in Edisease. Preserving the natural dentition prognosis. Implants provide the benefi t degree. He also earned his prosthodontics. He served has been the goal of endodontics since its that adjacent teeth do not need to be master of science in health as dean of the Loma initiation more than 100 years ago. Where involved in replacing a nonsalvageable professions education Linda University School of 1 degree from Loma Linda Dentistry from 1994–2013 teeth are not salvageable or missing, the tooth such as in fi xed prosthodontics. University. He is the chair and now serves as a introduction of implant dentistry has been After a period of time of confrontations of the department of distinguished professor of a very welcome addition to dental care. between endodontists and dentists endodontics. prosthodontics. In patient-centered practices, treatment promoting dental implants, it seems that Confl ict of Interest Confl ict of Interest options should be presented objectively for the time has come for coexistence of the Disclosure: None reported. Disclosure: None reported. the patient’s benefi t. When the popularity two treatment entities in the interest of of dental implants was rising several best patient care. In light of this, there are decades ago, most endodontists resisted times when retention of a compromised joining the move to incorporate the new tooth through endodontic and restorative treatment modality. Many were of the intervention is the most appropriate opinion that implants were a competitive choice in a region that would otherwise challenge. While that notion still exists, be aesthetically marginalized if a dental endodontists have in recent years become implant were considered.2 At other times, increasingly interested in incorporating the retention of some teeth with root canal

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treatment could result in a compromised autotransplanted teeth.11–14 The use of placement was a part of the specialty prognosis due to the extensive loss of tooth endodontic implants for root fractures scope, it was considered to be within the structure or an aesthetic compromise where the apical segment of the tooth is practice scope of endodontists to also place when adjunctive treatments such as crown removed is no longer recommended.15 endosseous implants. The Commission lengthening or orthodontic extrusions The placement of endodontic on Dental Education (CODA) modifi ed are required to restore the tooth. implants gained some popularity from the Standards for Advanced Specialty the mid-1960s to early 1970s.8 The Education Programs in Endodontics in History of Implant Dentistry popularity faded when the outcomes the early 1990s to include endosseous Dental implants have a history that became unpredictable and apical lesions implants, thus including this new surgical precedes Brånemark’s introduction of were often associated with the implants.16 procedure in the endodontists’ scope osseointegration. There is evidence of Despite the problems with apical of practice.18 Prior to the introduction prehistoric people attempting to adapt and lesions, these implants did solve the excess of this standard, the CODA Standards use foreign materials to replace missing mobility of teeth that would otherwise in 1985 stated that graduate students dentition.3,4 These early attempts included need to be extracted. An advantage should provide service and demonstrate replacement of teeth with wood, bone, ivory, in using endodontic implants was that experience with endodontic implants.19 gold and other materials. Early Egyptian Currently, dental implants are included to and South American cultures used cobalt varying degrees in all advanced endodontic alloy, tantalum, stainless steel and iridium.5 education programs and thus endodontists In the 1970s, physician Per-Ingvar It seems that the time may include them in their practices. Brånemark introduced the concept The American Association of of osseointegration (the physical has come for coexistence Endodontists (AAE) has recognized contact of bone to titanium) of dental of the two treatment the role implants play in the specialty implants.6 Brånemark had previously entities in the interest of of endodontics and have incorporated discovered — serendipitously in best patient care. curricula in its annual sessions to educate another experiment — favorable soft endodontists about treatment planning, and bony tissue reactions to titanium. problem solving and surgical aspects of the The Brånemark protocol involved placement of dental implants in practice. placing implants into the alveolar process in mandibular incisors the stress from Loma Linda University was a pioneer and then covering it with the soft tissue mobile teeth was shifted from the thin in the integration of endodontics and fl ap raised to expose the bone. Then, buccal bone to the thicker lingual bone.17 dental implants with the establishment of a following three to six months of healing, While the use of endodontic implants is program track in the advanced endodontic the implants would be uncovered and used rare today, it is interesting to look back program that would include an additional for support and retention of a prosthesis.7 and recognize the role endodontists year of surgical implant training. An Before the Brånemark root-formed had in the concept of implant dentistry advantage to including implant dentistry in implants were introduced, another form long before the advent of contemporary the endodontic program is the opportunity of implant had gained some popularity: endosseous root-form implants. for a patient with a nonsalvageable tooth to endodontic implants. These were have it replaced with an implant without implants developed for the purpose of Endodontists and Dental Implants the need to be referred to another clinic. retaining poorly supported teeth.8 These Despite a history of involvement with The patient may have been referred to implants were rigid (usually composed endodontic implants, endodontists did the endodontic clinic for evaluation of a of titanium) and extended through the not get involved with root-form implants tooth with a problem that turns out to be root apex into the apical bone to stabilize early on. Many endodontists viewed the a root fracture, for instance; such a patient teeth with weakened periodontal support. new innovation with some suspicion could receive both a thorough endodontic Other applications for endodontic and certainly with very little enthusiasm. evaluation along with information about implants were stabilization of overdenture Some endodontists, however, were treatment options that could include a abutment teeth9 and teeth with root curious enough to try the new implant dental implant. With the approval of the fractures10 and replanted avulsed and method and because endodontic implant referring dentist, the fractured tooth could

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be replaced with an implant and returned implant information and treatments if versus 36 percent opposing. Sixty-seven to the referring dentist for the prosthesis. accepted by the patient. Endodontics percent of respondents reported feeling Endodontists who offer dental implants and implant dentistry can not only endodontics has been negatively affected as a treatment option to their patients are coexist, but also must coexist for the by the growth of implant dentistry; 33 in a good position to present patients with benefi t of patients. Endodontic treatment percent did not feel that way. Implant clinical information about advantages and implant placement are uniquely dentistry has become a part of many and disadvantages of competing options positioned to challenge each other, endodontic practices in California; as may occur in certain circumstances. contradict each other and ultimately however, the opinions on the value of A maxillary molar with a compromised perfectly complement each other. including implant dentistry in practices buccal root but with minimal bone In a recent survey, the majority is split and many endodontists still feel support may be better treated with a root of general dentists polled reported that they have to compete with dentists amputation rather than replacement with unfavorable attitudes regarding who place implants in patients who could an implant; conversely, a mandibular endodontists placing dental implants.24 benefi t from endodontic treatment. molar with a vertical fracture of one root Sixty-six percent of respondents opposed In addition to the above may not be as suitable for root amputation. considerations, some referring dentists may feel that endodontists lack training Endodontists Placing Implants and Its in prosthetic reconstruction and soft Acceptance by Referring Dentists It has been shown that tissue management — skills that are Endodontists interested in including necessary to properly diagnose and place implant dentistry in their practices must postoperative discomfort dental implants. Thus they may hesitate show their referring colleagues that there related to root canal to refer their patients to endodontists for is patient-centered value in the practice of treatment and surgical such a service. From the endodontists’ implant dentistry by endodontists. Expertise point of view, their experience in in surgical placement of implants allows implant placement is equal. microsurgical procedures involving endodontists to offer patients that service root-end isthmuses, manipulating if indicated. This can save patients time neurovascular bundles and managing in reducing the number of visits to various the maxillary sinuses equip them with dental providers. It may also reduce the endodontists placing implants, and 73 both knowledge of anatomy and surgical number of surgical procedures. If surgical percent indicated they would not refer skills. Such skills and knowledge exposure of a root is needed to determine patients to an endodontist for implant can be employed by endodontists to presence of a fracture, the extraction of a placement. It is no surprise that these precisely place dental implants in tooth with fracture could be accomplished responses are in opposition to a survey of restoratively driven anatomic positions. at the same time.20 In addition to more endodontists regarding their thoughts on effi cient patient management avoiding implant placement.25 In the latter survey, Implant Dentistry and Endodontics a second surgical procedure to remove 57 percent of respondents supported Compared: Patient-Centric Factors the tooth, it may also help preserve the endodontists placing implants with 5.7 Endodontics has long been perceived bony housing. And there is evidence percent of responding endodontists by patients as being associated with that placement of an immediate implant reporting they currently place implants. pain and fear, but the evidence from the following extraction helps to minimize bone In an ongoing survey by the authors literature shows that pain is not often loss.21,22 Bone loss cannot be completely of California endodontists, 18 percent associated with endodontic treatment and eliminated and bone remodeling and of respondents report currently placing root canal treatment actually substantially soft tissue changes will usually occur.23 dental implants versus 82 percent who reduces pain (50 to 75 percent) compared Benefi cence — a core ethical do not. Approximately 25 percent of the to preoperative levels.26–28 It is often pillar in dentistry — is demonstrated state endodontists have responded so far. the preoperative pain that the patients fully when an unbiased provider can Of those, 64 percent indicated that they retrospectively associate with perceived clearly and knowledgably discuss and believe implant dentistry should continue postoperative pain, and it has been offer both endodontic and dental to be a part of the scope of endodontics shown that postoperative discomfort

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related to root canal treatment and In terms of biomechanical Contracture of the papillae occurs in 5 surgical implant placement is equal.29–31 considerations, implants have been to 20 percent of patients after implant Financial concerns about dental found to provide a signifi cantly lower placement compared to the contralateral treatment are important to patients. maximum biting force, reduced chewing natural teeth; retaining natural teeth Nonsurgical root canal treatment effi ciency and smaller occlusal contacts with root canal treatment has been and a prosthetic crown compare compared to root canal-treated teeth.39 recommended to help maintain the favorably to a comparable implant/ Implant placement has been shown papilla in the anterior aesthetic zone.44 crown treatment.29,32,33 Other options to increase patient quality of life Treatment planning is crucial when such as fi xed partial dentures are also measures, but this is more signifi cantly considering implant placement, as available at comparable cost.34 pronounced when implants are used thin gingival biotypes are more prone A concern that patients often have to anchor a removable partial denture to recession than are thick biotypes is treatment time. When comparing (thus replacing multiple missing teeth) and some authors have advocated endodontic treatment versus treatment than when an implant is used for single preservation of natural teeth in aesthetic involving dental implants, the latter tooth replacement. The majority of zones when a thin periodontal biotype is requires signifi cantly more time than present.2,33,45 Aesthetic concerns clearly the former.35 Patients experience more favor retention of natural teeth when inconvenience due to the increased possible in the maxillary anterior segment. treatment time of a two-stage implant Both treatment options Cost, success, treatment versus having a root canal-treated time, postoperative interventions, tooth back in function much more off er myriad benefi ts, but postoperative pain, biomechanical quickly. Even immediate placement they also have drawbacks factors, patient satisfaction with with provisionalization requires a that need to be fully treatment and aesthetics all play second appointment after healing an intertwined role in the patient’s to provide the defi nitive crown. explained to the patient. decision whether to elect tooth Postoperative complications occur preservation or replacement with a more commonly with dental implants dental implant. Clearly both treatment (screw loosening being the most options offer myriad benefi ts, but common complication) than with patients report some satisfaction or they also have drawbacks that need endodontic treatment and this both high satisfaction with both endodontic to be fully explained to the patient. adds to increased patient inconvenience treatment and single tooth implants. In and patient cost.36 The incidence of addition, endodontic treatment has been Outcomes of Dental Implants and postoperative complications rises to determined to signifi cantly improve Endodontic Treatment approximately 20 percent and can the quality of life for patients.26,40 Expected outcomes of treatment range from the need to retighten the Prior to including aesthetics in the options need to be presented to patients. abutment screw to refabricating the success criteria, poor aesthetics, implant Comparing such outcomes is, however, crown.35 Others have found that the malposition, soft tissue recession, bone diffi cult.46 Part of the problem comes three-year complication rate with maintenance and unfavorable soft tissue from differences in defi ning outcomes implants rises to 72 percent, but the confi guration were not considered since both success and survival concepts implant-supported crowns in this when evaluating implant success.41 It is have been used.46 Nevertheless, there particular study were acrylic resin fused- important to consider aesthetics when is information available to review. to-metal crowns, which are not widely judging implants to be a success or Contributing to the diffi culty used due to the higher complication failure, as aesthetic problems outnumber in comparing outcomes between rate.37 Despite the range reported mechanical failures in the anterior endodontic and implant treatments in the literature, there is consensus dentition.38 Loss of dental papilla is has been differences in success criteria, that implant-supported crowns have the most common complication after different lengths of historical data a higher incidence of complications implant placement and can result in black available and often less than rigorous than root canal-treated teeth.38 appearing triangles interproximally.42,43 research protocols.29 Success of root

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FIGURE 1A. FIGURE 1B. FIGURE 1C.

FIGURE 1D. FIGURE 1E. FIGURE 1F.

FIGURE 1G. FIGURE 1H. FIGURE 1I. FIGURES 1. Treatment approaches for a mandibular fi rst molar. Radiograph taken 10 years following root canal treatment due to pulp necrosis (1A). The tooth had developed a vertical root fracture in the mesial root and was extracted. In 1994, an implant was placed, but it was not centered in the edentulous space and there was a substantial mesial cantilever to the crown (1B). There were multiple episodes of screw loosening over the following years. In 1999, a new implant was placed due to the repeated mechanical complications with the initial implant (1C). However, it also was not ideally centered in the edentulous space and there was still an extension of the crown mesial to the implant. In 2006, the implant developed peri-implant mucositis, which was managed with improved home care (1D). Additional peri-implant bone loss was noted in 2010 (1E). Due to continued bone loss, bone grafting was performed (1F). In 2016, due to increasing bone loss, the implant was removed and bone graft material placed into the osteotomy (1G). Due to the regular recurrence of complications associated with the implants, the patient elected not to have another implant and instead have a fi xed partial denture. After healing following extraction and bone grafting, a three-unit metal-ceramic fi xed partial denture was placed (1H). Periapical radiograph of the completed fi xed partial denture (1I). canal treatment is defi ned in stages of to share high levels of success, with to 88.5 percent.59,60 Success of implants healing versus implant healing which no signifi cant difference in survival at the fi ve-year period has been reported is binary success versus failure. This of single tooth implants or teeth to range between 83 and 99 percent gives the appearance of less fully with root canal treatment.29,36,53 with the lower success specifi cally in healed endodontic treatments than Implant survival has been reported the maxillary molar region.61–63 implants due to the structure of the at very high levels, from 96 to 98.9 Initial and secondary (re-treatment) success and failure criteria.47–52 percent with at least a fi ve-year follow- nonsurgical root canal treatment Many publications have shown both up period.54–58 Others have reported outcome studies have looked both implants and endodontic treatments lower survival fi gures, ranging from 82 at success and survival. In terms of

264 APRIL 2018 CDA JOURNAL, VOL 46, Nº4

As dental implants are increasingly covered by dental insurance, the expansion of implant dentistry into the root canal treatment “market share” will likely continue to increase. Dentists also form opinions FIGURE 2A. based on personal experience. A colleague of one of the authors (T.S.), who works in a remote town with no endodontists FIGURE 2B. nearby, chooses to preferentially treatment FIGURES 2. Examples of failures due to poorly constructed prosthetic restorations of plan and urge patients to consider dental endodontically iterated teeth. The anterior fi xed partial denture failed due to the presence of implants rather than undergoing root canal a post and core in the lateral incisor abutment that was both short and too large in diameter treatment reasoning that “it’s faster for (2A). The maxillary canine root fractured due to the presence of a large diameter post (2B). me to place an implant than to do a root Note that the lateral incisor has a short post that also has excess diameter. canal … implants put more money into my wallet than do root canals.” This colleague’s survival, four-year retention has been An Evolving Change in Practice opinion presents a challenge to both shown to be 95 percent.64,65 Another Philosophy: Is This Change in Our organized dentistry and dental education. systematic review indicated four- to Patients’ Best Interest? An alarming trend was highlighted in fi ve-year survival of 93 percent and 87 The success and proliferation of a recent editorial in the Journal of Dental percent survival at eight to 10 years.66 dental implant therapy has caused Research. Dentists with less training who Epidemiological studies containing many endodontists to notice a declining are less educated about surgical placement greater than 1 million subjects have patient interest in preserving their natural of dental implants (as well as prosthetic found 93 to 97 percent survival of dentition when faced with the prospect reconstruction of dental implants) more root canal-treated teeth (both initial of saving a tooth through root canal often recommended removal of teeth and re-treatment).67,68 Others have treatment versus extracting the tooth and (as opposed to preservation of teeth via found success rates of endodontic placing a dental implant. Despite literature endodontic means).75 The editorial also re-treatment to range between 85 and showing similar survival rates for root canal mentions that there is a trend toward 96 percent.67,69,70 Some have found treated-teeth and single tooth implants, removal of teeth that are compromised but lower success rates during re-treatment, some dentists seem to consider dental salvageable, such as teeth with periodontal with success of 85.5 percent using implants to be the gold standard and that disease, endodontic needs or prosthetic more strict radiographic criteria.71 root canal treatment is a temporary effort reconstructive needs. While dental implants Endodontic microsurgery has a much to keep a tooth with endodontic disease a may seem to be a solution to all problem higher success rate than traditional few more years. To the contrary, one might teeth, the facts do not support that notion. root-end surgery (94 percent versus 59 say there is no better “implant” than a Iqbal and Kim53 have stated that routinely percent).72,73 However, a systematic natural tooth. After all, with proper care, choosing to place a single tooth implant review found that endodontic teeth have been lasting the entire lifetime for a compromised tooth that could microsurgery had a lower success of many patients. Additionally, implants otherwise be saved by endodontic treatment rate than that of single implants (98 and their restorations are not always cannot be advocated in light of the sparse percent versus 90 percent at a two- to successful due to systemic factors and literature that directly compares single four-year follow-up, respectively). other factors such as the surgical procedure tooth implants and restored root canal- Additionally, at two to four years used or the implant placement location treated teeth. As advocated at a Consensus posttreatment, single implants had that results in unfavorable biomechanics Conference regarding dental implants, the higher survival rates than teeth treated (FIGURE 1). Likewise, not all root canal decision to treat a tooth with endodontics with endodontic microsurgery.74 treatments are successful either due to or replace with a single tooth implant This was one of the few studies that the inability to instrument the presence should be based on criteria other than directly compared endodontic surgery of unique anatomy or the subsequent long-term outcome because the treatment and implant survival and success. restoration procedures (FIGURE 2). modalities produce similar outcomes.76

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Conclusion 17. Asundi A, Kishen A. Biomechanics of endodontic 36. Doyle SL, Hodges JS, Pesun IJ, Law AS, Bowles WR. Based on data from the literature, endosseous implants — a comparative photoelastic evaluation. Retrospective cross sectional comparison of initial nonsurgical Endod Dent Traumatol 1999;15(2):83–7. endodontic treatment and single-tooth implants. Compend it is evident that both endodontic 18. Nix JA. Commission on dental accreditation for the Contin Educ Dent 2007;28(6):296–301. treatment and dental implants have advanced education programs in endodontics. ADA 37. Wannfors K, Smedberg JI. A prospective clinical a place in the dental care of patients. Correspondence 1991:1–21. evaluation of diff erent single-tooth restoration designs 19. Commission on dental accreditation for the advanced on osseointegrated implants. A three-year follow- Patient-centered dental care must include education programs in endodontics. ADA Correspondence up of Brånemark implants. Clin Oral Implants Res providing patients with evidence-based 1985:1–15. 1999;10(6):453–8. information about treatment options 20. Lazzara RJ. Immediate implant placement into extraction 38. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. sites: Surgical and restorative advantages. Int J Periodontics Clinical complications with implants and implant prostheses. J suggested. Such an approach will Restorative Dent 1989;9(5):332–43. Prosthet Dent 2003;90(2):121–32. allow both disciplines in dentistry to 21. Paolantonio M, Dolci M, Scarano A, d’Archivio D, di 39. Woodmansey KF, Ayik M, Buschang PH, White CA, coexist for the patients’ benefi t. ■ Placido G, Tumini V, et al. Immediate implantation in fresh He J. Diff erences in masticatory function in patients with extraction sockets. A controlled clinical and histological study endodontically treated teeth and single-implant-supported

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preserving natural teeth with nonsurgical endodontic therapy. 69. Marquis VL, Dao T, Farzaneh M, Abitbol S, Friedman S. techniques with and without the use of higher magnifi cation. J J Endod 2008;34(5):519–29. Treatment outcome in endodontics: The Toronto Study. Phase Endod 2012;38(1):1–10. 54. Misch CE, Perel ML, Wang HL, Sammartino G, Galindo- III: Initial treatment. J Endod 2006;32(4):299–306. 74. Torabinejad M, Landaez M, Milan M, Sun CX, Henkin J, Al- Moreno P, Trisi P, et al. Implant success, survival and failure: 70. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors Ardah A, et al. Tooth retention through endodontic microsurgery The International Congress of Oral Implantologists (ICOI) Pisa aff ecting the long-term results of endodontic treatment. J Endod or tooth replacement using single implants: A systematic review Consensus Conference. Implant Dent 2008;17(1):5–15. 1990;16(10):498–504. of treatment outcomes. J Endod 2015;41(1):1–10. 55. Misch CE, Misch-Dietsh F, Silc J, Barboza E, 71. Ng YL, Mann V, Gulabivala K. Outcome of secondary root 75. Giannobile WV, Lang NP. Are Dental Implants a Panacea Cianciola LJ, Kazor C. Posterior implant single-tooth canal treatment: A systematic review of the literature. Int Endod or Should We Better Strive to Save Teeth? J Dent Res replacement and status of adjacent teeth during a J 2008;41(12):1026–46. 2016;95(1):5–6. 10-year period: a retrospective report. J Periodontol 72. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome 76. Iacono VJ, Cochran DL. State of the science on implant 2008;79(12):2378–82. of endodontic surgery: a meta-analysis of the literature — Part dentistry: A workshop developed using an evidence- 56. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen 1: Comparison of traditional root-end surgery and endodontic based approach. Int J Oral Maxillofac Implants 2007;22 M, Lang NP. A systematic review of the fi ve-year survival and microsurgery. J Endod 2010;36(11):1757–65. Suppl:7–10. complication rates of implant-supported single crowns. Clin 73. Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Oral Implants Res 2008;19(2):119–30. Outcome of endodontic surgery: A meta-analysis of the THE CORRESPONDING AUTHOR, Tory Silvestrin, DDS, MSD, can 57. Lindh T, Gunne J, Tillberg A, Molin M. A meta-analysis literature — Part 2: Comparison of endodontic microsurgical be reached at [email protected]. of implants in partial edentulism. Clin Oral Implants Res 1998;9(2):80–90. 58. Eckert SE, Choi YG, Sanchez AR, Koka S. Comparison of dental implant systems: Quality of clinical evidence and prediction of fi ve-year survival. Int J Oral Maxillofac Implants 2005;20(3):406–15. 59. Ottoni JM, Oliveira ZF, Mansini R, Cabral AM. Correlation between placement torque and survival of single-tooth implants. Int J Oral Maxillofac Implants 2005;20(5):769–76. 60. Norton MR, Wilson J. Dental implants placed in extraction sites implanted with bioactive glass: human histology and clinical outcome. Int J Oral Maxillofac Implants 2002;17(2):249–57. 61. Buser D, Ingimarsson S, Dula K, Lussi A, Hirt HP, Belser UC. Long-term stability of osseointegrated implants in augmented bone: A fi ve-year prospective study in partially edentulous patients. Int J Periodontics Restorative Dent 2002;22(2):109–17. 62. Bornstein MM, Schmid B, Belser UC, Lussi A, Buser D. Early loading of nonsubmerged titanium implants with a sandblasted and acid-etched surface. Five-year results of a prospective study in partially edentulous patients. Clin Oral Implants Res 2005;16(6):631–8. 63. Becker W, Becker BE, Alsuwyed A, Al-Mubarak S. Long- term evaluation of 282 implants in maxillary and mandibular molar positions: A prospective study. J Periodontol 1999;70(8):896–901. 64. Ng YL, Mann V, Gulabivala K. A prospective study of the factors aff ecting outcomes of nonsurgical root canal treatment: Part 1: Periapical health. Int Endod J 2011;44(7):583–609. 65. Ng YL, Mann V, Gulabivala K. A prospective study of the factors aff ecting outcomes of nonsurgical root canal treatment: Part 2: Tooth survival. Int Endod J 2011;44(7):610–25. 66. Ng YL, Mann V, Gulabivala K. Tooth survival following nonsurgical root canal treatment: A systematic review of the literature. Int Endod J 2010;43(3):171–89. 67. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: An epidemiological study. J Endod 2004;30(12):846–50. 68. Chen SC, Chueh LH, Hsiao CK, Tsai MY, Ho SC, Chiang CP. An epidemiologic study of tooth retention after nonsurgical endodontic treatment in a large population in Taiwan. J Endod 2007;33(3):226–9.

APRIL 2018 267 Specializing in selling and appraising dental practices for over 40 years!

LOS ANGELES COUNTY ORANGE COUNTY RIVERSIDE & SAN BERNARDINO COUNTIES CARSON— Long established GP in a small shopping ANAHEIM— Established in 1960’s this pracce is BEAUMONT—GP + Real Estate. Modern GP w/ 6 eq center. Grossed approx. $275K in 2017. Has 5 eq on a single story bldgSOLD w/ 4 eq ops. Grossed $735K ops in 2,400 sq offiSOLDce. Could be two suites. Grossed ops. Rering seller work 3 days/wk. Property ID in 2016. Net $308K. Property ID #5187. $960K in 2016. Property ID #5182. #5181. BREA— Beauful well established pracce located CHINO—Real Estate Only! This a rare opportunity to COMPTON— (GP + Real Estate) Established in 1982 on a corner locaon. Has 8 equipped ops and 3 w/ 4 eq ops / 3 plumbed not eq. Gross. $581K in chairs in open bay. Grossed $1.5M. On a busy purchase a condo located in a single story strip mall. 2017. Net $154K. Property ID # 5209. major street of the city. Property ID #5190. Has been a dental pracce for 40 years. Property ID 5076. ENCINO - GP w/ 4 eq ops in a prof. bldg. w/ widow BREA— GP + Bldg. Well established pracce w/4 views to the mountain. Fee for service. Net $144K. eq ops & 2 plmbd not eq. PPO & Cash Only. DESERT HOT SPRINGS— GP + Real Estate! Two Gross. $488K in 2017. Property ID #5210.0 Grossed $683K in 2016. Property ID #5197. partners one office. Consists of 4 eq ops / 1 plmbd GLENDALE—Beauful office w/ 3 eq ops in a 850 sq COSTA MESA - Est. in 1952 in a sing bld w/ 3 eq not eq. Est. in 1986. Proj. approx. $802K for 2017. . LH & Equip Only! Great starter office. Near resi- ops. Cash & Delta Premier Only!! Proj. approx. Property ID #5198. denal & commercial area. Property ID #5208. $373K for 2017. PropertySOLD #5202. FONTANA— GP + Real Estate!! Premier office with LA VERNE— Est. in 1980 w/ 4 eq op in a 1, 250 sq . FOUNTAIN VALLEY—GP in busy strip mall. Has 50 years of goodwill. In a 3,000 sq bldg with 8 eq Grossing approx. $64K/mo. Net of $195K. PPO & approx. 27 years of goodwill. Grossed $344K in ops. Has the latest technology. Grossed approx. Cash Only! Property SOLDID #5196. SOLD SOLD 2016. Net of $136K. Property ID #5165. $2.3M in 2016. Net of $968K. Property ID #5140. LOS ANGELES - Price Adjustment! GP w/ 40 years of IRVINE—LH & EQUIP ONLY! 4 eq ops in 2 story PALM SPRINGS – General pracce with 3 equipped goodwill. In a 10 story medical/dental bldg. Has 4 eq prof. bldg. Easy access freeway. Property ID #5195. ops with views to theSOLD mountains. PPO/Cash/Medi- ops located in a free standing bldg. Established in cal/CAP. Grossed $670K in 2016. Net of $166K. SANTA ANA— GP w/ 37 yrs of gdwll right off free- 2005. Suite is approx. 1,200. Seller work 5 days/wk. Property ID #5107. way in busy shopping center. Has 3 eq ops / 1 BUYER’S NET OF $153K. Property ID #4487. plmbd not eq. PPO/Cash/HMO. Projecng approx. LOS ANGELES - GP established in 1968 in a 6 story $184K for 2017. Property ID #5161. RANCHO CUCAMONGA— GP established in 2004 in bldg. NO HMO. Has 4 eq ops in a 1,211 sq suite. SOLD busy shopping center. Consists of 3 eq ops in a 1,200 Grossed approx. $531K in 2016. Property ID #5163. TUSTIN— Beauful GP NET OF $159K. Prop. #5199. SOLD sq suite. Grossed $422K in 2017. Net $146K. Prop- MOTEBELLO—Grossed approx. $1M in 2017, locat- erty ID #5169. ed in a free standing bldg w/ 5 eq ops. Established in 2002. Property ID #5168 COMING SOON IN NEWPORT BEACH & ORANGE RIVERSIDE—GP + Real Estate!! Established in 1975 in PASADENA – 56 yrs of gdwll w/5 eq ops in a 2 story free standing historic bldg.SOLD Has 4 eq ops in a 2,000 sq med/dent bldg. Fee for service. Proj. approx. $990K office. Projecng approx. $284K for 2016. Property for 2017. Net $217K. Great pracce. Prop. ID #5204. ID #5146.

VALENCIA — GP + Spec office with 9 eq ops in a busy TEMECULA—Modern designed pracce w/ 3 eq ops. single shopping center. Grossed $1.6M in 2016. Projecng approx. $1.2M . Net of $444K. Property ID Property ID #5171. SOLD SOLD SAN DIEGO COUNTY #5155. COMING SOON IN CENTURY CITY, MONTERY PARK & SANTA CLARITA CARLSBAD—Well established GP w/ 3 eq ops UPLAND—Pediatric dental pracce located in a and 2 plmbd not eq near residenal are. Buyer’s medical bldg with 40 years of goodwill. Consists of 4

net of $121K. PropertySOLD ID #5191. chairs in open with SOLDAlpha-Dent soware. Grossed KERN, VENTURA, & SAN LUIS OBISPO COUNTIES $271K in 2016. Property ID #5188. SAN DIEGO — Well established pracce w/ 3 COMING SOON IN FRESNO, GOLETA AND OXNARD new eq ops in a 1,087 sq suite. ProjecƟng COMING SOON IN PALM DESERT approx. $300K. NET $127K. Property ID #5200.

SAN DIEGO— GP in med/dent bldg. w/ 3 eq ops. Fee for service. Estab. circa 1950. Grossed $301K in 2017. Net $129K. Property ID # 5212.

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CONTACT US FOR A FREE CONSULTATION WWW.CALPRACTICESALES.COM Phone: (800) 697-5656 CA BRE #00283209 RM Matters CDA JOURNAL, VOL 46, Nº4

Spring Cleaning Isn’t Limited to the Offi ce:

Update Patient Records To Mitigate Risks TDIC Risk Management Staff

pring is a prime time to deep consider offering payment arrangements Is the patient’s health history form current? clean your practice and tie up any that will fi t their fi nances rather Ideally, you should review a patient’s loose ends from the previous year. than altering the treatment plan. health history at every appointment. Go It’s also a great opportunity to Keep a signed copy of the fi nancial over the previous health history form and review your patient records and agreement in the chart separate from update as needed. Be sure to clarify any Sensure all fi les are accurate and current. the medical history. This will help avoid unanswered questions and inquire as to any Below are some things to consider mixing the patient’s protected health recent visits to another health care provider. when revisiting patient charts. If you fi nd information (PHI) with their fi nancial Inquire about pregnancies, surgeries, something is missing, review the chart information should there be a need to radiation therapy, trips to the emergency with your patient at their next visit. share fi nancial data with a third party room or other hospitalizations. Review that should not have access to the their current medications and note if they Does the chart have a signed treatment plan? PHI, such as a collection agency. have begun, discontinued or changed any Before beginning any dental treatment, you should document the clinical exam fi ndings, diagnoses of the patient and your treatment recommendations. A treatment plan should include a complete overview of the treatment to be performed, how it will help your patient, alternatives available and alternatives selected, in You are not addition to any part of the treatment a sales goal. requiring referral to a specialist. Note patient expectations regarding cost of treatment, overall aesthetics and longevity of treatment. Should fi nances affect the patient’s treatment decision, the risks and consequences of delaying treatment should also be discussed and noted in the chart.

Does the chart have a signed You are a dentist deserving of an insurance company relentless fi nancial agreement? in its pursuit to keep you protected. At least that’s how we see For many patients, fi nances will it at The Dentists Insurance Company, TDIC. Take our Risk play a signifi cant role in the treatment Management program. Be it seminars, online resources or our plan. When discussing treatment Advice Line, we’re in your corner every day. With TDIC, options, be sure to include the patient’s you are not a sales goal or a statistic. You are a dentist. estimated dental benefi ts portion of payment and predicted out-of-pocket expenses while making it clear that ® the patient is ultimately responsible Protecting dentists. It’s all we do. for all fees regardless of what their 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 dental benefi ts cover. If a patient has concerns about paying for treatment,

APRIL 2018 269 APRIL 2018 RM MATTERS

CDA JOURNAL, VOL 46, Nº4

prescribed or over-the-counter medications. 10 years after the last date the patient is The dentist paid the individual Have the patient sign and date the health seen, if not indefi nitely. For patients who $200 to shred the fi les without having history form and all subsequent updates. are minors, you should retain their chart signed an associate agreement. The If you are concerned about treating for 10 years from their last treatment or dentist became concerned when a patient with underlying health issues, seven years past age 18. If you decide to he did not receive a shredding you can obtain medical consultation dispose of inactive patient charts, it is confi rmation. Ultimately, he realized with their primary care physician before imperative that you do so in a way that that he might never hear from him. proceeding. Keep the physician’s response is consistent with HIPPA regulations. The dentist also understood the in the patient’s fi le and follow their In one case reported to TDIC’s Risk potential for a claim of unauthorized recommendations to ensure patient safety. Management Advice Line, a dentist disclosure of PHI should these patient was seeking to shred outdated patient records be discovered intact. The Is the patient chart inactive? information. He canceled his prior Risk Management analyst suggested While there are no statutory contract with a licensed and bonded ways to avoid such problems in the requirements, The Dentists Insurance shredding company and hired a “friend future and recommended reporting Company (TDIC) recommends that you of a friend” who promised to shred the the matter to the police for any keep patient charts for a minimum of confi dential records at a reduced rate. assistance in locating the individual. Having a complete, well- documented patient chart doesn’t just keep your practice neat and organized, it may help resolve potential patient disputes. Your treatment records are yet another tool to clearly communicate expectations with your patient and build a foundation of trust and transparency. For more information on record keeping and to access patient forms and associate agreements, visit tdicinsurance.com/reference-guides. ■

TDIC’s Risk Management Advice Line at 800.733.0633 is staffed with trained analysts who can provide guidance on patient records and other questions related to a dental practice.

270 APRIL 2018 CARROLL “Matching the Right Dentist to the Right Practice” V &COMPANY 4159 SANTA ROSA GP Dedicated practitioner retiring from practice 4196 PACIFIC HEIGHTS SOLO GROUP Enjoy the benefits of a with emphasis on Restorative care. Located in a class “A” professional well established successful group while maintaining your individual building in well-travelled area. 2,330 square foot office with 5 ops., general practice in a modern fully-equipped office with well trained reception area, business office, private office, consult room, staff personnel. Approximately 1,400 active patients with an average of 10 lounge, lab area, sterilization area, and private bathroom. 4 doctor- new patients per month. Average gross receipts $689K+ with an days per week and approximately 1,000 active patients and average equivalent of 3 doctor days per week. Asking $423K. Gross Receipt of $733K+. Asking $557K. 4172 NAPA GP Amazing opportunity to own the practice of your 4225 EUREKA GP & BUILDING Established since 1981 in charming dreams in one of the world’s premier wine destinations! Situated in a Northern California port city. Retiring doctor is offering practice and prime commercial and residential mix neighborhood close to shopping building. Practice has approximately 1,200 active patients with new facilities and many amenities. Seller owned 1,200 square foot well laid- patients accepted on a selective basis. Average Gross Receipts of out office with 4 fully-equipped and updated operatories. Over 1,000 $765K+ with 61% average overhead. Free standing building at premier active patients. Average annual gross receipts over $700K based on Henderson Center location in the Heart of Humboldt county. Beautiful the past 5 years. Asking price for practice $484K. Building available for 1,400 square foot office with four (4) fully-equipped operatories. Asking purchase. price for practice $468K. Building available to purchase. 4219 SANTA CRUZ FACILITY Great dental facility close to several 4216 SIERRA NEVADA FOOTHILLS 23 year practice located in amenities and minutes to HWY 1, and HWY 17. Plenty of parking and the heart of the Sierra Nevada foothills in modern condominiumized great street visibility. Turnkey dental office in 1,200 square foot facility building close to downtown area. 1,024 square foot office with 4 fully- with 3 fully-equipped ops. Asking $75K. sale. equipped ops., upgraded major equipment and digital radiography. Seller is retiring and looking for a relaxed and personal practitioner for 4227 REDWOOD CITY GP Profitable, established, general practice his loyal patient base. Average Gross Receipts $890K+ with 56% available, now, in rapidly growing Redwood City. Over 1,000 active average overhead. Asking price for practice $604K. Seller is offering patients&a5yearaverage gross receipts of $890k net. Beautiful re- real estate for sale to the buyer of his practice. modeled handicap accessible office with 4 fully-equipped ops. Asking G $636K. 4207 MID PENINSULA GP Seller offering 40+IN year practice with an ND emphasis on Restorative and DiagnosticPE care. Asking $385K. 4230 SOUTH VALLEY GP Well-established GP offering 30+ years of goodwill in very desirable suburb of Silicon Valley. 3 fully equipped ops 4178 SONOMA COUNTY PERIO Seller retiring from 21 year in 1,000 sq. ft with room for 4th op. Beautifully appointed, pristine practice with trained, seasoned staff and great location. Exceptional office in Professional Complex. Owner/doctor works 3 days/week. 2,100 sq. ft. ample office with 6 fully equipped ops. Majority of 350+ active patients. 2017 GR $278K w/adj net of $110K. Asking equipment purchased in 2002. 4 doctor-days&3hygiene days per price $225K. week. Average gross receipts $1M+. Asking $677K. 4229 SARATOGA GP Absolutely beautiful turnkey office offering 30+ 4198 NORTH BAY PERIO Established Periodontic practice with loyal years of goodwill. All buyer has to do is move in! Fantastic location in referral sources in 1,564 square foot office with 5 fully-equipped well known Professional Building on well-traveled, major thoroughfare. operatories conveniently located close to Petaluma Valley Hospital. 4 fully equipped ops in 1,500 sq. ft facility. 600 active patients (all fee- Average Gross Receipts $480K. Seller is offering the condominiumized for-service). 1.25 days/hygiene week. Last 4 years average GR office for sale to the buyer of the practice. Asking price for practice $285K. Seller willing to help for smooth transition. Asking $290K. $284K. 4215 SILCON VALLEY ENDO Practice in prime Silicon Valley 4191 SONOMA COUNTY ENDO Seller retiring from 38 year location with 40+ loyal referral sources. 900 square foot office in endodontic practice located in attractive ground floor office (remodeled modern professional center with 2 operatories. Averaging 20 new in 2011) with updated modern equipment and cabinetry. Close to patients per month. Long term staff. 2017 gross receipts $603k. several regular referral sources. Doctor sees an average of 7-8 patients Asking $399k. per day. 5 year average Gross Receipts $700K+. Asking $447K.

4210 UNION CITY GP Retiring GP offering 40+ years of goodwill. Excellent location in Professional Bldg on major thoroughfare. 5 ops in 1,100 sq. ft. 350 active patients, all fee-for-service. 2 yr average GR $177K. Seller willing to help for smooth transition. Asking $85K.

4202 SANTA CRUZ COUNTY GP Retiring seller offering 40+ years ING of goodwill with emphasis on restorative care.ND Asking $300K. PE 4161 CONTRA COSTA COUNTY ENDO Seller retiring from well- Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll established practice in desirable neighborhood. Located in professional center with several loyal referral sources. 1,445 square Carroll & Company foot office with 3 operatories and current lease with two 5 year options 2055 Woodside Road, Suite 160 to extend. 2016 gross receipts $388K+. Asking $248K. Redwood City, CA 94061 BRE #00777682

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PRACTICE SALES • PARTNERSHIPS • MERGERS • VALUATIONS/APPRAISALS • ASSOCIATESHIPS • CONTINUING EDUCATION

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Managing Emergency Patients CDA Practice Support

dentist is obligated to make ■ For times when the dental practice reasonable arrangements is closed, leave an outgoing for the emergency care of a message on the telephone patient whether or not the Treating or consulting answering system that provides patient is a patient of record. with a patient for instructions on how a patient can AA failure to make reasonable the fi rst time in an contact the dentist or a colleague emergency care arrangements for patients emergency does not who is providing emergency of record may result in a charge of patient coverage. If using an answering abandonment. It is unprofessional make the individual service, instruct the operator conduct for a dentist to abandon a patient a patient of record. to collect information from the without written notice that treatment patient that includes full name, will be discontinued and before the date seen by the dentist, complaint patient has had suffi cient opportunity to and a phone number (ensure secure the services of another dentist. In addition, dental benefi t plans require contracted providers to arrange for after-hours emergency care of their enrollees. Dentists should check a contracted plan’s provider manual or handbook for the requirements. One major plan requires that emergency care be available 24 hours a day, seven days a week and to have an active after- hours mechanism, such as an answering machine, answering service, cellphone or pager, available for 24/7 contact or instructions. The plan also requires that urgent care be provided within 72 hours when consistent with the patient’s individual needs and required by generally accepted standards for dentistry. Professional ethics require that a dentist make a reasonable arrangement for emergency care of a patient who is not of record. Treating or consulting with a patient for the fi rst time in an emergency does not make the individual a patient of record. Examples of reasonable arrangements: ■ Before leaving on an extended vacation or absence from the practice, arrange for emergency coverage with one or more colleagues. Notify patients in advance and provide contact information for the colleagues.

APRIL 2018 273 APRIL 2018 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 46, Nº4

a HIPAA business associate ■ Direct the patient to present Do not leave an outgoing message agreement has been signed with the at your dental offi ce for an directing emergency patients to contact service). The dentist should have examination as soon as possible. the local dental society, unless the dental a method for verifying patients of A dentist who agrees to see a patient society has agreed to and implemented record as well as verifying patients at a time when the offi ce is typically closed a plan for handling such calls. A dentist of colleagues for whom the dentist should take appropriate precautions for may want to join or start a mutual is providing emergency coverage. personal safety. Dentists are not required to aid group to formalize arrangements After listening to a patient’s see an emergency patient in the middle of with colleagues for coverage. For complaint, a dentist may choose to: the night. If contacted by a patient in pain more information, review “Practice ■ Prescribe pain relief and other in the middle of the night, a dentist can Interruption and Mutual Aid Group medication, as appropriate, refer the patient to a hospital emergency Guidelines” on cda.org/practicesupport. with direction to the patient room or urgent care facility for pain relief to present for an examination and then direct the patient to present at Reference at the earliest possible time. the offi ce at the earliest possible time. ■ Direct the patient to an emergency Be sure to keep records of these CDA Code of Ethics room or urgent care facility. after-hours consultations. Section 8: Emergency Service A dentist has the obligation to make reasonable arrangements for the emergency care of his Help is or her patients of record. A dentist has the obligation, when one call consulted in an emergency by a away. patient not of record, to make reasonable arrangements for emergency care of that patient. The CDA Well-Being Program Advisory Opinion: If someone you know or love may have an 8.A.1. Continuity of care: In alcohol or chemical dependency problem, the interest of preserving the contact a support person near you for 24-hour confidential assistance. patient’s continuity of care, a dentist who treats a patient not Northern California of record shall recommend to the 530.310.2395 (cell) patient to continue treatment with the original treating dentist San Francisco/Bay Area unless the patient expressly 209.601.4410 (cell) reveals a different preference. ■ Central California 916.947.5676 (cell) Regulatory Compliance appears monthly and features resources about laws Southern California that impact dental practices. Visit cda.org/ 818.437.3204 (cell) practicesupport for more than 600 practice support resources, including practice San Diego management, employment practices, dental 858.692.4862 (cell) benefi ts plans and regulatory compliance.

274 APRIL 2018 Specialists in the Sale and Appraisal of Dental Practices Practices Serving California Dentists since 1966 How much is your practice worth?? Wanted Selling or Buying, Call PPS today! Visit PPS at CDA Anaheim Booth 1157 NORTHERNNORT RN CALIFCALIFORNIAORNIA SOUTHERNSOUTHERN CALIFORNIACALIF (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6140 SAN RAFAELRAFAEL Dentist retiring after long career. DeltDeltaa PPO ALTA LOMA  Shopping Center. Hi identity. Absentee Owner. provider. Has averaged $390,000 in annual collections on 3.5-day Grossing $700,000. Hands-on successor can do $1 Million. 5-ops, week. 900+ different patients seen in the last 18-months. 3 equipped. 6139 SAN FRANCISCO BAY AREA PROSTHODONTIC BAKERSFIELD Free-standing 3,000 sq.ft. building. 5-Ops. Established 60-years. Can do $1 Million. FP $650,000 includes RE. PRACTICE Very strong pedigree. Well positioned for the future.  BAKERSFIELD AREA Small City. Grosses $40,000/month on Excellent platform for younger Prosthodontist. Out-of-network! 2-day week. 1,800 sq.ft. 5-oSs with small apt. FXOOPULFH $330,000. 2017 billed $1.2 Million and collected $1.19 Million. 4-days of BELLFLOWER )HPDOHDDS doing $100,000. 3-ops. FP $65,000. Hygiene. Owner can work back to help assist with transition. &2/721 Hispanic practice grossing $350,000. Absentee Owner. 6138 SAN FRANCISCO BAY AREA’S SOUTH BAY Phenomenal 5-ops. Rent $1,450. Hands-on Owner will do $500,000 first year. opportunity shall secure a rewarding career. Best technology, DIAMOND BAR Korean / Chinese Shopping Center. Very busy perfectly designed suite and optimum stage to practice your craft. until 9 PM. Owner works 1-day week. Does $450,000. Hands-on 2017’s collections topped $900,000. Building included. Perfect for successor will do over $1 Million. skilled practitioner who seeks WRFUHDWHKLJKHQGEUDQG GLENDALE / BURBANK Absentee Owner grossing $840,000. Beautiful corner building. Newly renovated. 5-ops with room for 6137 SOUTH SACRAMENTO AREA Growing PPO practice  more.  RE includes small apt. HMO almost pays mortgage. topped $1.5 Million in collections in 20173rofits exceedHG $2Million location. Gorgeous. $500,000 after paying Associates. 6-days of Hygiene. 6-ops, 3-D INLAND EMPIRE 3,000 sq.ft. building. 7-Adec ops, Cone Beam. Pano and paperless. Over $400,000 invested here recently. Great Grossing $1.3 Million. FXOO3ULFH$2.5 Million includes real estate. location. INLAND EMPIRE DentiCal. Grosses near $300,000. 4-ops. 6136 SAN RAMON 6WURQJfoundation here. Collections for 2017 Rent$1,350. FXOO3ULFH$150,000. totaled $575,000. And this was on a work schedule averaging INLAND EMPIRE Union Practice can do over $1 Million. 5-ops. 2.5-days a week. 3-ops. Seller can work back 1-day a week to assist IRVINE Female Owner grossing $1.2 Million. 5-ops. in transition. LA MIRADA Hi identity shopping center. HMO pays rent. Like new 3-ops with 2-more available. Grossing $450,000. Million Dollar location. 6135 SONOMA COUNTY’S ROHNERT PARK 2017 collected New next-door tenant with 1,000 family members. Great upside. $1,050,000 reflecting nice growth over 2016 which collected LAKE FOREST Adec equipped. Like new in appearance. Female $940,000. Profits exceeded $500,000 for the second year in a row. DDS grossing $385,000. 30 new patients/month. Buyer shall do 6-days of Hygiene. There shall be no change in fees for the $500,000 first year. Option to purchase condo. Successor. New homes being built nearby. LOS ALAMITOS Gorgeous. 5-ops. Grossing $1.4 Million. 6133 SAN RAMON’S BISHOP RANCH Beautiful 4-op, Special "All on 4 " Program. Refers out OS, Endo, Pedo, Ortho. computerized and digital office. Located in the Bishop Ranch Absentee Owner. Medical Center. Bring Business Plan. Great addition to existing ORANGE COUNTY BEACH Professional building. 6-ops network. Full Price $150,000 equipped. Dentrix, digital & computerized. FXOO3ULFH $150,000. ORANGE COUNTY BEACH CITY Absentee Owner. Grossing 6132 UNION CITY $420,000+ invested here. Very high end for $550,000. 4-ops with room for 5th. Hands-on Owner will do great patient experience. 3-opsSOLD equipped (4th available), Panorex, $1+Million first year. Valuable RE possible. completely networked and digital. $600,000+ in revenues. ORANGE COUNTY’S FASHION ISLAND Unique situation. 6129 FOSTER CITY / SAN MATEO Wish to infuse your practice Female grossing $400,000. with quality patients? Out-of-network practice collected $500,000+ ORANGE COUNTY’S FASHION ISLAND Grossing $650,000. in 2017 on part-time schedule. Seller and Hygienist shall relocate into Rare opportunity. Buyer’s practice to transition patients. Full 3rice $100,000. PEDO – CHINESE / HISPANIC Grossing $450,000. Long 6125 OAKLAND’S LAKESHORE VILLAGE Collections established. FXOO3ULFH$285,000. REDLANDS 6-ops. Long established. Has done $1 Million. Lots average $735,000 per year. High income zip code with well  SOLD of potential. Low rent. Grossing over $400,000. HMO pays rent. employed Millennials next door. 10+ new patients per month. Digital RIALTO 210 Freeway. Professional building on 2.2 acres. HMO and paperless. practice once did $1+ Million. Now only $325,000. Can be 6122 SANTA CLARA - STARBUCKS "LIKE" LOCATION! restored to $1+ Million. Best exposure in beautiful strip center. Office just remodeled. 5-Ops. SANTA CLARITA 70,000 autos pass daily. 8-ops. Absentee Currently trending $1+ Million in Collections on 4-days. Perfect Owner. FXOO3ULFH$250,000. platform to operate 6-days a week. Can do $1.5+ Million. SANTA CLARITA Hi identity shopping center. Owner wants to 6121 NAPA VALLEY FAMILY PRACTICE Highly respected share office and remain 2-days in 2-ops. 5-ops available. Possible for long term employee DDS, with or without ownership. Upscale area. community asset. Collections last 5-years have averaged $1.28  SOLD WEST COVINA Grossing $650,000. 2-days hygiene. Absentee Million per year. Beautiful facility. Condo optional purchase. Owner. Refers out OS, Endo, Pedo. Ortho.

BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED CENTRAL VALLEY CONTINUED

AC-624 SAN FRANCISCO: Wonderful patients, DC-812 REDWOOD CITY Facility: Reasonable rent EN-791 SO. SACRAMENTO CO: IG-687 TURLOCK: Largest solid income in great stand-alone bldg $475k and great landlord! 740 sf w/ 3 fully equipped ops $450k $298k AC-649 SAN FRANCISCO Facility: Richmond Dis- $100k EG-788 ROSEVILLE: IN-764 STOCKTON: trict, 3 ops+1 add’l, Equipment less than 5yrs old DG-635 CASTRO VALLEY: Excellent locaon & stellar . $300k $267.5k Broker in $120k reputaon! Solo Group Pracce $650k EN-800 SACRAMENTO: IN-776 STOCKTON: AC-782 SAN FRANCISCO: Well maintained, mul-level DN-771 SOQUEL Facility: The perfect place to sink $150k $25k Professional Medical Complex. 1450 sf w/ 5 ops down roots, raise a family & build an empire! EN-797 WOODLAND: IN-830 LODI: Northern $250k 1100sf w/2 ops + 1 add’l. $50k Pracce $650k/ Real Estate TBD $360k, Real Estate $300k AN-752 SAN FRANCISCO Facility: 2 months Free Rent! DN-774 FREMONT: This opportunity has it all and EN-803 ROCKLIN: JC-811 FRESNO COUNTY: Opportunies like this one are few and far between! awaits your talent and skill! 1,150sf w/3 ops + 1 $425k $350k California 1007sf w/ 4ops. $99k add’l $150k EN-831 SACRAMENTO JG-778 FRESNO: BC-710 WALNUT CREEK: Desirable location in DG-785 SANTA CRUZ: Known for its amusement park “a cut above” $775k $295k stand-alone, single-story bldg. 1313sf w/ 3 ops & beach boardwalk, this community has much to FC-650 FORT BRAGG: JG-807 FRESNO: $150k offer! 1000sf w/ 4 ops. Now Only: $200k $350k for the Pracce & $400k for the Real Estate $158k BC-741 DANVILLE (FACILITY): Move in Ready facility DG-790 SAN JOSE: Two Pracces being offer at FN-754 SO. HUMBOLDT: JH-770 MERCED AREA: S Extensive Buyer to build the practice of your dreams! ~ 1600sf w/ one great price! Priced to sell at $1.4M. Call to- . $410k 3 fully equipped ops $150k day for more details! Now $150k! BC-758 PLEASANT HILL (FACILITY): Gorgeous décor DN-796 SAN JOSE: This well-oiled general pracce GC-472 ORLAND: SPECIALTY PRACTICES Database & & remarkable location! 768 sf w/ 2 ops $35k w/ emphasis on treang Pediatric paents! 3473sf $160k BC-789 OAKLAND (Facility): Perfect layout for Pedo w/10 ops + 2 add’l. $550k GN-717 YUBA CITY: Build- AC-759 SAN FRANCISCO Endo: Unsurpassed or Ortho. 2800 sf w/ 6 fully equipped ops. Plumb- DN-806 WATSONVILLE: This quality, family-oriented ing available for purchase! $475k $495k er for 2 add’l $250k pracce thrives $ focuses on delivering quality care. GN-746 YUBA CITY: Includes the latest technol- BC-784 CENTRAL CONTRA COSTA CO Perio: BC-793 BERKELEY: 2-story Prof Bldg. 1382 sf w/ 4 1,182 SF W/ 4 OPS. $550K/ Real Estate TBD ogy in CBCT Imaging. $395k Exposure allows ops & professionally designed for flow $475k DN-809 PLEASANTON: Ranked as “one of the best Pracce $480k/ Real Estate TBD. BN-801 SAN RAMON Ortho: BC-804 EMERYVILLE: Professional Complex (ADA- cies to live in”, one can certainly understand GG-769 REDDING AREA: $775k us to offer you compliant). 1740 sf w/ 4 ops & room for 2 add’l why! 1100sf w/ 3 ops + 1 add’l. $480k Pracce $390k Real Estate $540k EG-826 ROSEVILLE Perio: $395k GN-799 PARADISE: $150k BG-762 EAST BAY: Stellar, high Quality practice NORTHERN CALIFORNIA Pracce $375k, Real Estate $325k EN-821 GREATER SACRAMENTO AREA Perio: consistently generates ~ $3M annually. 3000 sf w/ HG-732 GRASS VALLEY:

6 ops $1.99M EC-729 GREATER SACRAMENTO AREA: Seller rer- $215k $395k BG-734 ANTIOCH: The perfect place to work, live ing! FFS Pracce and Real Estate Available! HG-815 SIERRA CO: EN-822 SACRAMENTO Perio: and play! Located in desirable professional neigh- EN-664 SACRAMENTO Facility: Great corner loca- $180k / Real Estate $437k $840k borhood. 1,323 sf w/ 4 ops. $315k on, excellent visibility & easy access! 2300sf w/ 4 HN-280 NORTHEAST CA: $60k IC-543 CENTRAL VALLEY Ortho: CC-798 PETALUMA: Partially equipped dental office ops. Now Only: $30k HN-618 SIERRA FOOTHILLS: $125k for lease. Only $2500/mo for 1400 sf! Call for De- EN-702 SACRAMENTO: Long-established pracce w/ $65k HG-763 GRASS VALLEY Ortho: tails! emphasis on preventave denstry! 1600sf w 4 ops HN-740 SHASTA CO: $210k CC-802 SANTA ROSA: Retail shopping center w/ 1200 + 1add’l. $450k Real Estate $325k $475k/ JG-757 VISALIA Perio: sf and 4 fully equipped ops $220k or $260k w/CT EN-747 CITRUS HEIGHTS Facility: Be the only dental Real Estate $350k Scanner office in this aracve, popular Retail Shopping HN-773 SUTTER CREEK: $395k CG-616 NAPA: State-of-the-Art practice. Seller mov- Center! 2200sf w/5 ops + 6 add’l. $75k $195k ing out of state! $425k EN-749 LINCOLN: Come sink your roots down and HN-816 CHESTER/ALMANOR AREA: CN-829 MILL VALLEY: This once-in-a-lifeme oppor- enjoy a fantasc lifestyle which can’t be beat! tunity awaits your drive, talent & skill! 1200sf 1877sf w/4 ops + 1 add’l. $320k Pracce $140k/ Real Estate TBD w/ /3 ops + 1 add’l $310k EN-755 FOLSOM: A perfect locaon, envied by all! DC-786 LIVERMORE Facility: Move In ready & recent- Enjoy an amazing quality lifestyle in this thriving CENTRAL VALLEY ly updated! 2380 sf w/ 3 fully equipped ops. city. 1200sf w/ 4 ops. $175k Plumbed for 3 add’l $190k EN-768 WEST SACRAMENTO: family-oriented prac- IC-468 SAN JOAQUIN VALLEY DC-805 CASTRO VALLEY: Seasoned Staff and Loyal PT ce, equipped with updated technology! 1612sf w/4 $425k base! 1800 sf w/4 ops in 2-story prof bldg $420k ops. $275k

800.641.4179 [email protected] Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD

BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED CENTRAL VALLEY CONTINUED

AC-624 SAN FRANCISCO: DC-812 REDWOOD CITY Facility: EN-791 SO. SACRAMENTO CO: Highly esteemed pracce to an adoring & IG-687 TURLOCK: Established quality pracce - remarkable opportunity! Largest $475k appreciave paent base! 1950sfw/ 5 ops. $450k 2000sf w/ 5 ops $298k AC-649 SAN FRANCISCO Facility: $100k EG-788 ROSEVILLE: Do not pass up on this remarkable opportunity! IN-764 STOCKTON: Well-established, fully computerized, paperless, digital- DG-635 CASTRO VALLEY: 2700sf w/ 6 ops.. $300k ized pracce just waing for your talent & skill! 5,000sf w/10 ops $267.5k Broker in $120k $650k EN-800 SACRAMENTO: Awaing your talent and skill to take it to the next IN-776 STOCKTON: Step right in and you won’t miss a beat in this long- AC-782 SAN FRANCISCO: DN-771 SOQUEL Facility: level! 1200sf w/ 4 ops. $150k established, quality pracce! 1046sf w/2 ops add’l. $25k EN-797 WOODLAND: Do not hesitate or this enviable opportunity will fulfill IN-830 LODI: Start living the life! Small town charm, stable paent base & Northern $250k $50k someone else’s dream! 2316sf w/ 6 ops. Pracce $650k/ Real Estate TBD low overhead! 1,550 + 800sf w/4ops. $360k, Real Estate $300k AN-752 SAN FRANCISCO Facility: 2 months Free Rent! DN-774 FREMONT: EN-803 ROCKLIN: Connue the philosophy of serving your paents as if JC-811 FRESNO COUNTY: Amazing Opportunity! Considerable Goodwill in they are family! 150sf 3 ops + 1 add’l. $425k Community! 3,000 sf w/ 6 ops $350k California $99k $150k EN-831 SACRAMENTO: Locaon & pracce philosophy make this opportunity JG-778 FRESNO: What a steal. Consistent collecons over $600k with cash BC-710 WALNUT CREEK: DG-785 SANTA CRUZ: “a cut above” others! ~1600sf w/4 ops. $775k flow over $300k!! 1452 sf w/ 4 ops $295k FC-650 FORT BRAGG: Family-oriented pracce. 5 ops in 2000sf, 6 npts/ JG-807 FRESNO: Reasonable Overhead, Stellar Reputaon, Excellent Loca- $150k Now Only: $200k mo $350k for the Pracce & $400k for the Real Estate on! 1000 sf w/3 ops $158k BC-741 DANVILLE (FACILITY): DG-790 SAN JOSE FN-754 SO. HUMBOLDT: If you love the lure of sea air, a relaxed lifestyle JH-770 MERCED AREA: Stellar family-oriented pracce with a loyal, stable Extensive Buyer $1.4M. Call to- & charm of coastal living, then look no further! 1500sf w/ 3 ops + 1 add’l. paent base! 1250sf w/ 4 ops.. $410k $150k day for more details! Now $150k! BC-758 PLEASANT HILL (FACILITY): DN-796 SAN JOSE GC-472 ORLAND: Live & practice in charming small town community. 1000sf SPECIALTY PRACTICES Database & $35k emphasis on treang Pediatric paents! w/ 2 ops. Seller Retiring $160k BC-789 OAKLAND (Facility): $550k GN-717 YUBA CITY: Seller Rering. All reasonable offers considered. Build- AC-759 SAN FRANCISCO Endo: Union Square. 1190 sf w/3 ops (plumbed for 1 Unsurpassed DN-806 WATSONVILLE: ing available for purchase! 2400sf w/ 5 ops $475k add’l) $495k $250k GN-746 YUBA CITY: State-of-the-Art Equipped! Includes the latest technol- BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like BC-793 BERKELEY: $550K/ Real Estate TBD ogy in CBCT Imaging. Real Estate also available! 1600sf w/ 3 ops +1 add’l. well-oiled machine! 3 ops $395k Exposure allows $475k DN-809 PLEASANTON: Pracce $480k/ Real Estate TBD. BN-801 SAN RAMON Ortho: Don’t wait or you may miss out on this spectac- BC-804 EMERYVILLE: GG-769 REDDING AREA: Offering a full spectrum of general denstry and ular opportunity of a lifeme! 1865sf w/ 5 chairs/bays. $775k us to offer you $480k total care! 2700sf w/ 6ops. Pracce $390k, Real Estate $540k EG-826 ROSEVILLE Perio: Create your success story with this warm and car- $395k GN-799 PARADISE: This remarkable opportunity is undeniably too good to ing, paent-centered pracce! 1000sf w/3 ops + 1add’l $150k BG-762 EAST BAY: NORTHERN CALIFORNIA be true! 1800sf w/ 4 ops. Pracce $375k, Real Estate $325k EN-821 GREATER SACRAMENTO AREA Perio: Live, pracce & play here! HG-732 GRASS VALLEY: Seller retiring. Well established practice. 1250sf w/ 3 It’ll be the BEST decision you’ll ever make! 1700sf w/4 ops + 1 add’l.

$1.99M EC-729 GREATER SACRAMENTO AREA: ops. Real Estate also available. $215k $395k BG-734 ANTIOCH: HG-815 SIERRA CO: Perfect location for outdoor enthusiast! 1000 sf w/ 3 ops EN-822 SACRAMENTO Perio: This pracce is known throughout Sacra- EN-664 SACRAMENTO Facility: $180k / Real Estate $437k mento for its stellar reputaon! 2200sf w/ 5 ops + 1add’l. $840k $315k HN-280 NORTHEAST CA: Only Practice in Town! 900sf w/ 2 ops $60k IC-543 CENTRAL VALLEY Ortho: 1650sf w/ 5 chairs in open bay & plumbed CC-798 PETALUMA: Now Only: $30k HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by for 2 add’l. Strong referrals and PT base $125k EN-702 SACRAMENTO: increasing office hours! 750sf w/ 2 ops $65k HG-763 GRASS VALLEY Ortho: Avg 30+ pts per day. Newer retail Shopping HN-740 SHASTA CO: Beauful mountain community, well-established Center $210k CC-802 SANTA ROSA: $450k Real Estate $325k pracce, exceponal long-term staff. 2400+sf w/5 ops + 1 add’l. $475k/ JG-757 VISALIA Perio: Keep implants in house and imagine the growth $220k or $260k w/CT EN-747 CITRUS HEIGHTS Facility: Real Estate $350k possibilities! 9 hygiene days per week! Rare Gem! 2,000 sf w/ 5 ops Scanner HN-773 SUTTER CREEK: Located in an area known for beauful scenery, $395k CG-616 NAPA: $75k excellent wine and rich history! 1536sf w/4 ops + 1 add’l $195k $425k EN-749 LINCOLN: HN-816 CHESTER/ALMANOR AREA: The perfect place to work, live and CN-829 MILL VALLEY: play! Do not hesitate, or this pracce will be gone! 1250 sf w/ 4ops. $320k Pracce $140k/ Real Estate TBD $310k EN-755 FOLSOM: DC-786 LIVERMORE Facility: CENTRAL VALLEY $175k $190k EN-768 WEST SACRAMENTO: IC-468 SAN JOAQUIN VALLEY: High-end restorave pracce! 6 ops in DC-805 CASTRO VALLEY: 2500+sf office. Call for Details! $425k $420k $275k

“ASK THE BROKER” CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 46, Nº4

A look into the latest dental and general technology on the market

Notability ($9.99, Ginger Labs) Vero (Free, subscription fee required, Vero Labs Inc.) Note-taking has an important place in human history. Whether In the world of social media, platforms such as Facebook, it is on a piece of scratch paper, notebook, mobile device or Instagram and Snapchat are some of the recognizable tablet, the ability to jot down ideas and memorable thoughts powerhouses. A new app is gaining popularity, however. It is is both invaluable and very personalized for each individual. called Vero and it touts itself as a “true social” experience. The Digital note-taking and its advances, such as the Apple Pencil idea is that users can share videos, photos, links, etc. like on other for iPad Pro, have given consumers a worthwhile alternative to platforms, without the things that are currently hampering the paper. Notability was created to give users the simple capability experience on other platforms. Vero claims there are no ads (there of writing notes with the fl exibility and freedom that extends far is a subscription cost to use it), no diving through user data, the beyond what paper can do. posts show up in chronological order without constant algorithm changes, and it features security settings that allow users to build Notability has myriad features that will satisfy any need. Pencil and friend lists. According to reports, downloads of Vero for iOS and highlighter sketch tools can be customized by stroke style, thickness Android soared by a whopping 1,465 percent in one week in and color. Text annotation can be modifi ed by font, size, color, February. Time will tell if this app makes a true dent in the social typography and paragraph style. Eraser, cut and picker tools allow media space. for easy content modifi cation. Voice annotations from the device microphone can also be attached to notes. Paper backgrounds can — Blake Ellington, Tech Trends editor also be personalized by color and line or graph confi gurations. Imported photos and PDF fi les from other apps can be marked up and annotated. Multiple undo and redo functions give users the 70 Percent of Adults Over 50 Own ability to correct any mistakes when sketching. Users have options Smartphones to print, email and share with Dropbox, Google Drive, OneDrive, Box or WebDAV accounts. Notes can be organized into subjects A new study details the use of technology among adults over and groups of subjects can be placed under dividers. Furthermore, the age of 50. The study, conducted by AARP, found that 70 notes can be backed up to any connected account and kept up percent of adults in this age group own a smartphone and about to date across MacOS and iOS devices with an iCloud account. the same amount have a presence on social media. In terms of Users can purchase multiple themes to further personalize their staying connected, text messaging is the preferred method for note-taking space within the app. those between the ages of 50 and 69. Adults who are in their 60s are more likely to use their device to manage medical needs Compared with the amount of supplies needed to take detailed than those who are in their 50s and 70s, according to the study. notes conventionally, Notability gives users the capability to take For the study, 1,520 adults over 50 were surveyed between Nov. powerful notes in a mobile or desktop app without the need for 16–27, 2017. For more information, visit aarp.org. extra supplies. People can now simply put down their thoughts and ideas wherever they go. — Blake Ellington, Tech Trends editor — Hubert Chan, DDS Would you like to write about technology? Dentists interested in contributing to this section should contact Andrea LaMattina, CDE, at [email protected].

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