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continuing education

Stress-free Endodontics

by Dr. Barry Musikant Private Practice New York, NY

Dentaltown is pleased to offer you continuing Educational objectives Upon completion of this course, participants should be able to achieve the following: education. You can read the following CE • Learn how to gain quick and simple endodontic access to root canals, includ- ing the MB2. article in the magazine and go online to • Learn alternatives to hand instrumentation and rotary nickel . • Discover engine-driven reciprocation. www.dentaltown.com to take the post-test • Learn obturation techniques that enable you to fill canals laterally as well as and claim your CE credits, free-of-charge, apically, often without the need for lateral or vertical condensation. • Perform superior, single visit endodontics. or you can mail in your post-test for a

nominal fee. See instructions on page 66. Most of us have a perception that the endodontic universe is divided into two worlds: traditional and engine-driven NiTi (rotary NiTi). Traditional endodontics uses stainless k-files to create a glide path and shape the root canal procedure whereas, engine-driven NiTi uses rotary NiTi shaping. Engine-driven NiTi has not completely escaped the shortcomings involved with traditional instrumentation, because k-files are still required to create a glide path, even when using rotary NiTi files for the shaping process. However, the use of the NiTi has enhanced effi- ciency and efficacy of the shaping procedure with increased flexibility, less hand fatigue and more accurate shaping.

Approved PACE Program Provider FAGD/MAGD Credit Dentaltown.com, Inc. is an AGD Approval does not imply acceptance PACE Recognized Provider. by a state or provincial board of This course offers two AGD PACE dentistry or AGD endorsement. 12/01/04 to 12/01/08 Continuing Education Credits AGD PACE Approval Number: 304396 free-of-charge. continued on page 60

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Traditional endodontics has a well deserved reputation for being frustratingly ineffective. There are seven negative consequences of using traditional endodontics for shaping: overfills, squiggly fills, hand fatigue, distorted canals, fractured roots, puffs of cement in vital cases and blocked canals using files. There are two counterproductive legacies of endodontic education; they are the use of files rather than and instilling fears of using Peeso reamers. These ideas made using traditional procedures more susceptible to hand fatigue and sub- sequently increased distortion. The use of standard reamers will provide more effi- ciency through less resistance by having fewer flutes. This will equate to less points “There are two counter- of contact which will result in less resistance. In fact, there are about 30 flutes on productive legacies of the shank of a file while there are 16 on the shank of a . With about twice as many flutes, on a file, the flutes will be about twice as horizontally oriented as endodontic education; compared to those on a reamer. Once it was clearly established that a k-reamer is superior to a k-file, we wanted they are the use of files to find an instrument that was superior to a k-reamer. We realized that part of the rather than reamers superiority lay in the fact that it engaged the walls of a canal less than a k-file. By placing a flat along the length of the canal, the contact points are reduced from 64 and instilling fears of to 48. This will reduce the engagement along the canal while enhancing flexibility due to a thinner cross-section. The incorporation of a flat created two columns of using Peeso reamers. that cut, one in the clockwise direction and the other in the counterclockwise These ideas made direction. This flat, in turn, enables our reamer to be used with a reciprocating hand- piece with no more than a 30 degree arc of motion in either direction at approxi- using traditional proce- mately 6,000 cycles per minute, creating highly efficient shaping with little resistance and no distortion. The above features of a flat sided (relieved) reamer allow dures more susceptible you to now have instrumentation that incurs less torsional stress than traditional k- to hand fatigue and files or k-reamers, has more durability than NiTi, is still more efficient than a rotary NiTi system – which is more susceptible to breakage, and is less costly. subsequently increased Interestingly, an article written more than 15 years ago by Dr. Anthony Martin, distortion. The use of an Australian dentist, concluded that the use of reamers used limited to a recipro- cating handpiece was the best way possible to negotiate through calcified canals. standard reamers will We believe that relieved reamers and a reciprocating handpiece are an improvement over an ordinary reamer, so Dr. Martin was most definitely on the right track. provide more efficiency NiTi and reamers have their pros and cons. NiTi files or reamers through less resistance are more flexible and less likely to cause distortion in traditional circumstances; for example a NiTi instrument used in a rotary system vs. a traditional stainless steel by having fewer flutes.” k-reamer or k-file. However, due to its shape memory NiTi begins to become more vulnerable to causing outer canal wall distortion when the curve of the canal and taper of the instrument increases. Stainless steel has less flexibility and would cause even more distortion if used in a rotary system similar to the one used in NiTi. However, when pre-bent, guided manually to the initial point of the curvature and reattached to the reciprocating handpiece, distortion is far less likely to occur. Most importantly, the potential for separation does not exist when using these reamers in the reciprocating handpiece, which encourages the dentist to shape the canals to larger diameters allowing greater clearance of debris as well as improved irrigation. A relieved reamer provides the capability for a dentist to deduce information about the apical anatomy that they might encounter. The resistance of a non- relieved reamer with no flat side will remain constant even when the canal diame- ter varies throughout the apical path. The resistance and speed will stay the same. Additionally, it will not be able to detect the degree of roundness (fully round vs. an elliptical shape). When working with the elliptically shaped canal, the relieved continued on page 62

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reamers used in the SafeSider system will go from more resistance to less resistance as it is rotated manually. This happens as the flat of the instrument starts to line up with the long diameter of the elliptically shaped canal and back to more resistance as the flat starts to line up with the short diameter. This easily perceived change in resistance tells the dentist that he should open the canal wider apically to better cleanse the wider extensions that are most usually in the bucco-lingual . The remainder of this article will discuss the system from end to end, from the start of accessing the canal with initial negotiation through the pulp chamber, to negotiating the canal to obturation. Just about all the components, with the excep- tion of the NiTi reamers, can be used either manually or with a reciprocating hand- piece. Most of the instruments are relieved k-reamers given the name SafeSiders. There are also other relieved NiTi instruments all used in the reciprocating hand- piece – the 30/.04, 25/.06 and 25/.08 which is rarely used and if used no closer then 2mm. We insist that the NiTis only be used in the reciprocating hand-piece because the short envelope of motion that the reciprocating hand-piece generates makes for far safer shaping than if used manually where even a small amount of excessive torque can lead to separation. The only instruments that are not relieved are the 08 and 10, which, if a flat were incorporated, would make these already thin instruments too weak. The flat has its advantages; less resistant as the instruments get to the apex (allowing for faster instrumentation to the apex), the debris is pushed aside rather than clogging up the flutes, thinner cross section that makes instruments more flexible, more flexibility which allows the instruments to negoti- ate curved canals more easily and the need for less hand pressure which gives the dentist superior tactile perception. The reciprocating handpiece limits the arc of motion to 30 degrees, a small enough envelope of motion to virtually eliminate torsion stress and cyclic fatigue that can plague rotary NiTi. Even when a sharp curve calls for pre-bending and manual insertion of any of the stainless steel flat-sided instruments, the canal will be shaped without distortion to a size significantly wider than can be achieved dis- tortion free with rotary NiTi. The handpiece is connected to a source of power. An e-attachment is required. The connection can be made to an airline using a 4-hole air-driven motor or an electric attachment that all dentists who presently use rotary NiTi already have. The reciprocating handpiece is best used at about 6,000 cycles/ minute with a firm pecking motion. If used slower, the instrument becomes less efficient and the tactile perception decreases. The instruments are typically used in the following sequence: • Use a high-speed surgical length No. 4 round bur with a 7mm stop to make the proper depth cut in looking for the pulp chamber which is necessary before looking for the canals. The 7mm stop on the bur prevents perforation thru the floor of the pulp chamber that could endanger the integrity of the pulp chamber. • A barrel-shaped non-end bur is now used to widen the access. It will not deepen the canal because there is no cutting tip. • The instrument used in a reciprocating hand piece is a flat sided k-reamer given the name SafeSiders. The first instrument is generally the .08 reamer which is taken to the apex with the instrument attached to the apex locator. This length will be our provisional length only changed after the Pleezer (tapered Peeso) straightens out the coronal curve. Note: If the canal is quite wide, the dentist simply wristwatches the reamer up to the apex in a matter of seconds. If the canal is much tighter, then a wristwatch motion is still used, but in addition, the wristwatch motion must be used with both continued on page 64

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an inward and outward motion. If it is a really tight canal, then a twist and pull Author’s Bio motion must be used repeatedly to gain apical length. Dr. Barry Musikant attended • After the .08 has determined the length, the No. 10 SafeSider is inserted into the University of Pennsylva- the canal using the reciprocating hand piece to guide it to the apex nia, receiving his BA in 1965 • The 10 is followed by the 15. Starting with the 15, there is a flat along the and DMD in 1969. An intern- entire working length of the reamers ship at the Jewish Memorial • The 20 is used next. Unlike those who are used to using k-files, the relieved k- Hospital (1969-1970) and endodontic resi- reamers provide far less resistance as they negotiate to the apex while providing dence at Kingsbrook Jewish Medical an increased apical tactile perception which allows the dentist the ability to Center (1970-1972) completed his post- know more accurately what he is encountering at the tip of the instrument graduate studies. Dr. Musikant is a mem- • After the use of the 20, if the length of the canal from orifice to apex is ber of the American Dental Association, American Association of Endodontists, 10mm, the diameter at the orifice will now be .40mm, wide enough to Academy of General Dentistry, The Dental accommodate the non-end cutting tip of the Pleezer, which looks very sim- Society of NY, First District Dental Society, ilar to the tapered Peeso. Academy of Oral Medicine, Alpha Omega • The Pleezer has a .75 mm tip at the apex compared to a .90mm tip for the Dental Fraternity, and the American Society No. 2 Peeso. In addition, the Pleezer has a .03 mm/mm taper. Its purpose is of Dental Aesthetics. He is also a fellow of simply to straighten the coronal curve which will then make all subsequent the American College of Dentistry (FACD). instrumentation easier. It is typically used within 6mm of the apex, after which all subsequent instrumentation engages no more than 6mm of length. Dr. Musikant is the president and co-direc- • After the coronal curve of the canal has been straightened with the Pleezer, the tor of Dental Research; and co-founder of canal is shaped to the apex with the Red 25 reamer. This generally only takes Essential Dental Systems (EDS), a dental a few strokes. products company located in South Hackensack, New Jersey. • The No. 30 SafeSider reamer is next used to the apex in the reciprocating hand- piece. Again, generally only a few strokes are needed to gain access to the apex. Disclosure: Dr. Musikant declares that he is • The 30/04 is the first relieved NiTi instrument used in the sequence. It part owner of Essential Dental Systems. increases the taper of the preparation without widening the apical prepara- tion. By using the 30/04 the subsequent instrument, the 35 relieved stainless steel reamer will go to the apex with minimal resistance • The 35 is used next, which encounters very little resistance because it cuts only the most apical 3mm. • The No. 40 is now used 1 mm short of the apex • The 25/06 relieved NiTi instrument is used to create some body shaping from 3 to 6mm from the apex. In most cases, the 25/06 will be the last instrument used in the sequence. • The 25/08 is used for shaping where the canal is significantly wider. • Now that the canal has been shaped, EZ-Fill gets applied to the canal walls with the bidirectional . EZ-Fill is a more radiopaque variation of epoxy- resin cements that have been successfully used for the last 50 years • The epoxy-resin, root canal sealer is applied with the bidirectional spiral. This material will hermetically seal the canal. The coronal spirals drive the cement apically while the three most apical spirals are oriented in the opposite direc- tion driving the cement coronally. In this way the canal can be thoroughly flooded with cement without driving the cement past the apex. • Lastly, the most apical 10-12mm of the gutta percha point is also coated lib- erally with the epoxy-resin cement and placed in the canal. You have just learned about an alternative way of doing endodontics using the SafeSider approach and Ez-Fill obturation. Our alternative system will give you a reason to appreciate the fact that excellence in endodontics can be attained This CE activity is supported by an unrestricted without the stress that many have come to associate with rotary NiTi and ther- grant from Essential Dental Systems. moplastic obturation. ■ continued on page 66

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continued from page 64 Post-test

Answer the Post-test Questions Online – for FREE You have two options to claim your CE credits: 1) Go online and answer the test for free or 2) answer the test on the Continuing Education Answer Sheet and submit it by mail or fax with a processing fee of $35. To take the test online: After reading the preceding article, type the following link into your browser and click the button TAKE EXAM: http://www.towniecentral.com/Dentaltown/OnlineCE.aspx?action=PRINT&cid=71 You can also view the course online in a Webcast format by clicking the above link and then the button REVIEW COURSE. If you choose that latter option, you can take the test by scrolling down and clicking “I wish to claim my CE credits.” Please note: If you are not already registered on www.dentaltown.com, you will be prompted to do so. Registration is fast, easy and of course, free.

1. The critical measurement to obtain access to the middle of 6. The Pleeser is used to flare the canal away from the furcation the pulp chamber and not perforate is: and get to within ____ of the apex. A. 3mm. A. 1mm B. 4mm. B. 3mm C. 5mm. C. 6mm D. 7mm. D. None of the above

2. The optimum instrument to be used in the reciprocating 7. The 30/.04, 25/.06 and 25/.08 SafeSiders are made of: handpiece is: A. stainless steel. A. a K-file. B. NiTi. B. a flat-sided reamer. C. . C. a Hedstrom file. D. Ti 6Al4V D. a rotary NiTi file. 8. The material that hermetically seals the canal is: A. root canal sealer (cement). 3. The 4:1 reciprocating handpiece should be run at B. gutta percha. A. 8,000-10,000 cycles per minute (cpm). C. calcium hydroxide. B. 5,000-6,000 cpm. D. EDTA. C. 20,000-25,000 cpm. D. None of the above 9. The bi-directional spiral with its two sets of spirals going in opposite directions does not spin the sealer (cement) 4. What the flat does to simplify endodontic instrumentation is: A. Apically A. faster instrumentation to the apex. B. Coronally B. greater flexibility of the instruments. C. Laterally C. negotiates curved canals more easily. D. Past the apex D. All of the above 10. The bi-directional spiral obturation technique does not 5. The Pleeser is: incorporate: A. a tapered Peeso. A. a single point technique. B. 0.75 mm at the apical tip and 1.02 mm coronally. B. multiple points of lateral condensation. C. non-end cutting. C. flooding the canal with cement. D. All of the above D. thermoplastic gutta percha.

Legal Disclaimer: The CE provider uses reasonable care in selecting and providing content that is accurate. The CE provider, however, does not independently verify the content or materials. The CE provider does not represent that the instructional materials are error-free or that the content or materials are comprehensive. Any opinions expressed in the materials are those of the author of the materials and not the CE provider. Completing one or more continuing education courses does not provide sufficient information to qualify participant as an expert in the field related to the course topic or in any specific technique or procedure. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, expertise, skill and judg- ment of a trained healthcare professional. Licensure: Continuing education credits issued for completion of online CE courses may not apply toward license renewal in all licensing jurisdictions. It is the responsibility of each registrant to verify the CE requirements of his/her licensing or regulatory agency.

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continuing education

Continuing Education Answer Sheet

Fill out this sheet ONLY if you wish to submit your test by mail or fax. A $35 processing fee applies. Instructions: To receive credit, complete the answer sheet and mail it, along with a check or credit card payment to: Dentaltown.com, Inc., 10850 S. 48th Street, Phoenix, AZ 85044. You may also fax this form to 480-598-3450. You will need a minimum score of 70% to receive your credits. Please print clearly. Deadline for submission of answers is 24 months after the publication date.

Stress-free Endodontics by Dr. Barry Musikant

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CE Post-test Program Evaluation Please circle your answers. Please evaluate this program by circling the corresponding numbers: (3 = Excellent to 1 = Poor) 1. a b c d 2. a b c d 1. Course objectives were consistent with the course as advertised 3 2 1 3. a b c d 2. Course material was up-to-date, well-organized and presented in sufficient depth 321

4. a b c d 3. Instructor demonstrated a comprehensive knowledge of the subject 3 2 1 5. a b c d 4. Overall, I would rate this course 3 2 1 6. a b c d 5. Overall, I would rate this instructor 3 2 1 7. a b c d 8. a b c d 9. a b c d For any questions, please contact Rita Zakher, DMD, MBA, director of continuing 10. a b c d education at [email protected]

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