Tạp chí Nội Nha tháng 5&6/ 2013 Vol 6 No 3

Performance Refined

a shift up in performance

May/June 2013 – Vol 6 No 3

a shift up in performance
New PROTAPER NEXT features the same variable tapered performance as the original
PROTAPER, but is refined with:
• New unique rotary motion that further enhances PROTAPER canal-shaping efficiency
ã Proven M-Wiređ NiTi alloy for increased flexibility and resistance to cyclic fatigue
• New rectangular cross-section design for greater strength
Call 1-800-662-1202 now to experience
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Performance Refined

1-800-662-1202
For the latest information consult www.TulsaDentalSpecialties.com

Rx Only

© DENTSPLY International, Inc. ADPTN1 11/12

Images Courtesy Dr. Cliff Ruddle

Product Profile

What’s next? PROTAPER NEXT™

“Endodontics is a clinical game. You’re supposed to have fun.” –John West, DDS, MSD
To me, it’s fun when you master a skill such as the mechanics of root canal shaping. It’s fun when
you have a plan and you know how to get there. ProTaper NEXT (PTN) was produced with a plan
in mind: an advanced technology that gives the clinician choices, confidence, competence, safety,
efficiency, technique simplicity, and yes, fun!

West

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What makes ProTaper NEXT, next? PTN is a convergence of: 1) ProTaper Universal progressively
tapered design, 2) M-Wire® refinements for added resistance to cyclic fatigue and increased flexibility,
and 3) offset axis of rotation.* The resulting NiTi “envelope of motion” allows a newfound level of
shaping control. With almost unanimity, these three critical distinctions have had many colleagues
describing their shaping experience with words like: “sleek,” “smooth,” “enchanting,” and “magic.”
However, the best endorsement in the world is your own.

The first step in successful endodontics is to decide which “tool” to use when, why, where, and how. Your plan gets you to

where you’re going. The resulting artistry is the signature that sets you apart. Your signature becomes your reputation and
your reputation ultimately becomes your endodontic legacy.

Technique Sequence I Used
to Treat These Two Patients

Case A

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Case B
*Following your online registration, a coupon code will be emailed to you for a 20% discount off one total online order, with a maximum discount of $200.
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1. Design unimpeded smooth-walled access while fully

preserving essential ferrule.

2. Brush gently on the outward stroke with ProTaper Universal

SX to remove dentin triangles and restrictive dentin when
present.

FIND WHAT YOU NEED. FAST.
Pretreatment #12

Pretreatment #15

3. Prepare manual Glidepath with at least half canal length



amplitude “super loose” #10 file. (confirm Glidepath with #15
file or mechanical file, if desired)

BETTER ORGANIZATION
Shop for products by procedure or brand.

4. Float, follow, and brush on the outstroke (“let it run and paint”

are useful watchwords) with PTN X1 to length. Usually 2-3
shaping waves are needed.

5. Float, follow, and brush on the outstroke with PTN X2 to

length. Usually 2-3 shaping waves are needed.

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Perpendicular downpack #12

Perpendicular posttreatment #15

If X2 flutes are visibly filled with dentin: irrigate, gauge, conefit
or use a verifier to validate proper shape. Follow irrigation
protocol then obturate with a vertical compaction of warm
gutta-percha technique.



ON-DEMAND CE COURSES
Enroll in courses, webinars and more, with your
Clinical Education credits tracked in your profile.

6. If X2 flutes are nude of dentin, proceed with X3 and larger if

occasionally needed. All shapes presented were finished with
X2 or X3. Note: PTN preserves proper root canal “Flow”.

*Ruddle CJ, Machtou P, West JD, The Shaping movement:
fifth-generation technology. Dent Today. 2013;32(4):94-99.

Oblique downpack #12

Oblique posttreatment #15

© 2013 DENTSPLY International, Inc. CWEP 4/13


s • technology reviews
May/June 2013 – Vol 6 No 3

PROMOTING

EXCELLENCE

Endodontics in 3D
Dr. Richard Kahan

Direct pulp capping
with a bioactive
dentin substitute
Dr. Markus Firia

Corporate profile

Ultradent Products, Inc.

IN

ENDODONTICS
Top Ten Tips

#

7

To determine length
Dr. Tony Druttman

Endodontics in
Jamaica: a fulfilling and
challenging experience

Dr. Gary Glassman

Practice profile

Dr. Nishan Odabashian

PAYING SUBSCRIBERS EARN 24
CONTINUING EDUCATION CREDITS
PER YEAR!

S
IT
D !
E
R E
C SID
E
C IN


ASSOCIATE EDITORS
Julian Webber BDS, MS, DGDP, FICD
Pierre Machtou DDS, FICD
Richard Mounce DDS
Clifford J Ruddle DDS
EDITORIAL ADVISORS
Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD
Professor Michael A Baumann
Dennis G Brave DDS

David C Brown BDS, MDS, MSD
L Stephen Buchanan DDS, FICD, FACD
Gary B Carr DDS
Arnaldo Castellucci MD, DDS
Gordon J Christensen DDS, MSD, PhD
B David Cohen PhD, MSc, BDS, DGDP, LDS RCS
Stephen Cohen MS, DDS, FACD, FICD
Simon Cunnington BDS, LDS RCS, MS
Samuel O Dorn DDS
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Tony Druttman MSc, BSc, BChD
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publisher.

Volume 6 Number 3

Endoscopic microsurgery for predicable and
successful procedures
The specialty of endodontics has improved so dramatically over the last several years,
thanks to technology and to so many new instruments and products now available
to us. Performing apical surgery has become such a predictable and successful
procedure. Whereas once a procedure with no greater than 70% success, with the

implementation of the surgical operating microscope, microsurgical hand instruments,
ultrasonics, biocompatible root-end filling materials, and bone regeneration materials,
endodontic microsurgery can now boast a success rate of greater than 90%. This author
feels strongly that the “pendulum” is starting to swing back towards saving the natural
dentition whenever possible, and therefore, one must include surgical endodontics
into their armamentarium. Apical surgery is NOT a substitute for excellent conservative
endodontics, but in an era of teeth that are heavily restored, and parts of longstanding
fixed prosthetic work, often a surgical approach is the safer and more conservative
approach. Many problems can occur during conventional endodontics, such as separated
files, ledged, or apically perforated canals, canal transportation, etc., and a surgical
approach can correct these issues. Teeth that contain large posts, which put the tooth at
great risk for fracture if accessed conventionally, can be saved by surgical endodontics.

Endodontic surgery prior to the microscope had fair success. Excess bone was
removed in order to be able to see the roots; excess root structure was removed to be
able to fit the handpiece inside in order to prepare the root end for an amalgam, which
could then corrode and cause reinfection. Under the microscope, we are able to keep
our osteotomies small; just large enough to gain access to be able to remove all the
diseased tissue. Forty-five degree handpieces are used for easier viewing and only allow
sterile water to enter the surgical site, while the air exits out the back of the handpiece
head. Only 3 mm of the root is removed, and then the surface is stained with methylene
blue dye to look for missed canals, microfractures, isthmuses between canals, and much
more. The root ends are then prepared with ultrasonic tips, remaining in line with the long
axis of the roots so as not to remove any unnecessary root structure, and then these
apical preparations are filled with biocompatible filling materials such as mineral trioxide
aggregate (MTA), or newer bioceramic materials. These root-end filling materials have
been shown to not only allow new bone and cementum to reform, but they help to induce
the formation of new cementum and bone, right up to the root.

We also have the great advantage of incorporating 3D imaging into our treatment

planning for endodontic surgery, thanks to the CBCT. This is an irreplaceable tool to help
us see periapical lesions not seen on films, to measure the amount of bone necessary
to drill through to access the apical portion of roots, as well as the proximity of roots to
significant anatomical landmarks, such as the mental foramen and the sinuses. One can
use the measuring tool on the CBCT to determine the distance between an MB and ML
root, for example, on mandibular molars, or the B and P root on maxillary bicuspids, as
well as the direction one has to go to find these sometimes elusive roots.
Also, as endodontic surgeons, we should be knowledgeable about the various bone
grafting and guided tissue regeneration materials available for those cases where there is
a combination of an endodontic and periodontal lesion. Of course there are cases where
the teeth are just not accessible surgically, such as the second molar region, where the
bone is so dense on the mandible and the patient’s lip cannot be pulled back far enough,
or those maxillary second molars that are completely in the sinuses. For cases like these,
we must consider extraction/reimplantation, which has a documented success rate of
over 80% when performed using modern protocol, proper case selection, and a transport
medium such as Hanks Balanced Salt Solution, to maintain the viability of the PDL while
the tooth is repaired extraorally.
Unfortunately, as a practicing endodontist, approximately 25% of my cases are
nonsurgical retreatments. These cases take the most time, are the most unpredictable,
and have the highest postoperative flare-up rate. As a comparison, endodontic
microsurgery is quicker, more predictable, especially in preserving the coronal
restorations, and has a negligible flare-up rate. Yes, implants are successful and popular
and predictable, but in the words of a well-known periodontist and former Dean of the
University of Pennsylvania Dental School, Jan Linde, “Implants replace missing teeth…
not teeth.” Endodontists are in the business of saving teeth, and therefore endodontic
microsurgery should be something that all patients should be offered as a viable
alternative to maintaining their own teeth.

Samuel I. Kratchman, DMD
Exton Endodontics, Inc.

Exton, Pennsylvania
Endodontic practice 1

INTRODUCTION

May/June 2013 - Volume 6 Number 3


TABLE OF CONTENTS

Clinical

Practice profile

6

Dr. Nishan Odabashian: A focus on patients, colleagues, and
family
Technology, attention to detail, and knowledgeable mentors combine to help
Dr. Odabashian provide a positive experience for patients

Endodontics in 3D
In the second in a clinical series,
Dr. Richard Kahan discusses
targeted endodontics.................. 12
Effects of smear layer and debris
removal with irrigation assisted
by the EndoActivator and the
Endo Brush
Drs. Joseph M. Morelli, Mark

Sakamaki, Ricardo Caicedo, and
Stephen J. Clark compare debris
and smear layer removal from
instrumented root canals after
irrigation...................................... 14

Case study
Maxillary molar endodontic case

Corporate profile

10

presentation
Dr. Rahul Bose presents the case
report that won him the acclaimed
title of Young Dentist Endodontic
Award 2012................................. 18

Ultradent Products, Inc.
Ultradent continues to lead the way through invention and innovation

2 Endodontic practice

Volume 6 Number 3


simple, adaptable

endodontic solutions

Files to fit your technique. And make apex location easy.

TiLOS hand files work with
your technique

Don’t change your technique.
Make it easier with TiLOS hand files.

No two root canal treatments are alike. Your techniques
are tried and tested, and you perform them on the entire
range of cases you see every day. So why not use the
hand files that make every procedure faster and easier?
Available in stainless steel and NiTi, TiLOS hand files do
just that. And they’re made to work with your technique.

Scan to watch a
short video about
TiLOS hand files.

800.552.5512
ultradent.com

The unique construction of the TiLOS hand files allows the apex
locator to be attached to the top of the file rather than below
the handle.

â2013 Ultradent Products, Inc. All Rights Reserved.

TiLOS

đ


TABLE OF CONTENTS

Research
The effect of different solvents on
root canal sealers
Drs. Ane Poly, Juliana Brasil, Paula
Marroig, Fabiola Ormiga, Patrícia de
Andrade Risso, Marcos Cesar Arẳjo,
and Helsa Gusman evaluate the
ability of solvents used in endodontics
to disintegrate different root canal
sealers...........................................41

Aspiring endodontists
in Jamaica

46

Case report
Detection and endodontic
treatment of a three-rooted
maxillary second premolar
Dr. Imran Cassim presents a case
report detailing treatment of a multirooted maxillary second premolar
.....................................................22

Endodontics in
focus
Top ten tips: Tip number 7 – To
determine length
Continuing his series on endodontics,
Dr. Tony Druttman looks at the best
ways to measure the length of a canal
....................................................26
4 Endodontic practice

Filling a need
Continuing
education
Preserving the natural smile by
immediate reattachment of a
fractured tooth
Drs. Ramesh Bharti, Deeksha Arya,
Anil Chandra, Aseem Prakash Tikku,
Rakesh Yadav, and Promila Verma
present two case reports detailing
the reattachment of a fractured tooth
fragment for the restoration of
function and esthetics....................28

Endodontics in Jamaica:
a fulfilling and challenging
experience
Dr. Gary Glassman takes his
endodontic experience on the road to
help aspiring dentists.....................46

Product insight
Barbed sutures
Dr. Michael Norton discusses the
barbed suture and its use in oral
surgery .........................................50

Anatomy matters

Direct pulp capping with a
bioactive dentin substitute
Dr. Markus Firla discusses various
solutions for pulp exposure............32

Do lateral canals really matter?

Technology

Diary.............................................54

3D Apical Cork – Part 2
In the second article of this series,
Dr. Wyatt Simons discusses the
technologic breakthroughs that
the Cork delivery device brings to
obturation......................................36

Part 6
Dr. John West explores the
significance of the lateral canal......52

Materials & equipment ..............55

Ruddle on the radar
The NITI shaping movement
Fifth generation technology ...........56
Volume 6 Number 3


ORTHOPHOS XG 3D
The right solution for
your diagnostic needs.

Implantologists

Endodontists

Orthodontists
will benefit from highquality pan and ceph
images for optimized
therapy planning.

will enjoy instantly
viewable 3D volumetric
images for revealing
and measuring canal
shapes, depths
and anatomies.

will appreciate the

seamless clinical
workflow from initial
diagnostics, to treatment
planning, to ordering
surgical guides and final
implant placement.

General Practitioners
will achieve greater
diagnostic accuracy
for routine cases.

ORTHOPHOS XG 3D

“With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, fractures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients.
Combine that with the metal artifact reduction software that reduces distortions from metal objects,
my treatment process is a lot less stressful. My patients benefit from the technology and my
referrals appreciate the value.” ~ Dr. Kathryn Stuart, Endodontist - Fishers, Indiana

The advantages of 2D & 3D in one comprehensive unit
ORTHOPHOS XG 3D is a hybrid system that provides clinical
workflow advantages, along with the lowest possible effective
dose for the patient. Its 3D function provides diagnostic accuracy
when you need it most: for implants, surgical procedures and
volumetric imaging of the jaws, sinuses and other dental anatomy.

For more information, visit www.Sirona3D.com
or call Sirona at: 800.659.5977
www.facebook.com/Sirona3D

PRACTICE PROFILE

Dr. Nishan Odabashian
A focus on patients, colleagues, and family
What can you tell us about your
background?
I am the oldest son, second of four
children, to parents of Christian Armenian
descent whose families ended up in the
Syrian Desert after the Armenian genocide
of 1915. My father was the oldest son of
five, of the oldest son of six. My mother
was the youngest of 12, who lost her father
at 6 months of age. Although my parents
had humble beginnings, my father worked
hard to improve his children’s chances of
making a better future for themselves. His
first major decision towards that goal was
to leave Syria and immigrate to the U.S. We
arrived in the U.S. from Damascus in 1977
to N. Providence, Rhode Island. I was 12. I
quickly adapted to the American way of life
by first picking up the English language, and
soon becoming a Red Sox, Celtics, Bruins,
and Patriots fan. We moved to California
after the 1978 snow blizzard. I attended
Hollywood High School, and then I realized
my father’s dream by being the first from
our extended family to attend a university

at UCLA. I continued to Tufts University
School of Dental Medicine and graduated
with a DMD degree in 1991. After 8 years
of general restorative dentistry, I went
back to school and received a certificate
of specialty and a Master’s Degree in
Endodontics from Loma Linda University
School of Dentistry (LLUSD) in 2001
under the leadership of two giants in the
field of endodontics — Drs. Leif Bakland
and Mahmoud Torabinejad. I have since
had a practice in Las Vegas, Nevada and
Bakersfield, California. In 2008, I returned
to Glendale, California where I had
practiced general dentistry. I run Glendale
MicroEndodontics (GME) and work with a
wonderful staff who all strive to provide a
most positive experience for our patients.
My biggest accomplishment in my life is
my family. I am married to Lilit going into
our tenth year of marriage. Lilit and I are
blessed with three children, Galia, 8, Sérge,
5, and Noah, 3, who is a special-needs boy
wonder.

Is your practice limited to
endodontics?
GME’s practice is limited to the specialty of
6 Endodontic practice

(Left to right) Lillia, Office Manager; Ingrid, Assistant; Elizabeth, Clinical
Manager; Laura, Assistant in GME’s reception area

endodontics. However, we try to distinguish
our office by practicing microscope-aided
restorative endodontics. What this really
means is that we recognize that endodontic
treatment is only half of the treatment, and
that the success of our treatment equally
depends on the restorative treatment.
To ensure our efforts have the maximum
chance for success, we provide the
permanent coronal restoration. Performing
the coronal restoration protects our root
canal treatment and reduces the likelihood
of: 1.) recontamination of the root canal
system, 2.) fracture of the tooth prior to
the patient having the crown placed by the
general dentist, 3.) procedural accidents
during the removal of the temporary and
post and core placement by the general
dentist, and 4.) having appropriate post
size and depth as needed. I also fabricate
acrylic temporaries when needed, and
make sure the patient returns to the
referring doctor almost ready for his/her
crown impressions.

Why did you decide to focus on
endodontics?

I owe my interest in endodontics to two
very well-known endodontists from Santa
Barbara, California — Drs. Cliff Ruddle
and Stephen Buchanan. They were very
influential in my becoming an endodontist,
as I am sure they have been for many like
me. When I graduated dental school, the

Dr. Odabashian’s children: Galia, 8, Sérge, 5,
and Noah, 3 during Christmas 2012

“endo” requirement to graduate was to
have treated nine canals with a minimum
of one molar tooth. Needless to say, I felt
inadequate with my root canal treatment
abilities, and so I took several courses from
Cliff and Steve, and began appreciating the
complexity of root canal systems. The more
I treated teeth endodontically, the more
I enjoyed the challenges that came with
treating each tooth. I was lucky enough to
have been accepted to LLUSD’s Graduate
Endodontics program (to a class of three
residents) by Dr. Torabinejad and the rest
of the faculty there. My program laid a
solid foundation for being an endodontic
clinician, an educator, researcher, and a
critical thinker.

How long have you been

practicing, and what systems do
you use?
I have been a dentist for over 22 years, a
restorative dentist from 1991-1999, and
an endodontist from 2001 till the present.
I started my training using the Surgical
Operating Microscope (SOM) in residency,
and I continue to do so on 100% of the
cases, from start to finish. I don’t know
how it is possible to perform endodontic
treatment at a high level without a SOM. I
have heard some endodontists who don’t
use the SOM say, “It’s just a tool!” I say
“You don’t know what you don’t know!”
Imagine walking in a pitch dark tunnel
Volume 6 Number 3


What training have you
undertaken?
As I mentioned earlier, I was fortunate to
be accepted to do my endodontic specialty
training under the well-known Mahmoud
Volume 6 Number 3

Torabinejad, the post-graduate program
director at LLUSD. Dr. “T,” as he is known
by his residents, is not only a program
director, he is a clinician, a clinical and
didactic instructor, a previous president of

the American Association of Endodontists
(AAE), inventor, and a father figure to his
residents. Dr. T is the developer of Mineral
Trioxide Aggregate (MTA), which has
been a game-changing material that has
allowed the successful repair of iatrogenic
and resorptive inflammatory perforations
during root canal treatment.

When I began the program at LLU, Dr.
Torabinejad advised me and the other two
incoming residents to expect to spend 1618 hours a day in the program. He was very
demanding of his residents, demanding for
them to be the best they can be. For me, it
was an honor to be one of his students.

Who has inspired you?
Professionally, my inspiration comes from
Dr. Gary Carr, an endodontist, an author, a
visionary, the developer of The Digital Office
(TDO) endodontic software, an inventor,
and a mentor to hundreds of endodontists
who are interested in performing
endodontics at a high level. Dr. Carr has
always challenged me to be the best that I
can be, to always question dogma, and go
beyond what is acceptable. I owe Dr. Carr
much for being the endodontist that I have
developed into.

Personally, my inspiration comes from
my children. They have taught me much
also — patience, humility, sympathy, and
understanding, among many other things. I
am blessed to have them.

What is the most satisfying aspect
of your practice?
I am sure I am not alone when I say that the
best satisfaction for a clinician is when the
result of a treatment is positive, the patient
is appreciative, and the referring dentist is
glad that he/she is referring his/her patients
to you. It is a great feeling when a patient
writes a positive review on Yelp, Google,
or your website, out of the blue! It is also
very satisfying when you receive positive
comments from referring doctors about the
level of treatment you are providing to their
patients. There is no greater professional
reward for me.

Professionally, what are you most
proud of?
I am most proud of the fact that I have the

privilege of helping people; that I have the
trust of my patients to take care of their
endodontic needs. I am proud that I have
built a reputation in my community of being

very good in my chosen profession. I am
proud that I don’t measure success with
the amount of wealth that I amass, rather
by the number of people I help. I am proud
that I stand for what I believe in, and that
I am not fearful of the consequences of
doing so.
I am also proud of the fact that, in
a small way, I am able to contribute to
dental education and organized dentistry.
Whether it is at the local, state, national, or
even the international level, I try to volunteer
my time, knowledge, and expertise to help
my chosen profession. As the saying goes,
“If you are not part of the solution, then you
are part of the problem.”
I have been a part-time faculty
member at LLUSD Department of
Graduate Endodontics for the past 10
years. I currently have the privilege of
serving as the President of the California
State Association of Endodontists, as well
as serving as the Chairman of the Bylaws
Committee of the International Academy of
Endodontics.

What do you think is unique about
your practice?
What I think is unique about my practice, at
least in my immediate community, is that I

am not in a hurry to complete a treatment.
Also we use the latest technology to
the patient’s advantage, whether it’s
the microscope, cone beam CT, digital
radiography, the Internet, or even social
media. If we allow patients to register online
or have them receive a text reminder of
their appointment, doesn’t that make their
lives easier? My endodontic practice is
50% initial treatment and 50% retreatment.
Unfortunately, gone are the days where
endodontists are referred routine cases.
Generally speaking, endodontists are
referred failing root canal treated teeth,
severely curved or calcified teeth, teeth
that have had procedural accidents, or
patients who are generally either hard to
manage or can’t afford treatment. It takes
an office with an experienced doctor, and
a knowledgeable and understanding staff
to manage these types of referred patients,
and at the same time to please the patient,
the referring dentist, as well as oneself. I
believe that we are able to accomplish this
at Glendale MicroEndodontics.
Endodontic practice 7

PRACTICE PROFILE

that has three-dimensional curves, where

the goal is to reach the end of that tunnel;
and now imagine projector lights turned
on throughout the tunnel. Which method
would you prefer to reach the end of the
tunnel? Which would our patients prefer if
the tunnel is inside their tooth that needs
treatment?

Dentistry in general is a profession that
requires attention to detail at every step
of treatment. One cannot pay attention to
detail at a certain part of the treatment, and
be sloppy, or even average at another part,
and still provide high quality dentistry. For
high quality treatment, an endodontist has
to be detail-oriented from medical history to
dental history, to proper use of radiography
(two-dimensional, or 3D if needed), to
diagnosis to proper treatment planning
to anesthesia, to isolation to cleaning and
shaping, to obturation to restoration, to
postoperative care. There is not one step
that is more important than the next to
have a successful practice that is patient
centered.
In my opinion, there are a few
fundamental “musts” as far as instruments
and equipment for practicing endodontics
at a high level: The SOM, an electronic
apex locator (EAL), and more recently

a cone beam computed tomography
(CBCT) machine (when needed). There
are numerous cleaning, shaping, and
obturation systems out in the market, and
it seems that almost daily, a new file, a
new metal, or a new system is introduced,
and hailed as the next panacea. These
different systems all work if used in the
manner in which they were designed. To
me, these are mostly secondary. What is
primary, in my opinion, is to take the time
to listen to the patients and pick up clues
about what is their chief complaint; to take
the time and diagnose the culprit tooth; to
understand that it takes time to perform
quality and successful endodontics; to
realize that the root canal system is very
complex and cannot be dumbed down to
three white stripes on a radiograph that
can be achieved in 30 minutes; and to
educate both patients and general dentists
about what is possible with meticulous
endodontic treatment.


PRACTICE PROFILE
What has been your biggest
challenge?

What advice would you give to

budding endodontists?

My biggest challenge has been to
deprogram general dentists from utilizing
endodontists as providers of prescription
root canal treatments. I try to get involved
in the treatment planning of a patient’s
teeth, and demonstrate that I can have
valuable input in the total outcome of the
dental treatment. It is very hard to get out
of the image of a “technician” who does
root canal treatment if endodontists do not
get more involved in the decision making of
the fate of teeth.

The best advice that I can give to budding
endodontists is to have a mission statement
that represents who they are, and keep
striving to reach and maintain it. Keep their
personal costs low at the outset of their
career. Surround themselves with quality
people, whether they are referring doctors
or staff people. Practice with their patients’
best interests at heart. Make sure and learn
things that were not taught in dental/endo
school, such as the business aspects of
running a practice and ergonomics. Make
quality their priority; people will notice. Put
patients first, and success will follow. Try to
distinguish themselves from others. Have

an online presence. Show concern for their
patients, and mean it.

What would you have become if
you had not become a dentist?
Had I not chosen to become a dentist, I
may have become an attorney, or a math
teacher. I like to teach, and I like to help
people. I especially like to help the weak,
and those who have been wronged, or
taken advantage of. Maybe that is why I
am always rooting for the underdog team
in sports competitions. Well, unless if it is
my favorite team that is playing!

What is the future of endodontics
and dentistry?
I believe that endodontics has gone through
its golden age. The specialty has challenges
that are multifactorial. More than ever,
there is the competition of tooth retention
versus tooth extraction and replacement
with an implant. There is competition with
general dentists performing challenging
root canal treatments that are beyond
the scope of their training or expertise.
There is competition with the corporate
dental offices that have been sprouting
around the nation; ones who mostly feed
on newly graduated dentists/endodontists

by pressuring them to perform complex
or extensive treatments in short periods
of time in order to increase production;
corporations who only care about quarterly
reports and profits for their shareholders
and not for the health of their patients. There
is competition with corporate-sponsored
speakers who give weekend courses that
promise to teach “Endodontics A to Z.”
There is competition with endodontists
who have conflicts of interest, promoting
their products and giving their generaldentist audiences a false sense of simplicity
to performing root canal treatments.
And, finally, there is competition with
endodontists delivering mediocre or
average care to their patients for different
8 Endodontic practice

The Odabashian family: Wife, Lilit, Dr. Odabashian, Galia,
Sérge, and Noah

reasons. Unless all endodontists get
involved in teaching at the dental schools;
unless we are more active in study clubs
and contribute to treatment planning;
unless we make high level of care a top
priority, and use the available technology;
unless we take the necessary time and
address the complex root canal anatomy,
and put the patient’s needs first; unless

we get the message across to general
dentists and patients, alike, that root canal
treatment can be painless, predictable,
yet requires skill and patience; and finally,
unless we as endodontists understand that
a successful tooth is much more important
than a successful root canal treatment, and
stop decoupling the endodontic treatment
from the restorative treatment, it is going
to be very challenging going forward and
maintaining endodontics in the high esteem
it has enjoyed in the past 50 years. I am
hopeful that this will happen. I will do my
part to educate my referring doctors and
my patients. I am hopeful I can maintain a
high standard of care of the specialty that
I love.

What are your top tips for
maintaining a successful
practice?
The best advice I can give for maintaining a
successful practice is listen to your patients.
Treat them with genuine care. Make sure
you communicate with your referring
doctors and colleagues. Be involved in the
community. Educate general dentists and
your patients. Always stay ahead of the
curve.

What are your hobbies, and what
do you do in your spare time?
My favorite thing to do besides spending
time with my family and performing
endodontic treatment is playing bridge.
Whether it is social bridge or tournamentstyle bridge, I forget about the rest of the
world when I am playing it. One day, I
would like to travel the world, and play at
national and international tournaments.
I also like to watch sporting events
especially live. Every chance I get, I take
my kids, five nephews, and two nieces
to professional basketball, baseball,
and hockey games. I want to one day
attend the French Open, Wimbledon, the
Australian Open, and the U.S. Open tennis
tournaments in the same year! EP

TOP FAVORITES
My wife Lilit, and my children, Galia, Sérge and
Noah
Reading the Bible
Playing bridge
Having a successful outcome on teeth that
would have been deemed not treatable by other
clinicians
TDO Clinical Forum
The Surgical Operating Microscope, without
which I don’t think I could practice endodontics
Traveling

Cars
Learning
Teaching
To contact Dr. Odabashian, email


Volume 6 Number 3


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B
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Ultrasonic Irrigator
• Distributes and ultrasonically activates sodium
hypochlorite to increase debridement of lateral
canals and isthmuses
• Ratcheting syringe permits controlled delivery
of 0.2 ml of solution with each audible click
Benefits of Continuous Ultrasonic Irrigation:
• Removes significantly more debris from narrow
isthmuses better than conventional needle irrigation*
• Significantly increases the penetration of
irrigation solutions into lateral canals**
*Adcock et al, J.Endod. 2011; 37 (4) **Castelo-Baz et al, J. Endod. 2012; 38 (5)

235 Ascot Parkway | Cuyahoga Falls, OH 44223
Tel. USA & Canada 800.221.3046 | 330.916.8800 | coltene.com
PATENT PENDING


CORPORATE PROFILE

History of Ultradent
Dr. Dan E. Fischer is the founder and
president of Ultradent Products, Inc.,
a dental manufacturer with a 35-year
history of innovation and quality. Now an
international leader in the dental industry,
Ultradent began humbly — in Dr. Fischer’s

basement with his children as its first
employees.

Following graduation from Loma Linda
University in 1974 and starting his own
dental practice, Dr. Fischer realized that
rapid, profound hemostasis was imperative
for quality tissue management and
operative dentistry. Because there were
no products on the market that predictably
controlled bleeding and sulcular fluid, he
decided to develop one. Using his naturalborn insight, determination, and willingness
to work after hours, Dr. Fischer began
experimenting with different chemistries,
even drawing his own blood to test their
hemostatic effects. Within a short time,
Dr. Fischer came up with what are now
Ultradent’s flagship tissue management
products,
Astringedent®,
and
later
®
ViscoStat .

Business grew rapidly, and over the
next 35 years, Ultradent expanded from
a home operation to a 220,000-squarefoot facility, which presently houses
more than 1,000 employees. Ultradent
is the most vertically integrated dental

company in the world — manufacturing
over 90% of its products (which includes
over 500 materials, devices, and
instruments) at its South Jordan,
Utah, headquarters. Ultradent prides
itself on its technologically advanced
way of doing things. In fact, with
the exception of the auto industry,
Ultradent uses more robotics than
any other company west of the Mississippi.
Instead of saving on production
costs through outsourcing, which many
U.S. manufacturers do, Dr. Fischer firmly
believes in the opposite. He says, “The
more one outsources, the more one ships
production, or R&D, or other aspects to
other parts of the world, the more one
loses touch with what has made them who
they are.”
Ultradent continues to lead the way
through invention and innovation. The
company holds numerous U.S. patents
(both granted and pending) and continues
to expand internationally into many parts
10 Endodontic practice

of Europe, Asia, and South America.
Beyond its humble beginnings in tissue
management products, Ultradent’s product
family now includes world-class adhesives,

composites, tooth whitening systems,
and more. Ultradent has also expanded
its reach to orthodontics, serving as the
parent company of Opal Orthodontics. Its
South Jordan headquarters even boasts
an onsite orthodontic clinic.
Although Ultradent strives to offer
the latest and greatest in technology, Dr.
Fischer’s passion for a minimally invasive
approach to dentistry has and will continue
to guide the development of every new
product created in the future.

Ultradent Endodontics
Like the story behind the conception of
Astringedent,
Ultradent’s
endodontic
solutions were born out of necessity. Dr.
Fischer noticed a need for a successful
endodontic protocol that could be done
with the minimally invasive criteria he
is so passionate about. The result was
Endo-Eze® AET™ (Anatomic Endodontic
Technology) classic stainless steel files,
which utilize a reciprocating motion.
These uniquely designed files proved very
effective in following the natural canal
shape and minimizing apical transportation
and ledging. This new approach paved the

way to the array of endodontic products
Ultradent offers the clinician today.


Building on the success of the EndoEze AET classic stainless steel files,
Ultradent developed the world’s first
hydrophilic and self-priming resin sealer,
EndoREZ® canal sealer. When paired with
the NaviTip® — with its flexible, stainless
steel cannula, designed to easily navigate
curved canals — EndoREZ canal sealer
offers easier obturation in less time, has the
same radiopacity as the gutta percha, and
consistently delivers a complete, thorough
seal. It’s also worth noting that the NaviTip
was the first tip on the market capable of
safely delivering irrigants to the apex.


Building on the success of the AET
files, Ultradent created the Endo-Eze®
AET™ TiLOS® system — a hybrid of
stainless steel and NiTi files optimized for
the company’s 30-degree reciprocating
handpiece, Endo-Eze® Arios®. The awardwinning TiLOS system features a userfriendly, straightforward instrumentation
sequence, and comes in autoclavable,
preconfigured packs. The RediPack offers
tools to address each canal according to
its unique anatomy and is equipped to treat
90% of endodontic cases. TiLOS’ ribbonshaped, ovoid handles also provide more

comfort and ease of grip to the clinician
than ever before. The Endo-Eze Arios’
reciprocating motion facilitates rapid,
complete, uniform instrumentation of all
the walls in an irregularly shaped canal,
while preserving more tooth structure
than traditional rotary systems. The
pairing of Arios with the TiLOS files thus
accomplishes a “milling” action, instead of
a “drilling” action, while also eliminating file
breakage.
Ultradent’s vision to “Improve Oral
Health Globally” through minimally invasive
dentistry and to design products as an

answer to the call of clinicians worldwide
continues to shape the success of the
company in this, its 35th year in the industry.
To learn more about the endodontic
products mentioned or the wide array of
additional endodontic solutions provided
by Ultradent, please visit ultradent.com, or
call 800-552-5512. EP
This information was provided by Ultradent
Products, Inc.
Volume 6 Number 3


J. Morita
Veraviewepocs® 3De

KODAK 9000 3D Extraoral
Imaging System

TDO IS CONE-BEAM
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Turns out there’s a correlation between quality of care and quality of life. TDO software is now
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patients alike couldn’t be more pleased. For patients, TDO CBCT means being able to review
scans chairside in the comfort of your office. For you, it means scans are saved to each patient’s
chart, and a comprehensive TDO CBCT report is generated within just three minutes—a function
no other software provides. Find out how TDO can save you time, money, and most importantly,
headaches. Switch to the only endodontic software that is truly CBCT integrated—TDO.
“With TDO’s CBCT integration, all of my volumes are acquired and saved within
each patient’s chart, so they can be pulled up effortlessly without searching. I
am able to review these volumes with my patients chair-side immediately after
acquisition. I could not imagine using CBCT imaging without TDO integration. It
saves a tremendous amount of time.”
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CLINICAL

Endodontics in 3D
In the second in a clinical series, Dr. Richard Kahan discusses targeted endodontics

T

his series of case discussions highlights
the use of cone beam computed
tomography (CBCT) in clinical endodontics,
and how it is used to enhance diagnosis,
decision-making, treatment planning, and
the treatment itself.
In the first article in the series, which
appeared in Endodontic Practice US,
September/October 2012, Volume 5, No.
5, I explained the reason why periapical
and periradicular lesions might not show
on conventional 2D radiographs. This
would explain the relatively poor scores of
55-77% for sensitivity in diagnosing such
lesions (Bohay, et al., 2000; Estrela, et al.,
2008). The accuracy of CBCT elevating
sensitivity to 91% in one study (de PaulaSilva, et al., 2009) means that as well as
providing the ability to detect disease
and find “hidden lesions,” it can be used
accurately to confirm the lack of disease.

This is particularly useful in endodontic

retreatment cases showing signs of failure.
In many cases, the endodontic treatment
objectives
have
been
satisfactorily
achieved in all but missed anatomy, with
a lesion only associated with an untreated
canal. In a situation where presence or lack
of disease cannot be absolutely confirmed,
it would be necessary to retreat the entire
canal system. With CBCT, a lesion can be
accurately traced to its source, possibly
a single root of a multi-rooted tooth;
therefore, sometimes treatment can be
targeted at the diseased root leaving the
other canals intact.

This principle of Targeted Endodontics
has benefits in time, cost to the patient,
simplicity, and reducing the chances of

Richard Kahan, BDS, MSc (Lond), LDS RCS
(Eng), is a specialist endodontist working
in Harley Street, London, and the former
Director of Endodontic Courses at UCL
Eastman CPD. He has lectured widely on endodontics
and technology and has recently set up the Academy
of Advanced Endodontics to teach the fundamentals
of endodontics to GDPs through extended mentoring

within his practice. With 5 years’ experience of
endodontic CBCT using the Morita Veraviewepochs
3D, his clinic has become a referral center for complex
cases used by both endodontists and GDPs. For more
information visit www.endodontics.co.uk.

12 Endodontic practice

Figure 1: Preoperative periapical radiograph. Distal
radiolucency associated with the LL4. Mesial radiolucency
at LL6

Figure 2: CBCT saggital slice – confirming
distal positioning of the periapical lesion at
LL4. The mental foramen is below the LL5.
The periapical lesion at the LL6 relates to
recent treatment

iatrogenic damage to sound roots during
retreatment for no benefit.

scan confirmed the presence of a small
lesion at the distal part of the root apex of
the LL4 (Figure 2). The coronal slice (Figure
3) confirms the periodontal ligament space
beneath the root filling is intact. The axial
slice (Figures 4A and 4B) reveals the source
of the lesion to be a separate untreated
distolingual canal. Vertucci (1978) quotes a
frequency of 74% for two separate canals

in a lower first premolar.
Importantly in this case, although
deficient in terms of a gap between the
post and apical extent of the root filling,
there were no signs of apical pathology
associated with the filled mesial canal
(Figure 3).

The position of the mental foramen,
which is an important consideration
in surgical planning, was found to be
inconsequential (Figure 2).

Clinical details
The patient was a 57-year-old male with
no relevant medical history, complaining of
mild pain associated with his post-crowned
and root-filled LL4. The tooth had been
treated and restored many years previously
and had an unblemished history until this
point. The porcelain-bonded crown was
esthetically and functionally satisfactory
with a good marginal seal. Clinically, there
was some minor tenderness to percussion
from both an occlusal and buccal direction
without any tenderness to palpation. The
surrounding periodontal condition was
satisfactory and soft tissues healthy.
The periapical radiograph (Figure 1)
revealed a post-crown restoration with

an associated root filling just sealing the
apical 3 mm of the root. The post was
relatively wide with a post-crown ratio of
2:1. Beyond the post and down to the
root filling was a void of approximately
4-5 mm. Both the post and the root filling
were asymmetrically positioned in the
root, suggesting some form of anatomical
deviation in the distal segment of the root.
A small apical lesion was associated with
distal part of the root apex.
Also noted was a satisfactory root
filling in the LL5. A periapical lesion was
present at the mesial root of the LL6 that
had been recently root treated. Both the
LL5 and LL6 were found to be clinically
asymptomatic.
The limited volume 4 cm x 4 cm CBCT

Treatment considerations
If we take the perspective given to us
by the periapical radiograph alone, the
best treatment option here is limited to
the removal of the crown, post removal,
retreatment of the existing root-filled canal
(due to the gap and possibility of apical
pathology), along with a search for any
further canal(s) in the distal root segment.
This would entail significant time and
expense in deconstruction, temporization,

and an eventual new post-crown, as well
as the risk of root fracture on post removal
and weakening tooth structure hunting for
further canal anatomy.
The surgical option runs the risk of
mental nerve damage and leaving large
Volume 6 Number 3


CLINICAL

Figure 3: CBCT coronal slice - The
periodontal ligament space below the
root filled canal is intact and healthy

Figures 4A and 4B: CBCT axial slices – The cross-sectional shape of the root of
the LL4 is a figure eight with an untreated canal in a distolingual position

Figure 6: Successful location of the distolingual
canal orifice in the LL4

segments of contaminated canal untreated,
with only the apical retro seals blocking
these off from the periapical tissues. Once
these inevitably leak, the lesion will return.

With the view that CBCT confers, the
fact that the unsatisfactory-looking root
filling can be confirmed as not contributing
to the pathological process liberates us

from the necessity to involve the mesial
canal and its post in the treatment plan.
Treatment can be targeted precisely at
the cause of the pathology, which is an
untreated distal canal. This allows us a
faster, safer, and cheaper plan, guided by
axial CBCT slices acting as a positioning
system, to locate and treat the distal canal
only.

Treatment
Although faster and potentially safer,
the treatment process was not without
technical difficulty as lining up a cavity
through a crown and cast core is fraught
with possibilities of missing the distal canal
orifice and perforating the root.

The safest means of guiding a bore
hole through the crown to the distal canal
orifice would be using a drilling jig built
on a 3D printed model of the tooth, in a
similar way to guided implant placement.
However, this was not feasible as it was
impossible to produce the accurate
stereolithographic files necessary for a 3D
printing with the metallic artifact and beam
Volume 6 Number 3

Figure 7: Check periapical confirming location

and negotiation of untreated distolingual canal in
the LL4

hardening around the post-crown.

In practice, I use a “Heads-Up display”
(HUD) means of working (Figure 5), with
positioning in the tooth constantly being
checked against landmarks on enlarged
scan slices. Through this technique, I was
able to successfully drill down to the distal
canal orifice (Figure 6) and check that I had
correctly entered the root canal (Figure 7).

Endodontic
treatment
was
completed in a single session following
chemomechanical
preparation
using
Hedstrom files and a hybrid ProTaper
(Dentsply) and GT® hand file protocol
(Dentsply Tulsa Dental Specialties),
together with heated sodium hypochlorite
and EDTA irrigation. Gutta percha and
Roth’s sealer cement obturation was
carried out using System B™ (SybronEndo)
vertical heat condensation with a Calamus®
backfill. The orifice was countersunk with a

Gates-Glidden No. 5 bur, and a permanent
amalgam alloy post core was placed
through the access cavity (Figures 8 and
9).

Follow-up
The patient was checked the next day,
and no ill effects were reported. One
week later, he reported that the area was
comfortable, and that the dull ache in the
lower left quadrant had resolved. A further
appointment for a review radiograph was
scheduled for 6 months.

Figure 5: Super-large clinical Heads-Up Display
(HUD)

Figure 8: View of the coronal gutta
percha in the distolingual canal of
the LL4

Figure 9: Postoperative periapical radiograph

Summary
An elegant and simple endodontic treatment
plan can sometimes become accessible if
accurate diagnostic information is made
available. In this case, CBCT was used
to target the pathology and allow us to
ignore an expensive and potentially risky

alternative that would have no impact on
the disease process. EP

References
Vertucci F J. Root canal morphology of mandibular
premolars. J Am Dent Assoc. 1978;97(1):47-50.
Bohay R N. The sensitivity, specificity, and reliability
of radiographic periapical diagnosis of posterior
teeth. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2000;89(5):639-642.
Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo
JR. Accuracy of cone beam computed tomography
and panoramic and periapical radiography
for detection of apical periodontitis. J Endod.
2008;34(3):273-279.
de Paula-Silva FW, Wu MK, Leonardo MR, da
Silva LA, Wesselink PR. Accuracy of periapical
radiography and cone-beam computed tomography
scans in diagnosing apical periodontitis using
histopathological findings as a gold standard. J
Endod. 2009;35(7):1009-1012.

Endodontic practice 13


CLINICAL
Effects of smear layer and debris removal with irrigation assisted by
the EndoActivator and the Endo Brush: A comparison with unassisted
standard syringe irrigation with 5.25% NaOCl and 17% EDTA
Drs. Joseph M. Morelli, Mark Sakamaki, Ricardo Caicedo, and Stephen J. Clark compare debris and smear

layer removal from instrumented root canals after irrigation
Abstract
Cutting of dentin during root canal
therapy produces a debris layer that
coats the dentin. This has been termed
“smear layer.” The purpose of this study
was to compare smear layer or debris
removal from instrumented root canals
using assisted and unassisted irrigation
methods. Eighty single canal teeth were
decoronated and hand instrumented to
a No. 20 K-file. Instrumentation was then
completed with .04 rotary K3 (SybronEndo)
files to a Master Apical File (MAF) of size
No. 40. One ml of 5.25% NaOCl was used
to irrigate canals between file sizes in all
groups. Samples were divided into four
groups. After instrumentation, all canals
were irrigated with 1 ml of 17% EDTA for
1 minute followed by a final rinse of 3 ml
of 5.25% NaOCl. This was accomplished
using a 3cc syringe and Monoject 27
gauge irrigation needle. Group one was
designated the control group. In the three
experimental groups, irrigation was also
assisted with either the Endo Brush®(Roeko)
in standard low-speed handpiece (Group

Joseph Morelli received his DDS degree
from Loyola University and his Endodontic

certificate from Tufts University. He is currently
an Associate Professor of Endodontics at the
University of Louisville and a Diplomate of
American Board of Endodontics.
Mark Sakamaki received his DDS degree
from the University of Colorado and his
Endodontic certificate from the University of
Louisville in 2008. He is currently in private
practice in Floyds Knobs, Indiana.
Ricardo Caicedo received his Dr Odont
degree from the Colegio Odontologico
Colombiana in Bogota, Colombia and his
endodontic certificate from the University
of Louisville. He is currently an Associate
Professor of Endodontics at the University of
Louisville.
Stephen Clark received his DMD degree and
endodontic certificate from the University
of Kentucky and is currently a Professor of
Endodontics at the University of Louisville.
He is a Diplomate of the American Board of
Endodontics.

14 Endodontic practice

Figure 1: SEM of dentin at 500X wth smear layer (left) and SEM of dentin at 500X after smear layer
removal showing less debris and patent dentin tubules

2), the EndoActivator® (Group 3) [Dentsply
Tulsa Dental Specialties], or the Endo

Brush® in Sonicare® toothbrush (Group 4).
Samples were scored for remaining debris
using digital photography and Adobe®
Photoshop® software. These samples
were submitted for statistical analysis. Four
samples from each group were randomly
selected and submitted for SEM analysis.
The EndoActivator group was found to be
somewhat more efficient, but there was no
statistical significance between the groups
when comparing debris or quantity of
smear layer removal.

Introduction
The smear layer has been a subject of
interest to investigators since the 1970s
(Figure 1). There is lack of agreement to the
significance of the smear layer and whether
it should be removed. There is further lack
of agreement regarding the significance of
smear layer on instrumentation, obturation,
and clinical outcome. Conflicting results
have been obtained in numerous in vitro
studies. Orstavik and Haapasalo1 showed
in an in vitro study that removal of smear
layer with resultant patent dentinal tubules
decreased time necessary for disinfection
of the dentin with intracanal medicaments.
Other studies have shown better adhesion
of obturation materials to canal walls after

smear layer removal.2,3 Other studies have
shown no effect of smear layer removal on
microleakage of root canals with various

sealers and obturation techniques.4-7
Timpawat, et al.,8 showed conflicting
results. This study reported that removal
of the smear layer has adverse effects
on microleakage of filled root canals.
Despite conflicting studies, Torabinejad
in a review article,9 states that “One may
deem it prudent to remove the initially
created smear layer in infected root canals
and to allow penetration of intracanal
medicaments into the dentinal tubules of
these teeth.”

Various methods have been used to
remove smear layer. McComb and Smith
were the first investigators that showed
REDTA (a commercially available solution
of EDTA) can remove smear layer.10 Goldman reported that REDTA alone removes
the inorganic layer but does not remove
the organic constituent.11 In later studies,
Goldman, et al., as well as Yamada, et al.,
and Baumgartner and Mader showed that
alternating the use of EDTA and NaOCI is
an effective method of removing the smear
layer.12-14 Other studies have tested various
mixtures and concentrations of chemicals

and application times.16-17 Products continue to come to the market claiming the
ability to enhance smear layer removal. The
Endo Brush (Figures 2 and 3) has been developed to mechanically assist the cleaning of the smear layer within the root canal. It is a synthetic brush thin enough to
fit into a root canal and can be attached
to the handle of a Sonicare toothbrush or
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Figure 2: Roeko Endo Brush as supplied from
manufacturer

MADE IN THE U.S.A.

Figure 3: Roeko Endo Brush in prototype
handpiece

standard low-speed handpiece. When activated, the brush rotates within the canal
during irrigation. The EndoActivator (Figure
4) uses a flexible, noncutting polymer tip attached to a special handpiece that vibrates
the tip up to 10,000 cpm, thus agitating the
irrigation solution. Manufacturers of both

of these products claim enhanced smear
layer removal. Solaiman, et al.,18 compared
a brush covered needle (NaviTip® FX®, Ultradent) to irrigation with a standard needle without the brush cover. They found
cleaner coronal thirds of instrumented root
canals compared to the control group, but
no significant differences for the middle
and apical third of the canals. Uroz-Torres,
et al.,19 evaluated the EndoActivator system in removing smear layer after rotary
instrumentation, with and without a final
flush of 17% EDTA in the coronal, middle,
and apical thirds of canals. They found no
significant differences. The purpose of the
present study was to compare debris and
smear layer removal from instrumented
root canals after irrigation with 5.25% NaOCI and 17% EDTA, either unassisted or
assisted by the Endo Brush in a standard
low-speed handpiece, Endo Brush in the
Sonicare toothbrush, or with the EndoActivator.
Methods and Materials: This study
followed the method previously used by
Crumpton, et al.20 Eighty single canal
anterior and premolar human teeth were
stored in 1:10 dilution of 5.25% NaOCI.
Volume 6 Number 3

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Teeth were decoronated, and the root
length standardized at 15 mm. Working
length was established with a No. 10
K-file placed in the canal until just visible
at the apex and 1 mm subtracted from this
length. All teeth were hand instrumented
to a size 20 K-file, then instrumented to
working length with rotary instrumentation
using K3 0.04 taper files in a crown-down
technique to a MAF size No. 40. One ml
of 5.25% NaOCI was used to irrigate each
canal between files.
The samples were then divided into
four groups of 20 teeth:
Group 1: (control) Samples were irrigated
with 1 ml of 17% EDTA for 1 minute
followed by a final rinse of 3 ml of 5.25%
NaOCI.
Group 2: Samples were irrigated with 1 ml
of 17% EDTA with mechanical assistance
by the Endo Brush in a standard slowspeed handpiece for 1 minute followed by
a final rinse of 3 ml of 5.25% NaOCI. When
used, the Endo Brush was placed into the

canal to within 2 mm of the working length
and activated. A pumping motion was
used to move the Endo Brush in 2-3 mm
vertical strokes for 60 seconds.
Group 3: Samples were irrigated with 1 ml

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of 17% EDTA with mechanical assistance
by the EndoActivator for 1 minute followed
by a final rinse of 3 ml of 5.25% NaOCI.
When used, the EndoActivator was placed
into the canal to within 2 mm of the
working length, and run at 10,000 cpm.
A pumping motion was used to move the
EndoActivator in 2-3 mm vertical strokes
for 60 seconds.
Group 4: Samples were irrigated with 1 ml
of 17% EDTA with mechanical assistance
by the Endo Brush in a Sonicare electric
toothbrush followed by a final rinse of 3
ml of 5.25% NaOCI. When used, the Endo
Brush was placed into the canal to within
2 mm of the working length and activated.
A pumping motion was used to move the
Endo Brush in 2-3 mm vertical strokes for
60 seconds.

Teeth were longitudinally grooved with
a diamond disk and split buccolingually. A

digital photograph was taken of the split
tooth using a Canon EOS 10D camera
with Canon Macrolens EF 100mm.
Magnification Ration: 1:1. (Figures 5 and
6). This image was imported into Adobe
Photoshop 7.0 and magnified X10 using
the zoom tool. Canal area and debris
were outlined using the Lasso tool. The
Endodontic practice 15


CLINICAL

Figure 4: The EndoActivator, Advanced Endodontics

e

Figures 5-6: Canon EOS 10D camera and set up to photograph
tooth specimens

Type III Sum of Squares

df

Mean Square

Hypothesis

.434

1

.434

Error

.090

2.009

.045

Hypothesis

.037

3

.012

Error

.154

6.066

.025

Hypothesis

.090

2

.045

Error

.153

6.041

.025

Hypothesis

.152

6

.025

Error

3.852

196

.020

F

Partial Eta
Squared

Sig.

9.713

.089

.829

.482

.707

.192

1.766

.249

.369

1.293

.262

.038

Intercept

Group

Evaluator

Group * Evaluator

Figure 7: Means Plot of different group means of percent debris

histogram function was used to calculate
the percentage of debris remaining in the
coronal, middle, and apical thirds.

Four samples from each group were
randomly selected and prepared for SEM
analysis. A representative sample from
the coronal, middle, and apical thirds of
each root was examined. Smear layer
was scored according to criteria used by
Torabinejad, et al.21 The three evaluators
were two full-time endodontic faculty and
one endodontic resident.

Results
A Linear Univariate Analysis was done to
test for a significant difference in means
among the four test groups and among
the three evaluators (Figure 7). There

was no significant difference among all
groups interacted with all the evaluators.
Because of the small sample size for the
photomicrographs, no statistical analysis
was performed. The evaluators’ scoring
indicated a similar number of clean canals
in the coronal and middle sections for all
16 Endodontic practice

test groups. With all techniques, clean or
moderately clean canals were seen in the
coronal and middle third of the specimens.
High levels of debris were seen in the apical
thirds in all groups. Scores of 3 (high level of
debris) were most common in apical third
specimens for all groups. Representative
photomicrographs are shown in Figure 9.

Discussion
This study compared smear layer and
debris removal from instrumented root
canals using assisted and unassisted
irrigation methods. Although there was no
statistical significance, the EndoActivator
tended to produce cleaner canals (Figure
8). Perhaps with a larger sample size,
there would have been some significance.
Evaluation of the photomicrographs
indicated that all methods produced similar
results and were capable of rendering

clean or moderately clean canals. All
photomicrographs showed some remaining
debris even in sections judged as clean
with little or none. Unlike the Solaiman

Figure 8

study in which no significant difference was
found between coronal, middle, and apical
thirds, this study found most debris in the
apical third for all methods. This study did
not compare coronal, middle, and apical
segments of the canals. However, all
methods appeared to be more effective
in the coronal and middle segments of the
instrumented canals. A future study could
test for significance at different canal levels.
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C

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D

References

Figures 9A-9D: A. Group 1, apical
third, 1000X. B. Group 2, apical
third, 1000X C. Group 3, apical
third, 750X. D. Group 4, middle
third, 750X

1. Orstavik D, Haapasalo M. Disinfection by endodontic irrigants
and dressings of experimentally infected dentinal tubules.
Endod Dent Traumatol. 1990;6(4):142-149.
2. Tidmarsh BG. Acid-cleansed and resin-sealed root canals. J
Endod. 1978;4(4):117-121.
3. White RR, Goldman M, Lin PS. The influence of the smeared
layer upon dentinal tubule penetration by plastic filling
materials. J Endod. 1984;10(12):558-562.
4. Evans JT, Simon JH. Evaluation of the apical seal produced
by injected thermoplasticized Gutta-percha in the absence of
smear layer and root canal sealer. J Endod. 1986;12(3):101-107.

Conclusions
There was no significant difference among
test groups.
Assisted
irrigation
with
the
EndoActivator appeared to produce the
cleaner instrumented canals although the
differences were not significant. It would
seem that the addition of sonic aggitation
to standard irrigation with syringe does
increase the efficiency of removing debris
and smear layer from instrumented
canals. Further studies are necessary to
find methods of improvng the cleanliness
of instrumented canals at the apical third

level as current methods produce the least
desirable results at this level. EP
Volume 6 Number 3

5. Saunders WP, Saunders EM. Influence of smear layer and
the coronal leakage of Thermafil and laterally condensed
gutta-percha root fillings with a glass ionomer sealer. J Endod.
1994;20(4):155-158.
6. Madison S, Krell KV. Comparison of ethylenediamine
tetraacetic acid and sodium hypochlorite on the apical seal of
endodontically treated teeth. J Endod. 1984;10(10):499-503.
7. Timpawat S, Sripanaratanakul S. Apical sealing ability of
glass ionomer sealer with and without smear layer. J Endod.
1998;24(5):343-345.
8. Timpawat S, Vongsavan N, Messer HH. Effect of removal
of the smear layer on apical microleakage. J Endod.
2001;27(5):351-353.
9. Torabinejad M, Handysides R, Khademi AA, Bakland LK.
Clinical implications of the smear layer in endodontics: a
review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2002;94(6):658-666.
10. McComb D, Smith DC. A preliminary scanning electron
microscopic study of root canals after endodontic procedures.
J Endod. 1975;1(7):238-242.
11. Goldman LB, Goldman M, Kronman JH, Lin PS. The
efficacy of several irrigating solutions for endodontics: a
scanning electron microscopic study. Oral Surg Oral Med Oral
Pathol. 1981;52(2):197-204.

12. Goldman M, Goldman LB, Cavaleri R, Bogis J, Lin PS. The

efficacy of several endodontic irrigating solutions: a scanning
electron microscopic study: Part 2. J Endod. 1982;8(11):487492.
13. Yamada RS, Armas A, Goldman M, Lin PS. A scanning
electron microscopic comparison of a high volume final flush
with several irrigating solutions: Part 3. J Endod. 1983;9(4):137142.
14. Baumgartner JC, Mader CL. A scanning electron
microscopic evaluation of four root canal irrigation regimens. J
Endod. 1987;13(4):147-157.
15. Baker NA, Eleazer PD, Averbach RE, Seltzer S. Scanning
electron microscopic study of the efficacy of various irrigating
solutions. J Endod. 1975;1(4):127-135.
16. Grawehr M, Sener B, Waltimo T, Zehnder M. Interactions of
ethylenediamine tetraacetic acid with sodium hypochlorite in
aqueous solutions. Int Endod J. 2003;36(6):411-415.
17. Teixeira CS, Felippe MC, Felippe WT. The effect of
application time of EDTA and NaOCI on intracanal smear layer
removal: an SEM analysis. Int Endod J. 2005;38(5):285-290.
18. Al-Hadlaq SM, Al-Turaiki SA, Al-Sulami U, Saad AY. Efficacy
of a new brush-covered irrigation needle in removing root
canal debris: a scanning electron microscopic study. J Endod.
2006;32(12):1181-1184.
19. Uroz-Torres D, Gonzalez- Rodriquez MP, Ferrer-Luque
CM. Effectiveness of the EndoActivator System in removing
the smear layer after root canal instrumentation. J Endod.
2010;36(2):308-311.
20. Crumpton BJ, Goodell GG, McClanahan SB. Effects on
smear layer and debris removal with varying volumes of 17%
REDTA after rotary instrumentation. J Endod. 2005;31(7):536538.
21. Torabinejad M, Khademi AA, Babagoli J, Cho Y, Johnson
WB, Bozhilov K, Kim J, Shabahang S. A new solution for the

removal of the smear layer. J Endod. 2003;29(3):170-175.

Endodontic practice 17