explorer Keystone Fall 2023 The Official Publication of the Pennsylvania Academy of General Dentistry Inside... Scratching the Surface PAGD Comes Up Aces in Vegas In Memoriam: Remembering Kurt Endodontics— The Apical Third The Practice Changing Magic 4 6 10 13 9
ii www.pagd.org President (2024) Carl Jenkins, DDS, MAGD Watsontown, PA President-Elect (2024) Amanda Sonntag, DMD, FAGD Wyomissing, PA Vice President (2024) Dale Spadafora, DMD, MAGD Hermitage, PA Immediate Past President (2024) Katherine Dangler, DDS, MAGD Altoona, PA Secretary (2026) Kyle Dumpert, DMD, MAGD Bedford, PA Treasurer (2025) Ann Miller, DDS, MAGD Chambersburg, PA Region 3 Regional Director (2025) Raymond Johnson, DMD, MAGD Warren, PA Region 3 Trustee (2025) Michael Kaner, DMD, MAGD, JD Feasterville-Trevose, PA Editor (2024) Alex Frisbie, DMD, FAGD Mechanicsburg, PA BOARD OF DIRECTORS Joseph Chipriano, DMD, MAGD (2024) Pottsville, PA Melissa DellaCroce Grosh, DDS, FAGD (2025) Lilitz, PA Dejan Golalic, DMD, MAGD (2025) Carlisle, PA David Killian, DMD, MAGD (2025) Carlisle, PA Jay Patel, DMD (2026) Exton, PA Cuong Tran, DMD, MAGD (2026) Allentown, PA PEAK Track I Chair Brad Strober, DMD, MAGD Edison, NJ PEAK Track II Chair John Gustafson, DMD, MAGD Hershey, PA Editor Alex Frisbie, DMD, FAGD Graphic Designer Hiakato Draconas Contributors Brett Cole, DMD Levi Evalt, DDS Alex Frisbie, DMD, FAGD Carl Jenkins, DDS, MAGD Steve Neidlinger, CAE John West, DDS, MSD Keystone Explorer is owned and published quarterly by the Pennsylvania Academy of General Dentistry. The purpose of the journal is to print timely and appropriate material to stimulate, educate, inform, and recognize the general dentists of Pennsylvania in their pursuit of professional excellence. Views expressed in this publication are those of the authors and do not necessarily reflect the opinion of the Academy. Deadlines for material to be printed are: March, June, September, and November. Keystone Explorer reserves the right to edit or reject any article submitted for publication. Subscription is included in the annual dues of PAGD members. Domestic subscriptions are available to non-members at $26 per year. Subscription queries go to the Executive Director, Steve Neidlinger, 4076 Market St, Ste 209, Camp Hill, PA 17011. www.pagd.org © 2023 PAGD. All rights reserved. Pennsylvania Academy of General Dentistry Board of Directors Keystone explorer The Official Publication of the Pennsylvania Academy of General Dentistry
KeystoneExplorer | Fall 2023 1 Endodontics seems to enjoy a cycle of popularity in the history of fixing teeth. Root canal therapy was once a revolutionary alternative to extracting a painful tooth (or at least a way to buy time before extraction). The earliest endodontics simply involved “breaching” a tooth to relieve the pain of pulpitis. Rudimentary root canals were done without X-rays, much less an understanding of pulp biology. New instruments were developed over time to help remove ever more of that painful pulp. Eventually, occasional successes led way to a legitimate treatment option to keep a tooth in service after the pulp had been damaged. The introduction of the X-ray must have been one of the true turning points in endodontics. Finally, there was some type of road map for avoiding the nerve. (When showing a patient an X-ray, I always refer to the pulp as the living part of the tooth rather than the “nerve,” in an attempt to get them to grasp the importance of this tissue.) Hess first showed dramatic anatomy that even a radiograph couldn’t detect, and for the first time we could appreciate that the pulp system was far more complex than just a tube-like canal. I remember the first time I saw slides of these vulcanized teeth I felt hopeless; negotiating, cleaning, and filling this anatomy seemed impossible. Histologically, we never remove one hundred percent of the pulpal system, but modern techniques in instrumentation, irrigation protocol, and imaging have allowed us to advance clinical endodontics to an extremely predictable level. Later, as tooth replacement and especially implants became more sophisticated, endodontics began to be seen as unpredictable, time consuming, and financially inefficient. We’ve all heard comments (or perhaps harbored belief) that endodontics is a “dying specialty.” Endodontics in dental education certainly seems to have taken a backburner to other disciplines. I can see a future where endodontics once again takes the spotlight from implant therapy. Regenerative medicine (and specifically endodontics) has continued to make promising strides in recent decades. Some of these are sensationalized and oversold and admittedly we are decades away from being able to regrow teeth. Nonetheless, our understanding of the pulp and periodontal tissues continues to develop. Regeneration of more complex dental structures could become a key addition to our toolkit. The general dentist continues to play a key role in endodontics and with proper training and case selection this should be an area of service we offer to our patients. The ability to deliver patients from pain never goes out of vogue. from the editor’s desk | The Dying Specialty That Keeps Regenerating Alex Frisbie, DMD, FAGD “I can see a future where endodontics once again takes the spotlight from implant therapy.”
2 www.pagd.org Carl Jenkins, DDS, MAGD PAGD President The primary goal of PAGD is to advance the field of dentistry by promoting excellence and fostering professional relationships through education. Our vision is to create a community of general dentists who constantly strive for more. Personally, I can attest to the impact PAGD has had on my career. Since attending my first PEAK meeting in 1999, I have been part of a group that has not only inspired my growth as a dentist, but also encouraged me to provide a higher standard of care to my patients. While I believe I would still have the same passion for dentistry without PAGD, the relationships I have formed within this organization have made my journey much smoother. Whenever I encounter a question or challenge in my practice, I know exactly who to turn to for guidance and inspiration. Thanks to the encouragement from my PAGD colleagues and the PEAK program, I have been able to offer my patients a range of services that I may not have otherwise pursued. These include neutral zone impressions for complex prosthetic cases, endodontics (including molars), CBCT diagnosis, implant restorations, comprehensive restoration of severe wear, and surgical implant placement. When I received my “license to learn” in 1990, I never anticipated delving into these areas of dentistry. The best part of this continuous learning journey has been the motivation and enjoyment it brings. Although I may not always be the quickest learner or the first to adopt new procedures, witnessing my colleagues present their work at PEAK motivates me to step out of my comfort zone and try new things. The benefits to my patients have been tremendous, and I owe much of my growth and knowledge to the inspiration I have received from all of you. But it’s not just about education and motivation; we have also had a great deal of fun along the way. Over the years, we have built teddy bears for our children, explored museums of medical oddities, participated in trap shooting and axe throwing, and dressed up in outrageous costumes for Halloween (and that’s just in Pennsylvania). In recent years, our adventures have reached new heights with PEAK conferences in the Caribbean. Imagine spending the morning engaged in enriching continuing education sessions, followed by relaxing on a sunny beach at an all-inclusive resort. If you haven’t experienced one of these trips yet, mark your calendar for the weekend before the Super Bowl and join us. This year, we’ll be in Antigua. We also want to take a moment to remember our dear friend and colleague, Kurt Laemmer, who enjoyed these trips with us. We will miss him dearly, especially seeing him in his Hawaiian shirt, diligently taking notes. As we raise our glasses, we will toast to his memory and express our gratitude for the inspiration he provided throughout the years. May your journey be peaceful, my friend. License to Learn Carl Jenkins, DDS, MAGD “The best part of this continuous learning journey has been the motivation and enjoyment it brings.” | president’s message Drs. Carl Jenkins and Kurt Laemmer
KeystoneExplorer | Fall 2023 3 executive director’s message | The Value of PEAK Steve Neidlinger, CAE Longtime PAGD leader and willing volunteer Dr. Kurt Laemmer died in July 2023 (more on Kurt in a later article). And while PAGD and its leadership have taken the opportunity to celebrate and mourn Kurt, the practical concern of his dental office and the community he serves was also present. Who will follow up with his patients if treatment had started? How will Kurt’s office staff continue to produce, and therefore get paid? How will this rural and isolated community have access to quality dental care? We often discuss the value of PEAK, the PAGD Mastertrack, in terms of what it can help you achieve. Sharper skills. Less referrals. Fellowship and Mastership. But something much more difficult to quantify is the value of the camaraderie that PEAK generates among its participants. And it is this camaraderie that helped to keep Signature Smile Designs in Bradford and Smethport, PA open and able to see patients. • Dr. Ray Johnson, Kurt’s friend and mentee from nearby Warren, took days and weekends away from his busy practice to complete treatments and triage cases with the dental team. • Dr. Ann Miller from Chambersburg (195 miles away) cancelled a planned sabbatical and utilized a transition in her own practice to make several multiday overnight trips to Bradford to see patients. • Dr. Jim Seitz utilized some of the time freed up due to his semi-retirement and trekked up from Bedford (167 miles away) to fill in a few days during Kurt’s hospital stay. • Dr. Amy Pieri, recent grad from the lauded Pittsburgh VA residency program (181 miles away) and first time PEAK attendee in Philadelphia 2023, paused her new grad transition to see patients in Bradford. • Dr. Fred Lally from Tunkhannock (205 miles away) took time away from his rural practice and made his away across Route 6 to help. • Local friends and colleagues Dr. Brian Volpe, Dr. Holly Mauser, and Dr. Ryan Koch filled in a few days. • Dr. Andrew Stewart from Lebanon (237 miles) had his bags packed to see patients in Bradford when he got the call with the good news in September that a new owner was stepping in. Which could be the best news of all. After coordinating with Kurt’s family, Ray, and several brokers and consultants, when this article was written in early October, it looks like Kurt’s practice will be sold and in good hands. There are still some details to work out, but assuming they do, the practice will stay vital, the team will stay busy, and the community will have an option in dentists. This gets to the true value of PEAK. While the ability to do molar endo or all-on-fours may get to some of the value of PEAK, it’s the friendships that make a difference in each other’s lives. Kurt’s friends in PAGD and PEAK stepped up in a time when he needed them most. And we smile as we remember Kurt and remind ourselves that he was there for us as well. “... something much more difficult to quantify is the value of the camaraderie that PEAK generates among its participants.” Dr. Ray Johnson with the team from Signature Smile Designs Celebrating Dr. Kurt Laemmer
4 www.pagd.org Ow, doc! My tooth you worked on hurts! Who doesn’t love to hear this? As an endodontist, this is part of the picture of pulpal breakdown/disease that we see all the time. My goal is to help you predict tooth pain and prevent the above comment. There are two main components to tooth pain: bacteria and inflammation. Obviously, without bacteria no painful abscesses would happen, but what about inflammation? A researcher out of Italy1 has performed histologic analyses of different stage of pulpal breakdown—reversible pulpitis, irreversible pulpitis, and necrosis—and uncovered some patterns. Now obviously every situation is unique, but general patterns are important for a conceptual understanding. This is what I aim to convey. First of all, inflammation is consistent throughout the body to varying degrees, with signs of redness, swelling, heat, and pain. I want to give an analogy that we can all understand—a scratch. Imagine if you will you bump up against a sharp corner and scratch your skin. The scratch will become red, swollen, hot, and painful and is a sign of inflammation. If the scratch is minor, the skin doesn’t break, bacteria doesn’t get in, and the inflammation can reverse to normal (think reversible pulpitis). If the scratch is severe, the skin breaks, bacteria gets in, and infection can develop. This would be analogous to irreversible inflammation leading to an abscess in a tooth. When a patient develops pain, first think of this as a sign of inflammation. Play the ‘find the inflammation’ game. See By Brett Cole, DMD SCRATCHING THE SURFACE Diagnosing Pain in a Way Patients Can Understand Q dentistry issues
if it can be detected with typical tooth testing. Maybe it’s non-odontogenic or unclear, in which case it may not be possible to locate and either more time or a referral to a physician is appropriate. If a tooth tests ‘different from the others’ or the painful inflammation can be stimulated, ask yourself, what ‘scratched’ this tooth/area and how severe is it? Was it like a scratch that doesn’t break the skin like heavy bite forces from clenching? An occlusal interference from a fresh filling? Is the patient wearing braces and they were just tightened? Does the person have a history of sinus infections causing the molars to be sensitive? Or was the ‘skin broken’ recently and now bacteria is getting in? Examples of this would be like pain after a deep filling, decay under a crown, cracks in the marginal ridges, or leaky old amalgam fillings. If there is nothing close to the chamber but a clear apical lucency, then a dreaded crack is suspected to be the scratch. It isn’t always possible to tell but looking for the usual suspects is a good start. After seeing enough scratches you can begin to see patterns. The nice thing about seeing patterns is the ability to predict these patterns. One of the main instances of this is noticing if anything is close to the pulp. It’s like seeing if the tooth has been ‘scratched’ deeply, by something like decay or the preparation necessary to remove the decay. The benefit of this information is using it to predict the scratch on a tooth with a large chamber on the radiograph. Look at the size of the tooth’s chamber prior to drilling and let the person know if it’s big. Turn the patient from ‘you hurt my tooth when it was fine’ to ‘the doctor told me this was going to happen.’ This is a much better outcome since you tried to help and no one was surprised by the outcome. Pain is not a fun thing to experience or have develop in the mouth. You as the dentist are the first person a patient usually sees and without an understanding of inflammation as the source of pain, it can leave us feeling insecure about diagnosing what’s going on. After playing the ‘find the inflammation’ game enough times however, you may find you are good at figuring things out and can resolve the problem for your patient and be their hero. If not, your local endodontist is happy to help and they will no doubt help you learn as time goes on. I hope this helps and makes pain less challenging to understand. dentistry issues Q KeystoneExplorer | Fall 2023 5 References 1. Correlation between Clinical and Histologic Pulp Diagnoses; Ricucci, Domenico et al.; Journal of Endodontics, Volume 40, Issue 12, 1932–1939
6 www.pagd.org pagd news PAGD COMES UP ACES IN VEGAS
KeystoneExplorer | Fall 2023 7 pagd news In July, twelve PAGD members were recognized for their hard work in pursuing excellence in dentistry at AGD2023. They were honored for achieving their Fellowship, Mastership, and Lifelong Learning and Service Recognition in Las Vegas. PAGD congratulates these members for their accomplishments and for their desire to provide the best possible treatment to the communities in which they serve. ♠ LIFELONG LEARNING AND SERVICE RECOGNITION RECIPIENTS Dr. Kyle Dumpert Dr. Ray Johnson Dr. Michael Kaner
8 www.pagd.org pagd news Dr. Alex Frisbie Dr. Lusai Qiu Dr. Shruti Tewari ♦AGD MASTERS Dr. Eric Ecker Dr. Adam Dai Dr. Bruce Spivak Dr. Stephanie McGann Dr. Amanda Sonntag Dr. Janine Burkhardt ♣AGD FELLOWS
KeystoneExplorer | Fall 2023 9 dentistry issues Q Longtime PAGD leader and friend to dentists everywhere, Dr. Kurt Laemmer of Bradford, passed away on Sunday, July 23, at the Cleveland Clinic as a result of cancer complications. He was 59 years old. Born in 1963 in Franklin, PA, Kurt earned his bachelor’s degree in Chemistry at Westminster College in 1985, followed by his DMD from the University of Pittsburgh School of Dental Medicine in 1990. Dr. Laemmer was an esteemed member of the dental community, serving his patients in Bradford and later Smethport since 1990. His unwavering commitment to learning and growth led him to attain the prestigious levels of Fellowship, Mastership, and the Lifelong Service and Recognition Award in the AGD. These achievements were a testament to his relentless pursuit of excellence and his desire to provide the highest quality of care to his patients. He served as PAGD President and as Regional Director of AGD, showcasing his dedication to advancing the field of dentistry. He volunteered at numerous organizations offering free dental care to the underserved as well as in Honduras and the Dominican Republic. Kurt’s passing leaves a void in the PAGD, but his legacy will continue to live on through the countless lives he touched. His dedication, mentorship, and unwavering commitment to the field of dentistry will serve as a guiding light for future generations of dentists. PAGD joins Kurt’s family, including daughters Kristen and Juliah and longtime partner Nina, in fondly remembering Kurt and the people he helped through dentistry. In Memoriam: REMEMBERING KURT
10 www.pagd.org Q dentistry issues I went through a long phase in my career when I believed a different rotary file was the answer to any of the endodontic problems I had; or maybe it was a rotary technique I hadn’t thought of or hadn’t mastered. I attended almost every new rotary product lecture in search of a better way to find successful results in the least amount of time. We have all become product-dependent to compensate for our insufficiencies. Sealer should not make up for my failure to instrument to the apex. Not long ago in my practice I believed that it was resin sealer and not love that could “cover over a multitude of sins.”1 Resin sealer will only give you a false sense of success and perhaps prevent others from seeing your insufficiencies. And now we have bioactive sealer! That’s like resin sealer with a Superman cape! EDTA is another product we use in endodontics to compensate for our shortcomings. As we plow debris into the apical third with our rotary instruments, we hope that the compaction can be overcome by a stronger concentration of product, and if it doesn’t work, we attest to the patient that the tip of the root must be calcified. Despite the lack of evidence that a higher times and concentrations of EDTA is unnecessary2,3,4 and that calcification happens from the crown down5,6 our ignorance is of the mistake in our technique, not the product. My point is not a material choice issue but rather a herald to maintain a tighter reign on our methods in approaching the apical third. After more than 20 years of doing endodontics in my general practice, some products and techniques have improved my success, but a few principles that guide me now are a bigger determinant of successful outcomes than anything. Any dentist who does endodontic therapy in their practice loves to show their colleagues the beautiful results of their wonderfully-discovered MB2 canal of an upper first molar. Although a missed fourth or even fifth canal is truly a concern for everyone involved, the largest group of failures involves the apical third of the root system.8,9,10,11 According to Siqueira et al, “In most cases, failure of endodontic treatment is a result of microorganisms persisting in the apical portion of the root canal system, even in well- treated teeth.”12 So, to improve our success rates, let’s make some rules about the apical third*: Don’t enlarge the diameter of the apical foramen beyond its original size. Start by determining what the foramen diameter is. In the same way most determine the original working length, you can also notate the original foramen diameter by bringing successively larger K-files until the apex locator registers that the file has exited the tooth. Modern apex locators are accurate in determining the working length only AFTER exiting the tooth and then retracting to the ideal apical constriction7; this is point of achieving patency and in conjunction with determining the maximum apical diameter, is the only time you need to exit the apex. As you increase the K-file size, when you encounter a file that cannot get out of the tooth, then you have the foramen (apical constriction) diameter. Assume that the previous file diameter is the apical diameter, not the file that cannot go through it. After determining the foramen diameter, in my opinion you should no longer exit the tooth. Other schools of thought suggest that you should continue to recapitulate after each successive rotary file, therefore “maintaining” patency throughout the procedure. Achieving patency and maintaining patency are two different things. Researchers and clinicians debate whether maintaining patency throughout the procedure By Levi Evalt, DDS Endodontics— The Apical Third
KeystoneExplorer | Fall 2023 11 dentistry issues Q is associated with post-operative pain13,14. I would argue that continually recapitulating into the foramen is a sure way to increase the foramen diameter and to introduce smear layer debris into the periodontal ligament. After establishing the working length, it is imperative rotary instruments do not go beyond the working length and therefore violate the apex. 1. Establish an obturator size at least 2 sizes (0.10”) larger than the foramen diameter. This seems intuitive but I have attended a few courses that advocate the final size of the gutta percha is the size of the first file to achieve an apical seal. Just because you plug the end, doesn’t mean you have an apical seal. 2. Treat the apical third differently. Always establish the lower glide path after establishing the working length. The glide path is a smoother shape to the apex than the original anatomical tortuous and narrow route. It is necessary in the beginning of accessing the canals to extirpate the pulp in the coronal portion of the canals in order to achieve hemostasis and be able to investigate for additional canals, but the mistake I often make is in getting overzealous about using rotary files to get to the finished product faster. The initial opening of the coronal portion of the canal with rotary instruments and correcting for better access angulation is part of creating the glide path but the final shaping of the apical third of the glide path is different from preparing the coronal glide path. Introducing rotary files into the apical third of the root system too early is a prescription for a variety of failures such as separated files, smear layer compaction into lateral canals or isthmuses, and transporting the apex to name a few and are beyond the scope of this discussion. If you treat the apical third differently, it will reward you. If there are two things I want to prevent in my endodontic therapy, they are: Don’t use rotary instruments beyond the apex, and don’t compact the apical third of the root with debris. The following method will help with both goals: METHOD After you establish the apical diameter, you can determine the final working length by subtracting a millimeter (or more) and you can determine the final diameter by adding two sizes. For example, if I bring a #10 file to a length of 21.5mm, and then a #15 goes to length, but a #20 does not go to length, then I will measure the #15 file at the length it exits the tooth then subtract a millimeter. My final rotary file will likely be a #25 file at 20.5mm, but I need to do a little more work before that goes to length. First, I make sure my #20 hand file will go to 20.5mm and that it measures to an ideal electronic reading (“doctors choice” according to my J.Morita RootZX). If my #20 file suddenly goes out the apex, then I will assume that my final file will now be a #30 and I will subtract another half millimeter. If I struggle to get my #20 file to the 20.5mm then I can assume the final diameter rotary instrument will be a #20. Once I establish what I determine to be the final rotary choice, then I can establish the apical portion of the glide path. (If we are going to keep with the flight terminology, *Footnote… Semantics: Regarding apical limit, foramen, [radiographic] apex, and working length, there is a great article by Stephane Simon et al that describes the use of electronic “apex” locators in defining these terms in endodontic therapy. For sake of brevity in this article, I would defer to the definitions and descriptions of these terms in that article. I will try to remain consistent in my terminology. To be clear though, ALL “apex” locators are foramen locators. They do not determine the radiographic nor anatomical apex. #21 previous endodontic treatment... is this failed endodontic treatment a result of overfill, underfill, overreliance on sealer, incomplete instrumentation of the canal walls, hyperocclusion, poor apical seal, C-shaped canal, coronal microleakage, or just ‘idiopathic’ apical root resorption?
12 www.pagd.org Q dentistry issues let’s call this the “landing zone” so we don’t confuse this with the coronal portion of establishing the glide path.) The landing zone is the final part of the root canal preparation and is where most of the problems arise if you haven’t done everything properly up to this point. For example, if you haven’t established a working length, you will either compact debris into the apex, or you will go out the end. If you don’t establish a larger diameter final obturator then you will be relying on sealer to fill in the voids at the terminus. Only after you’ve instrumented to the apical terminus (and not out) should you feel confident in beginning the obturation. By obturation, I also mean flushing the canal with EDTA and then NaOCl. EDTA is a mild acid that chelates calcium and other metals and is designed to dissolve the smear layer and open up access to the lateral canals, isthmuses that you were unable to instrument into, and the plug at the end. One minute of EDTA is all that is required, and the concentration doesn’t matter, so the lowest concentration is therefore the choice. After the inorganic components are dissolved, there are still organic components including bacteria that require dissolution. A side-port syringe to introduce it is best to ensure there is no forceful extrusion beyond the apex. Agitation with an ultrasonic as well as heating NaOCl have been shown to increase the bacteriocidal effects over 100 fold. I personally fear pushing it out the apex so I hand instrument to within 2mm of the apex using my working length and then allow it to set five minutes. Afterward thorough drying with paper points, application of sealer, and placement of the gutta percha are the final steps. I hope these methods and concepts help you improve the endodontic success of your practice. I welcome comments and suggestions that have helped you in your practice as well. References 1. I Peter 4:8 Amplified Bible 2. Sen, Bilge Hakan & Ertürk, Ozlem & Pişkin, Beyser. (2009). The effect of different concentrations of EDTA on instrumented root canal walls. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 108. 622-7. 10.1016/j.tripleo.2009.04.042. 3. Calt S, Serper A. Time-dependent effects of EDTA on dentin structures. J Endod. 2002 Jan;28(1):17-9. doi: 10.1097/00004770-200201000-00004. PMID: 11806642. 4. Teixeira CS, Felippe MC, Felippe WT. The effect of application time of EDTA and NaOCl on intracanal smear layer removal: an SEM analysis. Int Endod J. 2005 May;38(5):285-90. doi: 10.1111/j.1365-2591.2005.00930.x. PMID: 15876291. 5. Mahajan, Pardeep, Prashant Monga, Nikhil Bahunguna, and Nitika Bajaj. “Principles of Management of Calcified Canals.” Indian Journal of Dental Sciences 2 (2010). 6. https://www.dentaljuce.com/endodontics-initial-negotiationof-narrow-and-blocked-canals 7. Simon S, Machtou P, Adams N, Tomson P, Lumley P. Apical limit and working length in endodontics. Dent Update. 2009 Apr;36(3):146-50, 153. doi: 10.12968/denu.2009.36.3.146. PMID: 19480102. 8. Iqbal A. The Factors Responsible for Endodontic Treatment Failure in the Permanent Dentitions of the Patients Reported to the College of Dentistry, the University of Aljouf, Kingdom of Saudi Arabia. J Clin Diagn Res. 2016 May;10(5):ZC146-8. doi: 10.7860/JCDR/2016/14272.7884. Epub 2016 May 1. PMID: 27437351; PMCID: PMC4948527. 9. Tabassum S, Khan FR. Failure of endodontic treatment: The usual suspects. Eur J Dent. 2016 Jan-Mar;10(1):144-147. doi: 10.4103/1305-7456.175682. PMID: 27011754; PMCID: PMC4784145. 10. Mustafa, M; Almuhaiza, M; Alamri, HM; Abdulwahed, A; Alghomlas, ZI1; Alothman, TA2; Alhajri, FF3. Evaluation of the Causes of Failure of Root Canal Treatment among Patients in the City of Al-Kharj, Saudi Arabia. Nigerian Journal of Clinical Practice 24(4):p 621-628, April 2021. | DOI: 10.4103/njcp.njcp_290_20 11. Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J. 2001 Jan;34(1):1-10. doi: 10.1046/j.1365-2591.2001.00396.x. PMID: 11307374. 12. Gillen BM, Looney SW, Gu LS, Loushine BA, Weller RN, Loushine RJ, Pashley DH, Tay FR. Impact of the quality of coronal restoration versus the quality of root canal fillings on success of root canal treatment: a systematic review and meta-analysis. J Endod. 2011 Jul;37(7):895-902. doi: 10.1016/j.joen.2011.04.002. Epub 2011 May 24. PMID: 21689541; PMCID: PMC3815527. 13. Yaylali IE, Kurnaz S, Tunca YM. Maintaining Apical Patency Does Not Increase Postoperative Pain in Molars with Necrotic Pulp and Apical Periodontitis: A Randomized Controlled Trial. J Endod. 2018 Mar;44(3):335-340. doi: 10.1016/j.joen.2017.11.013. Epub 2018 Jan 19. PMID: 29370942. 14. Shubham, S., Nepal, M., Mishra, R. et al. Influence of maintaining apical patency in post-endodontic pain. BMC Oral Health 21, 284 (2021).
KeystoneExplorer | Fall 2023 13 dentistry issues Q The Practice Changing Magic This is an article about the success of the dental patient. The title that was assigned to me first seemed to be directed exclusively to the endodontist’s referring dentists. Again, my assumption could not have been further from the truth. This article is about three domains: Communication, Communication, and Communication. Everyone knows that communication results in better dentistry and better patient outcomes. But do we really communicate? Are we simply too busy or is it that the dentistry we know how to do seems more important than doing the best comprehensive diagnosis and treatment planning for the patient? In my experience, the interdisciplinary collaboration and treatment sequencing is prerequisite to a joyful and satisfying dental career. It is also prerequisite for our patients’ best treatment. And when the dental patient succeeds, the dentist succeeds, the interdisciplinary team succeeds, and the dental practice succeeds, then the practice of dentistry itself succeeds. Simple. “Fortune favors the brave” is the Latin translation of a proverb. To experience the promised “Magic” of this article will require a certain amount of bravery because it will mean becoming comfortable with being uncomfortable. This transformation is true for the dental specialist, in this case the endodontist, the referring restorative dentist, and your patient. A three-way WIN/ WIN/WIN. By Dr. John West, DDS, MSD GENERAL DENTIST ENDODONTIST PATIENT THE INTERDISCIPLINARY REFERRAL Everything Your Endodontist Wants You to Know but Is Afraid To Say “Our Specialists, One Team, Elevated Care” Endodontics
14 www.pagd.org Q dentistry issues This is an article written about someone who will never read it, but whom the article is all about…our patients. Using the interdisciplinary mind, our patients will soon discover that you are not just about a tooth, but that you are about oral health; that you are not just about restoring a cavity, but you are about their well-being; and, finally, that you are not just about the patient’s veneer—you are about embracing them as a person. My thesis, however, is a deeper question of anticipating and preparing for the dentist of the future and the future of dentistry. Like medicine, are dentists going to be further controlled by government, insurance companies, DSO organizations, and lack of group leadership? Are we going to preserve and even grow our boutique careers that truly represent us or is that a fantasy? Will we be truly caring for patients, or will we be caring about speed and the bottom line? When patients get it that we hear them and we see them, they feel safe. Only then can they hear us and hear what is possible for their smile and their oral health. We have all heard that patients don’t care how much we know until they know how much we care. They really do want to look good, feel good, smell good, and appear successful. They know that teeth are essential for this goal. Sometimes, all that a patient needs are trust in you and to give themselves permission that they are worthy of investing in a beautiful smile and healthy mouth. The purpose, therefore, of writing this article is not to point a finger, assess blame, belittle, discredit, or deprecate restorative dentists. It is quite the contrary. Dentists have been able to boast the most successful quality patient- oriented practices and there is no letting down. In fact, shame on endodontists for not creating better relationships with you sooner so that this article would never have even been required or requested. Endodontists, too, need to foster the essential three words for success: Communication, Communication, Communication. Now a word to restorative dentists. I request that you give your endodontist a little grace. We are what I refer to as “one tooth” dentists. In fact, our world is as narrow as it gets in dentistry. We are peering through a microscope at ONE canal in ONE tooth and we DO IT IN THE DARK. We cannot SEE and DO at the same time. We may think we can, but we can’t. This is unique to all of dentistry. We can only see the first millimeters inside a canal and then we make an educated guess about the patient’s root canal system anatomy using pretreatment CBCT 3D imaging, an apex locator, feel, and the wisdom that comes from previously making every possible mistake. We are very much alone, and a feeling of loneliness can overcome every endodontic clinician. For example, a few years ago, there was one group that I was teaching in Vancouver where the clinical assistants take a nap when an endodontic treatment was on the day sheet because it was boring, and they had nothing to do! Solo endodontics for any dentist can be lonely, indeed! It feels sometimes like no one cares but the dentist themself. Meanwhile, your patient assumes you are performing optimally at all times! This article is as much about endodontists as it is about what endodontists want the referring general dentist to know. After this article is published, I invite restorative dentists reading this article to write a sequel titled, “Everything the Referring Dentist Would Like to Tell the Endodontist but Were Afraid to Say.” The backstory of this interdisciplinary subject was born out of a need. The need belonged to Dr. Ralph O’Conner, a 1970’s progressive thinking dentist from Lakewood, WA. He was the founder of the Tacoma Study Club which was the world’s beginning mecca for the transformative and breakthrough operatory delivery systems and workflow including laydown dentistry, four handed dentistry, and the critical, and rarely practiced today, “Patient Interview” scheduled before ever seating the patient in the operatory. Ralph was mentor for our Northwest Network for Dental Excellence in Tacoma, WA. This group is represented by all dental specialties and has impacted global interdisciplinary dentistry in more ways than ANY other single group in the history of dentistry and continues to do so. Individually and collectively, the Study Club members have profoundly enhanced the level of global dentistry. Ralph called specialists “limiteds” because our knowledge, skill, care, and judgment were limited to a narrow scope of dentistry. He was and is still right. Specialists think they know everything, and it is the general dentist’s job, who knows about a lot of dentistry, that he or she is the dental treatment quarterback and all roads leading to comprehensive dentistry must go through the QB. Period. LESSONS LEARNED I surveyed the endodontists of Washington and although the response was minimal (because we are down in that dark canal and are ignoring the rest of the world), I did receive input and together with my want list, we offer TEN LESSONS for all of us to benefit from and to strengthen our tomorrow’s patient treatment outcomes and positive experiences. If restorative dentist and specialist do not
KeystoneExplorer | Fall 2023 15 dentistry issues Q sequence and monitor patient treatment, we become what I call “four-walled dentists.” We go to our four-wall office day in and day out, we do our four-wall dentistry, and then we leave our four walls and go back out into the world. Meanwhile, we have missed a universe of a world right there in the four walls of our office. We cannot do what’s possible for our patient if we cannot see it and we cannot see it, if we cannot know what is possible. Only by opening our walls to the flood of interdisciplinary dentistry can we know how, when, and why the different dental specialties can contribute to comprehensive biologic, esthetic, structural, and functional patient oral health. The intention of this article is to promote honest communication about the relationship of the referring restorative dentist and the endodontist. Listed are ten examples of what your endodontist wants you to know to make us more effective, more efficient, and more valuable in terms of your patient’s return on investment, time, optimum choices, predictability, and their faith that your interdisciplinary team will deliver. Ten Interpersonal AGD General Dentist/Endodontist Lessons 1. MAKE A POWERFUL REFERRAL • Make a compelling referral. A weak referral is telling your patient that you need to see an endodontist and give them two or more names. The patient wants, instead, to hear you say, “I am bringing in my endodontist for this part of your treatment because I want the same high level of care for you as you experience in my restorative practice.” Without this explanation, your patient feels like you are sending them away into an abyss. How do they choose? If you “send” your patient to two different specialists at the same time, such as an endodontist and periodontist, they feel torn apart. They feel loss of control and so should you. Dentists should have two endodontists that you consider competent. Then mix and match the personality of your patient and the endodontist. • Do not refer to an endodontist because they are the closest to your office. Refer to your #1 choice to whom you would refer yourself to. Most patients trust their dentist. They refer friends and call you “my dentist.” You have earned their trust and they do what you recommend for them. On all treatment options, patients ask, “Doc, what would you do if it were you?” Tell them the truth. What WOULD you do? Therein lies the answer for your patient as well. Before you answer your patient, always look in the mirror and tune into radio station WWIDIIWM. “What would I do if it were me?” They will smell it if you tell them your radio station truth. This is what they want and need to hear, and they need to hear it from you! • Tell your patient that regarding the distance to endodontist’s office, reassure your patient that endodontics is often a single visit so that even if there were a distance, it would not be like having to go to the orthodontist many times over multiple years. • Tell the endodontist not only the history of the endodontic tooth, but tell the endodontist about where the patient is in your practice such as new patient, middle of a large treatment plan, maintenance patient, etc. • Tell the endodontist about the patient’s dental IQ and dental value. A huge benefit is to know, for example, if the patient is an energy sucker, time burner, skeptical, asks lots of questions, trusts our judgment, accepting, etc. These patient characteristics are not meant to demean the patient in any way. Rather they are meant to help make a successful referral. For example, if the endodontist were to know in advance that your patient needed everything fully explained every step of the way then the endodontist could easily plan for this and put on their patient “Doubting Thomas” hat. Then the endodontist will plan the time to allow patient questions and answers. The endodontist then listens intently, facing the patient, at the same level as the patient and writing with a pencil and new legal pad. • Ask the patient if they could wave a magic wand or snap their fingers and have everything they wanted different in their teeth, what would it be? When they pause as if finished, end with the question of: What else do you need to know from me to proceed with what you want? Do not appear to be rushed. You have all the time in the world for them. This is where the magic happens: You’re sitting, facing your patient, looking at them, the staff knows not to interrupt. Perhaps for the first time your patient profoundly knows they are not teeth to you, but they are a person who has teeth. • Instead of a big case presentation at the end of the examination or at a case presentation appointment in a week, your patient has started with the most import-
16 www.pagd.org Q dentistry issues ant answer, “This is my new dentist. I trust this doctor.” Starting with your patient’s urgent need, which you must treat right away, you have your patient already telling you exactly what they want. This is where you come in. In Napoleon Hill’s famous book, Think and Grow Rich, he advised six words to create a successful future: “Find a need and fill it.” Your patient just identified their dental wish list. What are you waiting for? Fill them! • Benefit from the endodontist being your least paid motivator. Most dentists do not need more patients. Instead, you need to do more for the patients you already have. In our endodontic practice, we tell every patient what’s possible for their smile and dental health after, of course, attending to their urgent endodontic need. You send one tooth to the endodontist but every patient we see requires anywhere from $500–50K of needed dentistry. Almost every patient we see for endodontic treatment has crooked, dark, chipped teeth, calculus on the lingual of their mandibular anterior teeth, or is missing a tooth or teeth. • Sometimes, all your patient needs is a little permission to take the next step to accept your treatment plan. You just have to say what is possible, the benefit, the time, the investment, and then walk away. Learn to accept whatever is their answer. If they choose short of your treatment plan, no worries, just tell them to tell you when they are ready. In the meantime, let’s maintain your plaque and caries control so everything will be ready to go when you are ready. 2. BRING IN YOUR ENDODONTIST WHEN PROBLEMS ARE SMALL • Do not wait until a problem’s simple solution is too late: Broken file, block, ledge, transportation, perforation, wrong tooth, or wrong diagnosis. This speaks for itself. If you cannot make the diagnosis in short time, you cannot easily find a canal, or you cannot slide down the canal to length in the first time or two then quit. Be smart and bring in your endodontist before the treatment becomes impossible or there is catastrophic blunder that cannot be corrected without advanced treatments. It is hard to make the restorative dentist a hero in these circumstances. Better for us to say to your patient that, “Dr. Restorative Dentist is very smart to bring us in when it is easier to solve this problem. Other dentists often wait until it is too late.” We want your patient to be saying to themselves, “I am with the right dentist in Dr. Restorative.” He or she knows their strengths and limits. “Only by opening our walls to the flood of interdisciplinary dentistry can we know how, when, and why the different dental specialties can contribute to comprehensive biologic, esthetic, structural, and functional patient oral health.”
KeystoneExplorer | Fall 2023 17 dentistry issues Q • Remember your patients want to feel safe, be heard, and know that their well-being is your biggest interest. • “Get the endodontic monkey off your back” and invite the endodontist to carry and solve the monkey on your back problem. Then you can proceed treating your patient that needs six veneers which is a place that you enjoy and can impact the life of patient. 3. HANDLING THE PATIENT THAT WANTS A NEW DENTIST • Often, and now more so than ever before, patients see us, we solve the situation predictably, they have a positive experience, and then they say, “I am looking for a new dentist.” Our job is to find out why and have your permission to share that reason back to you WITHOUT JUDGMENT, OPINION, OR BIAS. Sometimes they report that my dentist just pops in, says a few words, and pops out. The clinical assistant says what I need, and I am supposed to schedule time. My dentist does not ask me what I would like to change in my mouth. The dentist TELLS me. I feel rushed. I see a different dentist every time I go in there. They don’t explain anything and so on. • Meet with your endodontist and welcome feedback. We are just the messenger. Whatever the feedback is, positive or negative, it is better being shared in a oneon-one vs. Yelp! This gives you an opportunity to solve the breakdown because, if it is negative, there may be a trend you want to change and one you may not even be aware of. This feedback circle goes both ways! 4. BEING HONEST ABOUT SPECIAL EQUIPMENT • Your patients often present with the comment, “My dentist says you have special tools.” This is true but that is only a half truth. Our real “special equipment” is advanced 2–3 year specialty training and years of experience. The “special equipment” is SKILL. Don’t water it down. Maybe the treatment is outside your skill level. I could not do a veneer if my life depended on it…not a good one, anyway. • This is not admitting failure, it is celebrating knowing the patient benefits from your team. Patients get this right away. Some dentists think they are sending production out the door. The smart dentists we know have their interdisciplinary team and are, by far, the most successful and satisfied dentists we know. The interdisciplinary team opens all the team’s eyes; especially the restorative dentist who now has interdisciplinary skills at their disposal to free you to focus on what you enjoy and are good at…probably profitably, too. 5. DIAGNOSING THE “CRACKED TOOTH SYNDROME” (CTS) • The illusive “Cracked Tooth Syndrome” exists in anywhere from 10–25% of your practice’s patients right now and is undiagnosed. Diagnosing sooner than later can prevent an endodontic misdiagnosis or prevent an unrestorable vertical fracture. 6. BE GUIDED BY AAE GUIDELINES FOR DIAGNOSTIC, TREATMENT PLANNING, AND ENDODONTIC TREATMENT COMPETENCY • Endodontists set the standard for endodontics. If the endodontist’s standards cannot be met, such as need for microscopy, 3-D imaging, regenerative procedures, radicular surgery, treatment of complex injuries, then the general dentist should refer the patient to the endodontist. In documenting general dentist endodontic competency, AAE Case Difficulty Assessment notes “that dentists should upgrade one’s skills to meet the standard of practice established by the endodontic specialty.” • The AAE considers the following as “high difficulty” and that all dentists be able to defend their endodontic treatment skills to successfully treat: for example, extreme curvature (greater than 30 degrees), S-shaped curve, indistinct calcified canal path, nonsurgical or surgical retreatments, anesthesia difficulty, limited opening, extreme tooth inclination or rotation, resorption, immature tooth, horizontal root fracture, endo/ perio lesion, confusing diagnosis, extreme difficulty in taking accurate radiographs, interpreting radiographs, performing pulpal tests, and trauma conditions. 7. PAVING YOUR WAY WITH WORDS • Tell every patient every time you prep a tooth that your clinical impact may be the final stimulus to cause pulpal breakdown requiring you to perform endodontics or you may want to bring in your endodontic specialist. 8. DO’S AND DON’TS TIPS • Don’t prescribe antibiotics for a toothache, which is a pulp ache, which means the diagnosis is a pulpitis, not a periradicular infection.
18 www.pagd.org Q dentistry issues • Don’t ask us if the tooth is restorable. You already know this. There must be 4mm of ferrule from bone to height of ferrule or, if not, can 4mm be created through forced orthodontic eruption or osseous recontouring. • Don’t anesthetize a patient that you are sending right over for diagnosis and emergency treatment. If anesthetized, we cannot duplicate the symptom or perform the needed tests to prove the diagnosis. • Do be cautious. If pulpal symptoms, cement the crown with temporary cement or leave the provisional in place until symptoms subside. Pulps can die slowly and quietly so be sure to pulp test before cementing with permanent cement. Also, take a PA as a quiet lesion of endodontic origin may be present; particularly if the pulp has been symptomatic. The worst thing to do is permanently cement a crown that turns into a pulpitis. We get this almost every day from one of your patients, “What, you are going to drill a hole through my new crown! Who is going to pay for that? Shouldn’t my dentist have known this before they cemented the crown?!” Hard to make you look good. • Do PAVE YOUR WAY WITH WORDS. Again, whether you are restoring a buccal pit cavity or full mouth rehabilitation, let these words flow from your mouth, “It is an infrequent possibility but as we restore your teeth to health and a beautiful appearance, occasionally the tissue inside a tooth or teeth will need to be removed and, if this were to happen, we would do root canal treatment to predictably save your tooth, or sometimes I will bring in our endodontist.” No need to make a big deal out of it. Say it and get on with your treatment plan explanation. This is simply informed consent. Note it in your chart that the patient has been informed about possible endodontics. • Do probe the apparent toothache tooth. It may be periodontally hopeless or an obvious fracture. Of course, if unsure, get that endodontic “diagnostic monkey” off your back and bring in your endodontist. • Do not refer a sinus tract tooth as an emergency. It is not. • Do establish with your endodontist what constitutes an emergency. • Do not tell the patient the endodontic fee. We do not know what it is until diagnosis. Tell the patient they will know the fee after diagnosis and before endodontic treatment. If the patient insists to know a range, tell them it is about the same as new TV. And, of course, there are different qualities of TV’s. Your patient understands this. • Do not think you have to be perfect. We ALL make mistakes. We all have unintended outcomes from time to time. We are human and we do not make perfect results every time. In fact, to be honest, most dentistry is not perfect but rather a degree of perfectionism. Dr. Bob Barkley, the father of preventive dentistry, is quoted as saying, “Dentistry makes patients worse at the slowest possible rate.” He was right. We do our best and sometimes best is not enough. • Do not attempt an endodontic treatment unless you have a strong confidence that you are competent to treat successfully. Remember, you are held accountable, as with all specialty care, to the standards of, in this case, the endodontist. • Don’t tell the patient that the treatment will be done first visit unless that is what you and the endodontist have agreed to. • Do tell the endodontist what you know about a treatment that you have attempted. For example, “I found all the canals but cannot find the MB2 canal of a molar or I did not try to go down the canals.” Another example, “I have tried to get down this canal for an hour and so I gave up. Can you finish?” Knowing EXACTLY what you have done or attempted to do and how long you spent on attempting the desired outcome is hugely valuable. Treating a patient with a broken file in a canal without your telling the patient once again makes it hard to make you look good or to stay away from a litigious situation. • Do keep accurate records. “Good clinicians keep good records.” • Do be honest about a new associate becoming your “in house” endodontist. • Change is the only constant and one constant change that I am observing as a teacher is that groups are sending their new dentist to learn as much as they can about endodontics so that they can keep endodontic patients in their practice and reduce the number of patients being referred to the endodontist. Typically, this new dentist enjoys endodontics and is happy to
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