Book One

Gary D.
Glassman
DDS, FRCD(C)
CURRICULUM VITAE: SYNOPSIS

Gary D. Glassman, DDS, FRCD(C) graduated from the University of Toronto, Faculty of Dentistry in
1984 and was awarded the James B. Willmott Scholarship, the Mosby Scholarship and the George
Hare Endodontic Scholarship for proficiency in Endodontics. A graduate of the Endodontology
Program at Temple University in 1987, he received the Louis I. Grossman Study Club Award for
academic and clinical proficiency in Endodontics. The author of numerous publications, Gary is on
staff at the University of Toronto, Faculty of Dentistry in the graduate department of endodontics, and
a visiting lecturer at Queens University in Belfast, Ireland. A renowned international lecturer on
endodontics, Gary has presented at major dental conferences around the world including the annual
conference for the European Society of Endodontology, the Canadian Dental Association, Ontario
Dental Association, The California Dental Association, The Texas Dental Association and the Irish
Dental Association. A Fellow and endodontic examiner for the Royal College of Dentists of Canada,
Fellow of the Academy of Dentistry International, and Fellow of the Academy of Dental-Facial
Aesthetics, Gary is the endodontic editor for Oral Health dental journal. Past President of the George
Hare Endodontic Study Club and the H.M.Worth Radiology Study Club he maintains a private
practice, Endodontic Specialists in Toronto, Ontario. He can be reached through his website
www.rootcanals.ca.
PHIL SHEDLETSKY, DDS, MS

GARY D. GLASSMAN, DDS, FRCD(C)
GLEN PARTNOY, DDS, MS, FRCD(C)
RITA KILISLIAN, DMD, Cert. Endo.
SIMONE SELTZER, DDS, Cert. Endo.
OFFICE PHILOSOPHY
It is our duty and obligation to maintain the highest standard of our profession and to
render treatment accordingly in a safe and clinically healthy environment.
The doctors and staff who work in this office have dedicated their professional lives to
improving the comfort and dental health of those who seek their care.
It is our sincere belief that our patients have the right to be thoroughly examined and
diagnosed in order to determine the nature and cause of their discomfort and concern.
Anyone directed to our office is entitled to receive prompt emergency care at any time.
We are here to deliver quality care while providing a warm and friendly atmosphere.
We will always be sensitive to the needs of our patients and treat all with the respect
they deserve.
1235 Bay Street, Suite 201, Toronto, Ontario M5R 3K4 Tel: (416) 963-9988 Fax: (416) 963-9143
145 King St. W., Concourse Level, Toronto, Ontario M5H 1J8 Tel: (416) 360-1553 Fax: (416) 360-7008
Email: info@rootcanals.ca Website: www.rootcanals.ca
Table of Contents
ENDODONTIC DIAGNOSIS
Clifford J. Ruddle, DDS, FICD, FACD
BACTERIA: THE EVIL OF ALL ROOT
Steven Cohen, DDS, Cert.Endo, Gary Glassman, DDS, FRCD(C)
USE OF OPHTHALMIC DYES IN ROOT CANAL LOCATION
Sashi Nallapati, BDS, Gary Glassman, DDS, FRCD(C)
THE NEW ERA OF FORAMENAL LOCATION
Kenneth S Serota, DDS, MMSc
THE ELEMENTS DIAGNOSTIC SYSTEM: GETTING DIALED IN
Richard E Mounce, DDS
A PREDICTABLE PROTOCOL FOR THE BIOCHEMICAL CLEANSING OF
THE ROOT CANAL SYSTEM
Gary Glassman, DDS, FRCD(C), Kenneth S Serota, DDS, MMSc
DOES NITI NIRVANA EXIST?
MANAGEMENT OF THE CORONAL THIRD
PROGRESSIVELY AND PASSIVELY
Richard E Mounce, DDS, Gary Glassman, DDS, FRCD(C)
EFFECTIVE ROTARY NICKEL TITANIUM FILE USE:
MASTERING THE RIGHT TOUCH
CREATION OF LARGER MADS: THE HYBRID TECHNIQUE
THE THERMOSOFTENED MILLENNIUM REVISITED:
CONTINUOUS WAVE OF CONDENSATION
Gary Glassman, DDS, FRCD(C), Fadi and Kenneth S Serota, DDS, MMSc Fadi
ELEMENTS OBTURATION UNIT
Sybron Endo
BONDED ENDODONTIC OBTURATION:
ANOTHER QUANTUM LEAP FORWARD FOR ENDODONTICS
ADHESIVE BONDING IN ENDODONTICS:
AN IDEA WHOSE TIME HAS COME
ENDODONTIC OBTURATION: ONE GIANT LEAP FOR ENDODONTICS
SEQUELAE OF ENDODONTIC THERAPY
THE BIOLOGIC RATIONALE FOR POSTOPERATIVE PAIN
ENDODONTIC DIAGNOSIS
E N D O D O N T I C S
Endodontic Diagnosis
because a tooth is clinically asymptomatic or a wellangulated radiograph does not reveal a lesion of
endodontic origin (LEO).1 Many pulpally involved
teeth do not exhibit symptoms or demonstrate a
LEO even though considerable breakdown and destruction may have already occurred in the less
dense trabecular bone. Research has demonstrated
diagnosticians only see an incipient radiolucency
when the more dense buccal or lingual cortical
entists are trained to thoroughly review medical

and dental histories and perform comprehensive extraoral and intraoral examinations. Yet,
in spite of these efforts to optimally serve patients,
the dominant clinical reality is the vast majority of
dentists do not know the status of the pulps within
the teeth of the patients who visit them daily. If a
complete endodontic examination is not conducted,
then the pulpal status of any given tooth is unknown. The rationale for conducting a complete
endodontic examination is similar to conducting a
complete intraoral screening for soft tissue pathology; conducting a complete periodontal examination; or a physician conducting a complete physical
examination on a seemingly healthy patient.
Clinical judgment should be used to determine
which patients, and which teeth, should receive an
endodontic examination. Regretfully, a significant
number of endodontically involved teeth are not
diagnosed or treated. In fact, the vast majority of
all endodontic procedures are performed secondarily to patients presenting with symptoms. It is critically important for dentists to accurately diagnose
endodontic disease associated with both asymptomatic and symptomatic teeth.
FIGURE 1This human skull demonstrates several important

anatomical relationships and serves to illustrate how a LEO
can hide between intact cortical plates of bone.
THE REALITY
It should be completely understood and fully
appreciated pulpal health is not guaranteed just
12
oralhealth
December 2003
1
FIGURE 2This table serves to reveal the enormous health and

financial consequences when endodontically involved teeth
are not identified and treated.
FIGURE 3A radiograph of a maxillary first bicuspid showing

a gutta percha point tracing a sinus tract and pointing to a
lesion of endodontic origin.
plates of bone have been invaded by a lesion.2 If a

complete endodontic examination was conducted on
each patient before commencing with any dental
procedure, then a staggering and sobering number
of quiescent, pulpally involved teeth would be identified (Fig. 1).3 Frequently, patients report they
were comfortable before treatment, then following
a so-called routine procedure developed a toothache. In summary, clinicians regularly treat the
toothache, yet only sporadically find other obvious endodontic problems.
duce an additionally $1,000,000 of dentistry.4

Although it is impossible to quantify the magnitude of undiagnosed endodontically involved teeth,
it is an unmistakable fact that a significant number
of endodontic problems are not identified or treated.5 When a complete endodontic exam is performed, the results clearly communicated, and
mutual trust has been established, then patients
will generally schedule, as convenient, the appropriate treatment. Dentists have a professional
responsibility to clearly communicate the risks versus benefits associated with the recommended
treatment, alternatives to treatment, and the clinical ramifications of no treatment. Each clinician
should carefully evaluate all the diagnostic information, consider the strategic nature of the tooth,
and anticipate the treatment challenges. Additionally, each practitioner needs to evaluate their
training and experience and, if they have the appropriate technology, decide if a referral would be in
the patients best interest.6 Importantly, when a
comprehensive endodontic examination is conducted, then virtually all of the non-obvious endodontically involved teeth can be identified. The
endodontic examination serves to improve treatment planning, performance and prognosis. Endodontic diagnosis and treatment represent important
aspects of ideal oral health. In fact, oral infection
has been identified as a risk factor for certain systemic diseases.7 The possibility is present to
improve oral health by accurately diagnosing previously undiagnosed endodontically involved teeth.
Regarding the expression, At the end of the rainbow there is a pot of gold, my assertion is, There is
a pot of gold and it can be found within the teeth
that visit you daily.
THE POSSIBILITY
It has been said, At the end of the rainbow there
is a pot of gold. However, the real endodontic pot
of gold is typically not discovered. If found, undiagnosed endodontics represents a significant
source of additional practice income (Fig. 2). As a
conservative example, assume a mature practice
has 1,000 active patients. Assume that each
patient has an average of only 20 teeth. Then it
could be said this practice is the custodian of
20,000 teeth. Appreciate the enormous endodontic
implications if pulpally involved teeth are not
diagnosed between one percent and five percent of
the time. In this hypothetical scenario, if the
endodontic diagnosis is missed just 5 percent, then
this would represent 1,000 teeth. Assume all
endodontic procedures cost $500 per tooth, then
potentially this could result in not performing
$500,000 of endodontic work. Additionally, the vast
majority of all endodontically treated teeth require
a core build-up and restoration. If we assume these
restorative efforts cost $500, then another $500,000
worth of dentistry could have been produced. This
assumption demonstrates there is a conservative
yet massive potential to diagnose, treat and pro-
December 2003
2
oralhealth
13
FIGURE 4AA photograph reveals significant swelling secondary to a LEO that

has broken through the buccal cortical
plate of bone.
FIGURE 4BA photograph demonstrates

a gutta percha point tracing a sinus
tract and a tattoo associated with an
endodontically failing maxillary left central incisor.
ETIOLOGY OF PULPAL BREAKDOWN
three-step diagnostic process comprised of the

clinical examination, the radiographic examination
and vital pulp testing. This examination should be
appropriately scheduled and performed on all new
and existing patients regardless of whether they
are asymptomatic or symptomatic. In the instance
where there is a chief complaint, it is important to
inquire as to the region, magnitude and duration of
the pain. Additionally, the dentist should ask if the
sensitivity is diffuse or localized, intermittent or
continuous, and if there is a specific stimulus that
provokes the pain. It is important to listen, clarify
and then accurately record this information.13 The
purpose of a full mouth endodontic examination is
to differentially diagnose between odontogenic versus nonodontogenic problems. Specifically, the
endodontic examination serves to identify endodontically involved teeth and additionally enables the
clinician to classify any given tooth into one of four
categories:
1. Teeth that are asymptomatic and do not have a LEO
2. Teeth that are asymptomatic and have a LEO
3. Teeth that are symptomatic and do not have a LEO
4. Teeth that are symptomatic and have a LEO
The dental pulp is a dynamic tissue whose status at

any given time can be assigned a position on a continuum that ranges from optimal pulpal health to
pulpal necrosis. It is wise to appreciate that not all
asymptomatic teeth that exhibit a normal response
to pulp tests have the same degree of health or
capacity to heal.8 The dental pulp has a restricted
capacity to heal because it has a limited blood supply, is encased in unyielding dentinal walls and represents terminal circulation. As such, the ultimate
fate of the dental pulp is dependent on the magnitude and duration of an injury.9 The major threats
to the pulp are caries, traumatic episodes, specific
developmental anomalies, certain periodontal conditions and related treatment efforts, and extensive
dental procedures.10 As an example, following many
operative procedures, patients may report transient
pain to a cold stimulus indicating a pulpal inflammatory response that is potentially reversible. In
other instances, patients may report intense and
lingering pain to a cold stimulus which generally
infers an irreversible pulpitis.11 Obviously, recurrent caries, a leaking restorative and repeated
episodes of dentistry on the same tooth sharply
escalate the potential for pulpal breakdown and disease flow. Pulpal injuries frequently progress from
reversible to irreversible inflammatory conditions
and rapidly advance from ischemia, infarction and
partial necrosis to complete pulpal death (Fig. 3).12
The progressive cascade of pathohistological events
that occur within a degenerating pulp as it symbolically journeys along this continuum are well
understood.8-12 Regretfully, clinicians who perform
dental procedures without diagnostic pulp tests are
unable to forecast the ultimate fate of the pulp.
CLINICAL EXAMINATION
The purpose of the clinical examination is to thoroughly evaluate all aspects of the extraoral and
intraoral tissues. The extraoral examination allows
the dentist to observe a patients face and look for
symmetry, color and the overall complexion. Further,
the examination reveals the presence of various diseases, traumatic injuries, and facial scars. Examining dentists should bilaterally palpate the submandibular nodes for lymphadenopathy as this is
the site for regional drainage from the head and
neck. The intraoral portion of the examination is
directed towards inspecting all aspects of the soft
and hard tissues. The soft tissue portion of the exam-
THE ENDODONTIC EXAMINATION

The comprehensive endodontic examination is a
14
oralhealth
FIGURE 5A surgical photograph of an

endodontically failing molar reveals a
vertical root fracture possibly caused by
the use of excessive force during obturation.
December 2003
3
ination includes, but is not

limited to, carefully evaluating
the oral mucosa, oral pharynx,
tongue, and floor of the mouth.
Additionally, a thorough intraoral soft tissue exam reveals
the color, texture, consistency
and contour of the soft tissues
including the presence of a
swelling, sinus tract or tattoo
(Fig. 4). The periodontal examination provides the opportunity to evaluate the mucogingival soft tissues, attachment
apparatus, and probable pocket depths. Importantly, broad
crater-shaped defects are more
often associated with periodontal disease, whereas narrow vertical defects suggest
either endodontic etiology or a
radicular fracture (Fig. 5).
FIGURE 6AA photograph shows discoloration of the clinical crown of the

mandibular left central incisor as a
result of a traumatic accident.
FIGURE 6BA clinical photograph of the

lingual surface of this maxillary incisor
reveals a dens evaginatus and a sinus
tract located high in the palatal vault.
a tooth exhibits a coronal fracture, then light will

not uniformly pass through the clinical crown, and
the fracture breaks a beam of light.
The intraoral hard tissue exam reveals missing

teeth, fractured teeth, dark teeth and developmental anomalies (Fig. 6). Further, all existing restoratives are evaluated for marginal adaptation, contour and esthetics. The diagnostician looks for
caries, recurrent caries, and inspects the cervical
area of teeth for erosions, abrasions and abfractions. The presence of inflammation or infection
can contribute to the loss of attachment and excessive mobility of a tooth. Roots should be palpated
laterally and apically, both on the facial and lingual aspects as a lesion of endodontic origin can
invade through the cortical plate. The percussion
test is performed gently and conducted laterally,
then vertically on the incisal edges of anterior
teeth or on the buccal and lingual cusps of posterior teeth. A positive percussion test indicates an
injury to the attachment apparatus, may cast suspicion regarding the status of the pulp, but, in and
of itself, does not disclose information regarding
the health of the pulp. The bite test is useful to
identify teeth with incomplete or complete dentinal fractures and is best performed with a cotton
roll, q-stick or the Tooth Slooth (Sullivan Schein
Dental, Melville, NY). These devices are placed
interocclusally and patients are instructed to initially bite gently and, if possible, to then bite firmly. Additionally, patients should demonstrate they
can move their mandibles into working and balancing excursions. A fiberoptic wand can be used
to transilluminate the clinical crowns of teeth
without extensive, full restorative coverage. When
a natural crown is transilluminated facial to lingual, light will uniformly pass through tooth structure if there is no fracture. On the contrary, when
The clinical examination focuses on the masticatory system including the jaws, temporomandibular
joint and muscles of mastication. The occlusion is
carefully checked by having the patient move into
various lateral and protrusive excursions. Marking
paper can be used to identify and address prematurities that can contribute to harmful wear facets,
increased mobility and thermal sensitivity. Habitual
grinding is a behavior that promotes malocclusion
and is frequently associated with fractured teeth. In
summary, the clinical examination reveals valuable
information regarding a patients dental history, and
can serve as an indicator of their motivation to pursue oral health.
RADIOGRAPHIC EXAMINATION
The radiographic examination is generally performed following the clinical examination. In fact,
the clinical portion of the diagnostic work-up often
serves to identify the specific location(s) where the
radiographic exam should be focused. The endodontic radiographic examination is optimized when
three different, well-angulated, and high quality
images are obtained.14 A straight-on diagnostic film
should be taken such that the x-ray cone is aimed
perpendicular to both the facial aspect and long axis
of the tooth. A second, mesially angulated film is
attained by horizontally aiming the xray cone up to
30 mesial to the straight-on angle and perpendicular to the long axis of the tooth. A third, distally
angulated film is attained by horizontally aiming
the x-ray cone up to 30 distal to the straight-on
December 2003
4
oralhealth
15
FIGURE 7A radiograph suggests the

anterior bridge abutment is endodontically involved. Note the crown/root orientation and inclination of the canal
coronally.
angle and perpendicular to the

long axis of the tooth.
Frequently, dentists inquire
as to the need for three preoperative radiographs when,
indeed, a single film, in conjunction with the results from
a vital pulp test and the clinical examination, will generally
confirm a definitive diagnosis.
The answer is simple: The best
film is still a two-dimensional
image of a three-dimensional
object. A single film, along with
the other diagnostic information, may endodontically condemn a tooth; however, a single
radiographic image will not
adequately prepare the clinician for optimal treatment
planning and patient communication.
FIGURE 8A radiograph suggests this

maxillary right central incisor has a dens
in dente, internal resorption, a large
asymmetrical lesion and multiple canals.
FIGURE 9A radiograph of a maxillary

central incisor reveals a horizontal root
fracture with displacement and a previously accessed lateral incisor.
The diagnostic quality of a

radiographic image is definitely
enhanced using film holding
and aiming devices and adherFIGURE 10BThis radiograph reveals masFIGURE 10AA radiograph of a mandibing to well-recognized and sucsive root resorption associated with the
ular left lateral incisor shows evidence
cessful darkroom protocols.
maxillary incisors possibly caused by the
of internal resorption and an apical
Digital radiography is improverupting and mesially inclined canine.
lesion of endodontic origin.
ing the field of dental radiology
as it provides several advantages over film-based radiography.15 Digital radiogimages, such as zoom, measurements, adjustable conraphy reduces radiation, eliminates chemicals and
trast, image colorization, black/white reversal, and
film processing, and provides nearly instant, high
density measurement and comparison. Perhaps the
quality images that patients can clearly see.
greatest advantages of digital radiography is the
Centralized storage and retrieval allows clinicians to
potential to more effectively communicate with
send, receive, and print images. Software tools afford
patients by allowing them to participate in co-discovseveral features that can be utilized to enhance
ery, co-diagnosis and co-treatment planning.
16
oralhealth
December 2003
5
FIGURE 11AA radiograph of an endodontically involved mandibular first

molar showing a gutta percha point
passing through the buccal sulcus to a
furcal lesion.
FIGURE 11BA radiograph of an endodontically involved maxillary first bicuspid reveals a distocrestal lesion that is
threatening the sulcus.
When performing the radiographic examination,

the clinician will observe that different angulated
images enhance detecting the location and extent
of caries or recurrent caries. A restoration should
be evaluated radiographically regarding marginal
adaptation, contour, relative depth and relationship to the pulp chamber. At times, a bitewing film
is useful as it can provide additional information as
to splinted teeth, and the presence of pins and
build-up materials. Radiographic images frequently allow the clinician to determine the size of the
pulp chamber as compared to adjacent teeth, the
presence of stones, and if calcific material projects
into the coronal aspect of a canal (Fig. 3). Clinicians
can visualize a radiograph to appreciate the crown/
root ratio and orientation, and the angle of the
coronal aspect of a canal relative to the long axis of
the root (Fig. 7). Different, horizontally angled
films disclose information regarding the length and
curvature of a root and, when present, the depth of
an external concavity. High quality radiographic
images can be studied to better appreciate the root
canal system and, at times, disclose canals that
merge, curve, recurve, dilacerate or divide. The
astute clinician will identify atypical tooth morphology such as a C-shaped molar, taurodontism or
dens invaginatus (Fig. 8).16
FIGURE 11CA radiograph shows a

mandibular first molar with a poor fitting crown, incomplete endodontics and
a LEO associated with the mesial root.
abnormal radiolucent lesion. At times, additional

films may be prescribed to augment an examination; including a panograph, lateral jaw, or occlusal
radiograph. Diagnosticians should recognize that
regardless of the various radiographic options, in
the final analysis, interpreting a radiographic
image is subjective and is a learned skill.17
Various horizontally angulated radiographs also
provide critical information as to the etiology of
endodontically failing teeth.18 Many endodontic
failures can be attributable to coronal leakage
resulting from failed restorations. Radiographs can
clarify if the obturation material was gutta percha,
a silver point, carrier-based obturator or paste filler.
Additionally, radiographs reveal a particular canal
was well-shaped, and the vertical extent of obturation. Dentists who expend a considerable amount of
their clinical time performing retreatment appreciate that a short fill could suggest a blocked canal.
Off-angled films enhance the diagnostic assessment
of root canals that exhibit a ledge, transportation or
perforation. A radiograph will generally reveal the
presence of a post and additionally provide information as to its length, diameter and orientation
relative to the long axis of the root. Off-angled
images can demonstrate the presence and position
of a broken instrument or a missed canal. At times,
a patient will be asymptomatic and demonstrate a
radiographic radiolucency associated with a root
apex. If there was a history of endodontic surgery,
then the differential diagnosis should include the
possibility of a surgical scar. However, discounting
radicular fractures and hopelessly involved periodontal teeth, virtually all other endodontic surgical
failures should be attributable to microleakage and
bacterial invasion.
Different, well-angulated films allow clinicians to

observe the result of a traumatic episode such as a
coronal fracture, horizontal root fracture, and at
times, a vertical root fracture (Fig. 9). The clinician
needs to carefully observe films for the possible
sequelae to traumatic events, such as internal and
external resorptions (Fig. 10). High quality images
clarify root end proximity to normal anatomical
structures such as the maxillary sinus, mental foramen or mandibular canal. In fact, at times clinicians
should expose a contralateral film to rule out a normal radiolucent anatomical landmark versus an
The radiographic examination also provides

information regarding the periodontal supporting
December 2003
6
oralhealth
19
FIGURE 12This radiograph suggests the mandibular first

bicuspid has a carious pulp exposure and reveals a LEO
associated with the mesial root of the molar.
FIGURE 13A clinical photograph demonstrates a reliable

method and technique for performing the cold test.
structures. Certain probable defects masquerade as

a periodontal lesion when, in fact, the etiology may
be attributable to significant lateral canals disseminating pulpal irritants.19 Clearly, pulp testing
schemes must be conducted to corroborate this suspicion allowing the clinician to differentially diagnose the presence or absence of a LEO. Over time it
is becoming well understood that LEOs occur in
the furcations of multi-rooted teeth (Fig. 11A).
Additionally, a LEO may be positioned crestally,
laterally along a root surface, or symmetrically or
asymmetrically around the apex of a root (Figs.
11B & C). It must be understood that radiographic
radiolucencies or radiopacities could represent a
normal anatomical landmark, a nonodontogenic
lesion, or a LEO, and the differential diagnosis is
made by performing vital pulp tests.20
Importantly, performing repetitive pulp tests, as

described, will tend to relax the patient, build confidence and reduce the probability of a false positive or false negative report.
VPT procedures are initially performed to
establish a normal baseline for any given tooth
on any single patient. Once a baseline has been
established then, and only then, should the appropriate VPT be performed in the quadrant where
the patient is experiencing symptoms. Performing
VPT on asymptomatic teeth establishes the baseline for testing and comparing an abnormal
response in a symptomatic tooth. In fact, when
VPT schemes are conducted in this manner, patients will frequently question why another tooth
is either overreactive or nonreactive to the specific
test. In these instances, additional diagnostic evaluation may be required to clarify the endodontic
status of any given tooth.
VITAL PULP TESTING

The clinical and radiographic steps of the examination oftentimes cast suspicion of endodontic
involvement of a specific tooth. Vital pulp tests
(VPT) are essential components of the endodontic
examination and serve to disclose the status of the
dental pulp.13 Frequently, patients present reporting pain to a thermal stimulus in a specific
quadrant. In these instances, vital pulp testing
schemes should be performed first on presumably
pain-free teeth, away from the area of the chief
complaint. Specifically, the preferred sequence is
to test contralateral teeth first, opposing teeth second, then presumably healthy teeth within the
thermally painful quadrant, and finally, the most
suspicious tooth last. This strategy of sequencing
the vital pulp tests allows both the doctor and the
patient to appreciate the range of normal pulpal
responses exhibited by asymptomatic teeth.
20
oralhealth
When pulpal inflammation is confined to the

root canal space, diagnosticians should be skeptical
when patients attempt to identify a specific tooth
they perceive as the source of their pain. This doubt
is justified since the dental pulp does not have proprioceptive nerve fibers.21 On the contrary, the
attachment apparatus has proprioceptive nerve
fibers that allow a patient to identify a tooth that is
sensitive to biting pressure. As such, inflammatory
conditions involving the dental pulp are diagnosed
by reproducing the patients chief complaint as this
is diagnostic. Thermal pain is pulpal in origin
whereas biting or chewing pain is related to
injuries involving the periodontal attachment
apparatus. The origins of attachment apparatus
injuries are multifactorial and, as examples, could
December 2003
7
intensity of a response to thermal testing can vary

significantly depending on, as examples, the depth
of a carious lesion, the placement of a new restoration, or recent periodontal surgery. It is useful to
have the patient subjectively rate the intensity of
a response utilizing a zero to ten (0-10) scale where
zero (0) is a no response and ten (10) represents
maximum pain. Regardless of the immediacy and
intensity, if the response rapidly dissipates upon
removing the thermal stimulus, then although the
pulp may have tested inflamed, this may be a
reversible condition. Importantly, it is the duration of the response, compared to the baseline
that was established by testing other teeth, that is
most diagnostic.
be periodontal or endodontic in etiology or attributable to a recently placed restoration in hyperocclusion. In summary, it is wise to appreciate that a
symptomatic patient can present with two separate, distinct and unrelated problems and, as an
example, the tooth that is symptomatic to biting
pressure may not be the tooth that is symptomatic
to a thermal stimulus (Fig. 12).
There are four methods that may be employed to

determine the vitality of the dental pulp: the cold,
hot, electric, and cavity tests. Selection of the cold
test or the hot test is based on the patients chief
complaint. If a patient does not report any history
of thermal pain then, for ease, the cold test is
selected. However, it should be recognized that once
In certain instances, a tooth tested with a therthe pulp is stimulated with cold, there is a refracmal stimulus may elicit a no response which
tory period of several minutes before a second cold
could infer the pulp is necrotic. It should be recogor hot test can be accurately conducted. The electric
nized a patient may not respond to a thermal test
pulp test is more technique sensitive, requires a
if the pulp chamber
dry field and is oftenhas significantly caltimes impractical to
cified or receded apiutilize in teeth with full
cal to the crest of
restorative coverage.
The patient is instructed to raise
bone. Further, a no
The cavity test is rarely
their hand when they first feel the
response to a therused, and only considmal test could imply
ered when the clinical
sensation from the thermal stimulus
a tooth has been
and radiographic inforinvolved in a recent
mation and pulp test
in the tooth, to keep their hand up
episode of trauma,
results prove inconcluas long as this sensation lingers,
has an immature
sive. In these instances
apex, or the patient
and, when the patient
and to lower their hand when
may have premedsituation supports inicated. Additionally, a
tervention, then the
the sensation dissipates.
patient will not gencavity test could be conerally respond to a
sidered as a last resort.
thermal stimulus on
If employed, the cavity
a tooth that has had root canal treatment.
test is initiated on a suspicious tooth, without anesHowever, an endodontically failing tooth with a
thetic, and involves drilling a small window
missed canal will, at times, illicit a painful
through either enamel or a restoration to dentin.
response when tested with a hot stimulus.
The cavity test will stimulate a vital pulp and provoke a painful response when dentin is invaded. In
the event of a vital response, a simple restoration is
COLD TEST
placed. On the contrary, the cavity test will not
When a patient presents and reports a history of
stimulate a partially necrotic pulp to the same
pain to a cold stimulus, then the clinician should
extent as a vital pulp. In this situation, the dentist
logically conduct the cold test. Although there are
initiates the access cavity, invades progressively
a few different methods that may be selected to
deeper into dentin and often reaches the pulp
apply a cold stimulus, one reliable source is to utichamber uneventfully.
lize an ice pencil.22 A pencil of ice is easily formed
by first purging all the anesthetic from an unused
Thermal tests should be conducted on the cervicarpule. Dental floss may then be cut about one (1)
cal aspect of a tooth, and as close as possible to the
inch longer than the length of the carpule and
free gingival margin. This location represents the
inserted into this glass tube. Several of these
thinnest aspect of enamel or a restoration and,
carpules are filled with water, held upright in a cup
importantly, the closest distance to the pulp chamand then placed in a freezer. When a pencil of ice is
ber. When performing a thermal test, the clinician
needed, a frozen carpule is briskly rolled between
is evaluating the immediacy, the intensity, and
the gloved palms of the hands. This action serves to
the duration of the response. The immediacy and
warm and contract the ice pencil which may then be
December 2003
8
oralhealth
21
FIGURE 14A clinical photograph shows the Hot Pulp Test Tip
with thermosoftened gutta percha contacting the cervical
aspect of a maxillary lateral incisor.
FIGURE 15A clinical photograph demonstrates syringing

60C hot water onto a tooth that has been carefully isolated
with a rubber dam.
liberated by gently pulling the floss. The pencil of

ice is placed in a 2x2 gauze to prevent warmth from
the fingers from prematurely melting the ice.
seconds after the stimulus is removed. As mentioned, the diagnostician is observing the immediacy, intensity, and importantly, the duration of the
response. At times, the ice pencil and resultant slurry of cold water will not elicit a response and reproduce the patients chief complaint. In these
instances, a tooth or group of teeth may be individually isolated with a rubber dam, and ice water
syringed onto each tooth. Although more time consuming, this method of testing is very effective at
simultaneously bathing the entire clinical crown of
a tooth and stimulating an inflamed pulp. Astute
clinicians appreciate that a test that elicits a lingering response is diagnostic and separates the
reversible pulpal conditions from the irreversible
conditions.
Before initiating any thermal pulp test the diagnostician needs to establish reliable hand signals.
The patient is instructed to raise their hand when
they first feel the sensation from the thermal stimulus in the tooth, to keep their hand up as long as
this sensation lingers, and to lower their hand
when the sensation dissipates. It is wise to repeat
and clarify these instructions as both asymptomatic and, especially, symptomatic patients are frequently nervous and may inadvertently not follow
directions. This is precisely why thermal pulp tests
should not be initially performed on suspicious or
symptomatic teeth. As such, before instituting any
pulp test, advise the patient how this test works,
ask permission to test, and then initiate the test on
pain-free teeth.
HOT TEST
When a patient reports a history of pain to a hot
stimulus, then the clinician should logically conduct the hot test. A toothache precipitated by
hot liquids or foods usually suggests an acutely inflamed or partially necrotic pulp. Necrotic tissue
frequently harbors bacteria, which can produce
gasses that potentially expand against tissue
encased inside unyielding dentinal walls. This phenomenon causes sensory fibers of the pulp to transmit pain.21 There are a few different devices that
may be selected to apply a hot stimulus, including
the Touch n Heat or System B (SybronEndo,
Orange, CA). Either device has a handpiece, which
is designed to receive various inserts such as the
Hot Pulp Test Tip (SybronEndo, Orange, CA). Regardless of the device chosen, the continuous mode
is selected and the intensity is set at the manufacturers recommendation for performing the hot
pulp test. Within a few seconds, the insert tips
metallic end becomes sufficiently hot.
The specific technique for pulp testing is

straightforward.23 The ice stick is placed towards
the cervical aspect of a tooth on either the buccal or
lingual aspect of a crown and quickly moved back
and forth (Fig. 13). This action creates a slurry of
cold water which will effectively bathe, conduct and
penetrate into a tooth. To prevent a false positive
result, a cotton pellet should be placed just distal to
the tooth being tested to prevent ice water from
potentially contacting a more posterior tooth. When
the patient signals they feel cold in the tooth being
tested, the ice is immediately removed. However,
the patient is reminded to keep their hand up as
long as the cold sensation lingers in the tooth. When
testing teeth with healthy pulps, once the patient
has signaled they feel cold in a tooth, their hand will
generally remain raised approximately two to five
22
oralhealth
December 2003
9
The clinician may use the heat from the insert tip
to thermosoften a gutta percha cone into a round
ball, which is then attached to the Hot Pulp Test Tip.
A thermosoftened ball of gutta percha will readily
adapt to the morphological contour of a tooth, which
results in achieving better conductivity into the pulp
chamber. As with the cold test, the diagnostician
must first establish a baseline by testing asymptomatic teeth. The hot test and related hand signals
are performed as described for the cold test. Thermosoftened gutta percha is placed towards the cervical
aspect of a moist or lubricated tooth, on either the
buccal or lingual aspects of the crown (Fig. 14).
each response. As with the cold test, the response

that lingers disproportionately, as compared to contralateral, opposing and adjacent teeth, is diagnostic. On occasion, certain patients present with a
glass of cold water tightly grasped in their hand.
These patients typically have a necrotic pulp and
the attendant pain can be turned off when they
drink cold water or when the diagnostician places
an ice pencil on the offending tooth. Provoking a
toothache with a hot stimulus then turning off the
pain with a cold stimulus is profoundly diagnostic.
On occasion, after conducting a thorough clinical

and radiographic examination and performing VPT,
there may be a diagnostic dilemma, such as when a
When the patient raises their hand, the diagnospatient reports acute, radiating or diffuse pain that
tician should immediately remove the hot stimulus.
cannot be localized. In these situations, it may be
In the event the patient does not perceive any heat
helpful to remove a specific crown or administer
sensation in their tooth after 5-6 seconds, then the
block anesthesia in
stimulus should be reeither the maxillary or
moved. However, certhe mandibular archtain pulpally involved
Reliable information serves to
es to help localize the
teeth may not initially
source of the chief
be stimulated by the
improve diagnostics, treatment
complaint. Clinicians
hot test, then after several seconds, elicit sigplanning and patient communication. should recognize that
in spite of performing
nificant pain. For this
The comprehensive endodontic
a thorough and comreason, it is advisable
to wait several seconds
examination increases the possibility prehensive endodontic
examination,
there
before placing a hot
will be times when a
stimulus on the next
for patients to receive more timely
definitive diagnosis
tooth. Some teeth with
care and for dentists to find the
cannot be made. It is
irreversible
pulpitis
wise to remember the
require a repeated hot
proverbial pot of gold!
Hippocratic
oath
stimulus over time to
which states, Do no
reach a threshold that
harm while doing
provokes pain. Theregood. In these instances, it is appropriate to disfore, when a patient reports pain upon drinking hot
miss the patient and reschedule when their sympcoffee, it is informative to inquire if the pain is
toms can be localized.
experienced on the first sip or after repeated sips.
This information may be useful when performing
and sequencing the hot pulp test.
CONCLUSION
A comprehensive endodontic examination serves to
At times, after carefully conducting the hot test
systematically identify pulpally involved teeth and
as described, the diagnostician may not be able to
is critical for providing optimal dental care. The
reproduce the patients chief complaint. An alterendodontic examination should be performed and
nate method of heat testing involves isolating the
the results recorded before initiating any dental
crown of a tooth with a rubber dam, and then applyprocedure. Specifically, full mouth vital pulp testing
ing hot water with a syringe.23 The advantage of
procedures establish a baseline and provide inforthis method is that hot water instantaneously
mation, which can be utilized to make more prebathes the entire clinical crown, improves conducdictable decisions. In many states, trained members
tivity, and more closely replicates the way heat natof the dental team can legally perform and record
urally contacts the tooth during the ingestion of hot
the observations and results from the endodontic
foods and liquids (Fig. 15). The disadvantage of this
examination. Reliable information serves to
test is the cooperation required to comfortably place
improve diagnostics, treatment planning and
a clamp on a tooth, then the time required to perpatient communication. The comprehensive endoform this test on several teeth. Regardless of which
dontic examination increases the possibility for
hot pulp test method was utilized, the clinician is
patients to receive more timely care and for dentists
assessing the immediacy, intensity and duration of
to find the proverbial pot of gold!
OH
December 2003
10
oralhealth
23
6. Dorn SO, Gartner AH: Ch. 4, Case selection and treatment planning. In Cohen S,
Burns RC, editors: Pathways of the Pulp, pp. 60-76, 6th ed., Mosby, St. Louis, 1994.
7. Mattila KJ, Valtonen VV, Nieminen M, Hattunen JK: Dental infection and the risk of
new coronary events: Prospective study of patients with documented coronary artery
disease, Clin Infect Dis 20:588-592, 1995.
8. Van Hassel HJ: Physiology of the human dental pulp, Oral Surg Oral Med Oral Pathol
32, pp. 126-134, 1971.
9. Kim S: Microcirculation of the dental pulp in health and disease, J Endod 11:11, pp.
465-471, 1985.
10. Takahashi K: Changes in the pulp vasculature during inflammation, J Endod 16:2, pp.
92-97, 1990.
11. Stanley HR, Swerdlow H: Reaction of the human pulp to cavity preparation, results
produced by eight different operative grinding techniques, JADA 58, pp. 49-59, 1959.
12. Kim S, Trowbridge H, Suda H: Ch. 15, Pulpal reaction to caries and dental procedures. In Cohen S, Burns RC, editors: Pathways of the Pulp, pp. 573-600, 8th ed.,
Mosby, St. Louis, 2002.
13. Cohen S: Ch. 1, Diagnostic procedures. In Cohen S, Burns RC, editors: Pathways of
the Pulp, pp. 2-24, 6th ed., Mosby, St. Louis, 1994.
14. Kaffe I, Gratt BM: Variations in the radiographic interpretation of the periapical dental
region, J Endod 14:7, pp. 330-335, 1988.
15. Antenucci EL: Digital radiography, clinical applications of a maturing technology, AGD
Impact 30:7, pp. 18-19, 2002.
16. Mangani F, Ruddle CJ: Endodontic treatment of a very paticular maxillary central
incisor, J Endod 20:11, pp. 560-561, 1994.
17. Goldman M, Pearson A, Darzenta N: Reliability of radiographic interpretation, Oral
Surg 38, pp. 282-293, 1974.
18. Ruddle CJ: Ch. 25, Nonsurgical endodontic retreatment. In Cohen S, Burns RC, editors: Pathways of the Pulp, pp. 875-929, 8th ed., Mosby, St. Louis, 2002.
19. Schilder H: Cleaning and shaping the root canal system, Dent Clin North Am 18:2,
pp.269-296, 1974.
20. Bhaskar SN: Part III pathology of the teeth and jaws. In Bhaskar SN, editor: Synopsis
of Oral Pathology, pp. 119-337, 4th ed., Mosby, St. Louis, 1973.
21. Gluskin AH, Goon WWY: Ch. 2, Orofacial dental pain emergencies: endodontic diagnosis and management. In Cohen S, Burns RC, editors: Pathways of the Pulp, pp.
25-50, 6th ed., Mosby, St. Louis, 1994.
22. Augsburger RA, Peters DD: In vitro effects of ice, skin refrigerant, and CO2 snow on
intrapulpal temperature, J Endod 7:3, pp. 110-116, 1981.
23. Ruddle CJ: Ruddle on CleanShapePack, 2-tape video series. Studio 2050, producer. Santa Barbara, California: Advanced Endodontics, 2002.
Dr. Ruddle is founder and director of Advanced

Endodontics, an international educational source in Santa
Barbara, California. He is an Assistant Professor of
Graduate Endodontics at Loma Linda University and is an
Adjunct Professor of Endodontics at University of the Pacific,
School of Dentistry, in San Francisco. Dr. Ruddle is the
author of two (2) chapters in the new 8th Edition of Pathways
of the Pulp: Cleaning & Shaping the Root Canal System
and Nonsurgical Endodontic Retreatment. He is internationally known for providing superb endodontic education as
a lecturer and through his clinical articles, training manuals,
and multimedia products. In addition, Dr. Ruddle has recently completed a new CleanShapePack video. He can be
reached at (800) 753-3636 or www.endoruddle.com.
Reprinted with permission. Originally published in
Dentistry Today, October, 2002.
REFERENCES
1. Bender IB: Factors influencing radiographic appearance of bony lesions, J Endod 8:4,
pp. 161-170, 1982
2. Bender IB, Seltzer S: Roentgenographic and direct observation of experimental
lesions in bone (part 1), JADA 62, pp. 152-160, 1961.
3. Ruddle CJ: Nonsurgical endodontic retreatment: issues influencing treatment,
Dentistry Today 17:2, pp. 64-71, 1998.
4. Ruddle CJ: How to profit from endo: finding the fair fee for endodontics, Dental
Economics 88:11, pp. 30-42, 1998.
5. Endodontic trends reflect change in care provided, Dental Products Report 30:12, pp.
94-98, 1996.
24
oralhealth
December 2003
11
BACTERIA: THE EVIL OF ALL ROOT
Steven Cohen, DDS, Cert.Endo, Gary Glassman, DDS, FRCD(C)
E D I T O R I A L
Bacteria: The Evil of All Root

Steven Cohen, DDS, Cert. Endo, Gary Glassman, DDS, FRCD(C)
icture this: A small town in

the Wild West Frontier. The
street is deserted, its high
noon, and the sun is beating
down on this dust bowl of a town.
Two gunfighters square off for a
showdown, each at one end of the
main street. At one end is the
lawman, wearing the white hat,
defending all that is good and
honourable for the people. At the
other end is the villain, wearing
the black hat, who feeds on the
weaknesses, and fears of these
same people. Hanging in the balance is the moral health of this
small outpost of civilization.
This struggle is classic to our
species. It can be played over and
over in almost every facet of
human life. We enjoy a greater
quality of life because of the
advances we have made in biologic research, in technology, and
in understanding our bodies and
the processes of disease and
aging. The status of our oral
health is not any different.
At one end of the street, wearing the white hat is the dentist.
Traditionally, he/she was armed
with a handpiece, a toothbrush,
some floss, some fluoride and a
pair of forceps. Over time, the
handpiece artillery expanded to
include higher speed turbines,
sonics, ultrasonics, and even
lasers. Restorative materials
evolved to better adapt and bond.
Dr. Steven Cohen is an endodontist on

staff at Sunnybrook Hospital Dental
Clinic and clinical instructor in the
graduate programme of Endodontics at
the University of Toronto. He maintains
a private practice limited to endodontics in Mississauga, ON, Canada.
Dr. Gary Glassman is a fellow and

examiner for the Royal College of
Dentists of Canada, is the endodontic
contributing consultant for Oral Health
Journal and maintains a private practice limited to endodontics in Toronto,
ON, Canada.
Joining the chemical warfare front

with fluoride are sodium hypochlorite, EDTA, calcium hydroxide,
chlorhexidine, citric acid, mineral
trioxide aggregate, and many
other agents. The single solitary
dentist has become a team leader,
delegating specific battlegrounds
to different specialists, each with a
specific niche. Replacing the pulps
of teeth is one battleground. Regenerating and /or grafting the
periodontal support structures are
another. Replacing the battlefatigued tooth (soldier) with an
implant is yet another.

At the other end of the street,
wearing black, is the bacteria.
Primitive, and very, very small,
this adversary has been around
since the beginning of time. What
it lacks in size, it makes up for in
huge numbers. It defines the
term opportunistic. The bacteria also have an armoury of
weapons, but these weapons are
not quite as tangible. First, there
is the huge number of them and
their ability to reproduce rapidly.
May 2006
12
oralhealth
E D I T O R I A L
Then there is resistance that

develops and evolves and challenges all the dentists chemical
antimicrobials. Mother Nature
then throws in the wild card of
genetic mutation, and new strains
and species develop. And if, just
for an instant, the dentist appears
to be gaining a foothold in this
battle; there is the one advantage
that bacteria have always made
the most opportunity out of. That
is the weakness of being human...
the human body, a variable
immune system, and at times a
non-compliant healing response.
Decay can and will happen.
Probing depths can get deeper.
Gingival tissue will recede. Pulps
can get inflamed and turn necrotic. Crown margins will leak after
a certain amount of time. Root
canal treatments can fail. When
asked how long a root canal treatment will last, probably the most
oralhealth
correct answer is: as long as the

coronal restoration of that tooth
stays sound. Coronal microleakage and recurrent contamination
is the most common cause for root
canal failure.
If a patient could not master
oral hygiene when there were
teeth present, what would change
when an implant is placed? The
added challenge with implants is
that there is an entire issue of the
health of the host and the health of
the recipient site that has to be
contended with. It doesnt matter
to the bacteria. They are opportunistic! They will go where the
microscopic space allows them,
and set up shop. It doesnt seem to
matter to the bacteria whether the
pocket they are thriving in is the
gingival-root cementum interface,
or the gingival-titanium interface.
To some degree, we are too crit-
May 2006
13
ical of ourselves. When we discuss

procedures and materials and
quote a success rate, we must
not forget that the other side of
that coin is failure rate. Of
course there are failure rates. We
are human beings treating other
human beings.
Throughout any battle, time
should be taken to stop and appreciate the victories and the gains
that have been made. The
weapons we use now to complete
basic and complex dentistry are
fantastic. Our arsenal has expanded tremendously, and the quality
of oral health in our country is
ranked one of, if not the highest in
the world. We should just be wary
of that same old enemy. The villain in the black hat is still waiting at the edge of town...and the
clock seems to be stuck at five
minutes before noon.
OH
@ARTICLECATEGORY:594;
USE OF OPHTHALMIC DYES IN ROOT CANAL LOCATION

C A S E P R E S E N TAT I O N
Use of Ophthalmic Dyes

in Root Canal Location
he relationship between uninstrumented root canals

and endodontic treatment
failure has been studied extensively. Locating all the canals,
then subsequently shaping and
cleaning them in their entirety
has shown to be essential for
predictable clinical and biological success.1-4
High visual magnification and fibre optic illumination incorporated in the
surgical operating microscope (SOM) has revolutionized endodontic therapy. The use of the SOM
has facilitated the ease
with which root canals are
found in their typical as
well as aberrant positions
during orthograde endodontic treatment.5,6
ORAL HEALTH
This is of even greater significance in teeth with full coverage

where the orientation markers of
the natural tooth cannot be seen,
floor anatomy, and teeth with

pulp chamber obliterations and
canal calcifications.
Any help in terms of marking
the pulp tissue in canal orifices
will facilitate the location of
canals in both conventional and
retreatment cases.
It is the purpose of this article to
illustrate the significance
and use of ophthalmic
dyes in the location of
and
root canal orifices.7
High visual magnification

fibre optic illumination
incorporated in the surgical
operating microscope (SOM)
has revolutionized
endodontic therapy.
Although the SOM is an indispensable aid in visualizing the

detailed anatomy of the pulp
chamber, it is essential to develop
the visual acuity to appreciate the
subtle differences that aid in the
location of the root canals. The inherent color differences between
the axial dentin and pulpal floor
10
dentin, the coronal dentin and

radicular dentin, as well as the
differences in color and consistency between soft tissue and hard
tissue will assist in locating the
root canal orifices.7
such as cusp tips, grooves and the

external contours of the root outlines. Other situations where the
pulpal road map has been
altered are teeth that have been
previously endodontically treated
where canals have been missed,
where prior occlusal access has
been made, altering the chamber
July 2003
14
Ophthalmic dyes (e.g.

Fluorescein sodium, rose
bengal) are currently
being used in opthamological diagnostic procedures and for locating
damaged areas of the
cornea due to injury or
disease.
Other uses for these dyes in

ophthalmology include detection
of epithelial defects, evaluation of
the nasolacrimal system, determination of tear breakup time,
angiography, location of nonepithelialized foreign bodies and
contact lens pressure points.8
Fluorescein sodium is available

in pharmacies as a clear, orangered solution as sterile, single-dose
disposable eye drops in cartons of
10 units. Each unit contains
approximately 0.5 ml. It is also
available as individual strips.
When the strips are used, the
agents can be reconstituted by
immersion in a dappen dish that
contains sterile water or 90%
alcohol (Figs. 1 & 2).
There are no serious contraindications reported for its use topical-
ly except possible hypersensitivity.

No serious side effects have been
reported except for nausea.8
There are few references for
the use of ophthalmic dyes and
fluorescence in dentistry. Those
that of are significance have studied the use of ultra-violet induced
fluorescence spectroscopy in diagnosis, pulp and root canal location, as well as using fluorescent
spectroscopy to measure the relative sealing efficiency of root
canal sealers.9-11
HOW THEY WORK

When these dyes come into contact with vital or nonvital pulp tissue they are readily absorbed by
the connective tissue elements of
the pulp in the chamber and root
canal system. When exposed to
blue light, these dyes dramatically
fluoresce showing scattered tissue
segments that contrast with the
surrounding monochromatic dentin. It is this quality that makes
them useful in the location of pulp
tissue in root canals especially in
those that are calcified and have
FIGURE 1Fluorescein sodium strips.
FIGURE 2Dye can be reconstituted by

placing the strip in sterile water.
FIGURE 3High magnification image

showing the isthmus between distobuccal and disto lingual canal in a lower
first molar.
FIGURE 4Pulp tissue in the isthmus takes

up the dye and on exposure to blue curing light fluoresces bright green.
FIGURE 5Canal orifices are enlarged

and the isthmus troughed between both
the distal canals.
FIGURE 6High magnification image

showing a clean isthmus, devoid of any
pulp tissue.
FIGURE 7Initial Access into the pulp

chamber of a maxillary first molar.
FIGURE 8Straight line access achieved

to Mb, Db and palatal canal. Notice the
hemorrhagic pulp and the pulp stone
obliterating entry into the canal orifices.
FIGURE 9 Pulp stone is removed exposing the floor of the chamber.
July 2003
15
ORAL HEALTH
11
FIGURE 10Pulp Chamber flooded with

Fluorescein sodium dye.
FIGURE 11Excess dye is vacuumed.

Stained pulp tissue can be seen as light
green under the incident light in the
microscope.
FIGURE 12Pulp tissue fluoresces bright

green under blue curing light with the
microscope light turned off.
FIGURE 13Red arrow points to the

stained and fluorescing pulp tissue
marking the orifice of MB2 canal.
FIGURE 14Black arrows point to stained

pulp tissue in the isthmus between MB ,
MB2 canal and DB and palatal canal
FIGURE 15MB2 canal located with a

.10 stainless steel hand file.
FIGURE 16Both the mesiobuccal canals

prepared.
FIGURE 17All canals obturated with

guttapercha. Palatal canal not in the
view. Matrix band with wedge in place
for the core placement.
FIGURE 18Preoperative radiograph of

a maxillary left first molar.
tissue remnants within.7
the operator can now visualize

the bright green fluorescence
emitted by the pulp tissue that
has absorbed the dye (Figs. 3 6).
tis subsequent to dental caries

had been made and endodontic
treatment was advised.
TECHNIQUE
Once straight-line access is
achieved and the coronal pulp tissue us removed, the pulp chamber
is flooded with fluorescein sodium
and allowed to contact all the
walls for a couple of minutes. The
excess is then suctioned away.
With the incident light from the
SOM turned off, blue light (dental
curing light) is used to illuminate
the chamber. With the aid of SOM
12
ORAL HEALTH
CASE REPORT 1
A 25-year-old healthy female
patient reported at the primary
authors private practice with
the chief complaint of toothache in the upper left first
molar. After clinical and radiographic examination completed,
a diagnosis of irreversible pulpi-
July 2003
16
Access into the pulp chamber

revealed a hemorrhagic pulp which
was removed. Three canals (mesiobuccal [MB], distobuccal [DB] and
palatal [P]) were readily detected
and straight-line access was directed to these canals.
In order to locate the mesiolingual (MB2) canal, the pulp
FIGURE 19Immediate Postoperative

radiograph of the maxillary left first
molar.
FIGURE 20Preoperative radiograph of

a maxillary right first molar with prior
access. Referring dentist could not
locate any of the buccal canals.
FIGURE 21Pulp chamber cleaned and

dried with 100% alcohol. No obvious
signs of any of the buccal canals.
FIGURE 22Access extended to below

the mesiobuccal cusp tip. Still no sign of
any of the buccal canals.
FIGURE 23Pulp Chamber flooded with

fluorescein dye.
FIGURE 24Pulpal tissue remnants fluorescing under blue curing light marking
the presence of the canal orifices.
FIGURE 25 Further troughing with ultrasonics in the marked areas reveal the
DB (red arrow) and mesiobuccal (blue
arrows) canals.
FIGURE 26All canals prepared. Red

arrow pointing to the unseccessful
attempt made by the referring dentist to
locate the Db canal. Notice the actual
location of it.
FIGURE 27Immediate postoperative

radiograph. Mb and Mb2 join in the
coronal third to exit as one canal.
chamber was flooded with fluorescein sodium. After suctioning the

excess, a blue curing light was
used to fluoresce the pulp tissue
in the chamber including the isthmus between the MB and MB2
canal. The MB2 canal was readily
located by the uptake of the dye
that emitted bright green fluorescence. All four canals were then
cleaned, shaped and obturated
and the access subsequently
restored (Figs. 719).
CASE REPORT 2
cleaned thoroughly with 5.25%

sodium hypochlorite, rinsed with
100% ethyl alcohol, and then
dried to visualize the anatomy of
the chamber floor. There were no
hints of thepulpal road map
leading to the buccal canals. The
access was then extended to
below the cusp tips to facilitate
straight-line access and pulp
chamber was flooded with fluorescein sodium. After suctioning
the excess, the chamber floor
A 42-year-old male patient was

referred to the primary authors
private practice after the referring dentist could not locate any
of the buccal canals in a maxillary
right first molar.
Radiographic examination revealed the canals appeared to be
calcified in the coronal two millimeters. Once access was
achieved, the pulp chamber was
July 2003
17
ORAL HEALTH
13
was examined through the SOM

with a blue curing light (with
the SOM light turned off). There
was a dramatic bright green florescence where the remnants of
pulp tissue were. On troughing
further with ultrasonic tips
(Endotips.com, San Diego, California) and exploration with DG16 endodontic explorers (HuFreidy, Chicago, Illinois) MB,
MB2, and DB canals were located. All canals were cleaned,
shaped and obturated and the
access
cavity
subsequently
restored (Figs. 20 through 27).
There is no one single technique that will allow all canals to
be found predictably 100% of the
time. Keeping an open mind to
new ways of thinking and accumulating the knowledge from
different sources will allow new
methods to emerge. The use of
ophthalmic dyes in finding hid-
14
ORAL HEALTH
den and calcified canals is another useful tool to be included in

the endodontic armamentarium
to guide our pathway to predictable clinical and biological
success.
OH
Acknowledgement
The authors would like to thank
Dr. Gary Carr (PERF) and members of ROOTS the Internet
based endodontic discussion forum, for their invaluable support.
Dr. Sashi Nallapati graduated

from the University of Health
Sciences, Govt. Dental College,
Hyderabad, India. He is currently in
general practice with special interest in endodontics in Ocho Rios,
Jamaica.
Dr. Glassman is the endodontic
Editorial Board member for Oral
Health.
July 2003
18
Oral Health welcomes this original article.

REFERENCES
1. Hoen, M. and Pink, F. Contemporary Endodontic
Retreatments: An Analysis based on Clinical Treatment
Findings JOE, Vol. 28, Number 12 (Dec 2002) 834-836.
2. Siqueira Junior JF, Etiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J 2001
Jan; 34(1): 1-10
3. S Crump, M. C. (1979). Differential diagnosis in
endodontic failure. Dental Clinics of North America
23(4): 617-35.
4. Cheung, G. S. (1996). Endodontic failureschanging
the approach. Int Dent J 46(3): 131-8.
5. Carr GB Retreatment, Pathways of the Pulp 7th edition, 1998, page 810,832.
6. Ruddle CJ, Microendodontic Non-surgical Retreatment dent.clin North America 41(3); 429,1997
7. Stephen Niemczyk, Intrinsic and extrinsic aids in
root canal location, Endodontic Therapy, vol 2 number 1, pg 7.
8. Newell FW.Ophthalmology; Principles and Concepts.
6th Ed St.Louis, MO, CV Mosby Co; 1986:124.
9. Foreman PC, Ultra-violet light as an aid to diagnosis.
Int Endod J (1983 Jul) 16(3): 121-6
10. Pini R, Salinbeni R, Vannini M, Cavalieri S, Barone R,
Clauser C, Lasers: Root canal diagnostic technique
based on ultra-violet induced fluorescence spectroscopy. Surg Med (1989) 9(4); 358-61
11. Taher, M, E. Sidky, et al. (1973). The use of fluorescent
dye for detecting the relative sealing efficiency of various root canal sealers. II. Qualitative assessment for
the effect of aging. Egyptian Dental Journal 19(2):
197-210.
THE NEW ERA OF FORAMENAL LOCATION

Kenneth S Serota, DDS, MMSc
The New Era of

Foramenal Location
Kenneth S. Serota, DDS, MMSc, Jorge Vera DDS,
Frederick Barnett, DMD, Yosef Nahmias, DDS, MSc
redictable endodontic success offering resistance and matrix cal narrowing (bracketed by the
demands accurate determina- style retention form against the minor apical diameter and apical
tion of, and strict adherence to condensation pressures of obtu- foramen.5,6,7 In teeth/roots with
the preparation length of the root ration (Figs. 2A-C).
apical periodontitis (AP) for examcanal space in order to create a
ple, a millimeter loss in working
small wound site and good healing
The determination of the in- length can increase the chance of
conditions.1 Each portal of exit strumentation finishing level is treatment failure by 14 percent.8
(POE) on the root face has biolog- one of the primary factors associic significance; this includes
The Toronto Study noted
the furcal canals of bifurcathat the highest healing
New modes of
tions and trifurcations, latrate differential (15 percent)
eral and accessory arborizaobserved
teeth with
debridement and disinfection was that wereinmost likely
tions and the myriad of apiAP
cal termini (Figs. 1A-D).
over-instrumented resulting
are constantly arriving
in transportation of contamin the endodontic
The ability to distinguish
inated debris periapically.9
between the inner-most
The evidence is indisputable
armamentarium.
(physiologic/histologic forathat electronic root canal
men) and outer-most (analength measuring devices
tomic foramen) diameters of the ated with the resolution of an provide significantly more accuapical terminus is essential to the endodontic infection both clinical- rate results than radiographs10,11
creation of the Apical Control ly and histologically.3,4 The major- and therefore offer greater control
Zone.2 The Apical Control Zone is ity of studies postulate that opti- of the creation of the Apical
a mechanical alteration of the mal success rates occur when Control Zone (Fig. 3).
apical terminus of the root canal instrumentation, debridement,
space that addresses the rheology disinfection and obturation are
In 1942, Suzuki discovered
of thermolabile filling materials, contained within the region of api- that the electrical resistance (sin-
48
oralhealth
August 2004
19
FIGURES 1B & CThe complexity of the root canal system has been graphically evidenced
since the work of Hess in the 1920s. Radical improvement in materials and techniques are
now enabling the clinician to replicate that complexity as evidenced in the cleared specimen (1B) and the radiograph (1C). (Courtesy of Dr. William Watson.)
FIGURE 1AArrows indicate multiple POEs associated with the
mesial-buccal and distal-buccal
apices of a maxillary first molar.
FIGURE 1D(right) The number, shape and diameter of the

physiologic foramena at the root apex mandate the continuing pursuit of excellence in endodontics through increased
sophistication in materials and methods and the alliance of scientific innovation and clinical acumen. From Gutierrez and
Aguayo, OS, OM, OP June 1995.
gle current source) between an

instrument inserted into a root
canal and an electrode attached
to the oral mucosa registered a
consistent value. In 1962, Sunada
using a direct current device with
a simple circuit, demonstrated
that the consistent electrical resistance between the periodontium and the mucous membrane
was 6.5 kOhms [DC Resistance].
Through the 1970s, frequency
measurements were measured
through the feedback of an oscillator loop by calibration at the
periodontal pocket of each tooth.
This culminated with the efforts
of Hasedgawa in 1979 with the
use of high frequency waves and a
specially coated file which could
record in conductive fluids.
In 1983, Ushiyama introduced
the voltage gradient method
where a concentric bipolar electrode measured the current density evoked in a limited area of
the canal. Maximum potential

was reached when the electrode
was at the apical constriction.
The mid 80s saw the development of a relative value of frequency response method where
the apical constriction was picked
by filtering the difference between two direct potentials after
a 1 kHz rectinlinear wave was
applied to the canal space.
A Third Generation electronic
foramenal locator (EFL) developed in the late 80s by Kobayashi
used multi-channel impedance/
ratio based technology to simultaneously measure the impedance of two different frequencies,
calculate the quotient of the
impedance and express it in
terms of the position of the electrode (file) in the canal. This
formed the basis of the technology used in the ROOT ZX (J.
Morita USA, Inc. Irvine, CA)
where no calibration was re-
quired and a microprocessor calculated the impedance quotient.

Fourth Generation EFLs (Elements Diagnostic, SybronEndo,
Orange, CA) measure resistance
and capacitance separately rather
than the resultant impedance
value (impedance being a function of resistance and capacitance) [Fig. 4A]. There can be different combinations of values of
capacitance and resistance that
provide the same impedance (and
thus the same foramenal reading); this can then be broken
down into the primary components and measured separately
ensuring better accuracy and less
chance for error. In addition, the
Elements unit uses a lookup
matrix (Fig. 4B) rather than making any internal calculations.
While calculations take place
very quickly, they are still relatively much slower than simply
August 2004
20
oralhealth
49
FIGURE 2AThe definitions of the morphologic

entities comprising the regional terminus of the
apex are shown diagrammatically with superimposition of the histologic anatomy.
looking up comparative values in

a pre-calculated matrix (in the
range of 10-20x slower). This
allows the unit to crunch
through much more data in a
given amount of time; a larger
sample size tends to make the
results more accurate. Figure 5
demonstrates the technologic
protocol difference between 3rd
and 4th generation foramenal
locators.
In the course of preparation of
this paper, the importance of regulation of battery power was
assessed. The Elements Diagnostic
circuitry runs at 3.3 volts (common
for electronics), which is internally
regulated to remain extremely
consistent. The battery pack is
rated at a nominal 6 volts, 7.5 volts
with a full charge and no load.
As the battery pack is depleted,
the voltage decreases to a point
where the electronics cannot continue to regulate the operating
voltage to such a precise value
and therefore the signals sent
through the electrodes will not be
as reliable either. The device is set
to automatically shut off when
battery voltage is a little above
this threshold.
50
oralhealth
FIGURE 2BRetreatment of tooth #4.6 with K3 nickel-titanium [NiTi] files

(G Pack system). The goal is identification of the histologic terminus of the
root canal space and the use of variable tapered rotary NiTi instrumentation to create an apical control zone and optimize the seal produced
by the new generation of resin thermoplastic root canal filling materials
and sealers. (Courtesy of Dr. Gary Glassman.)
FIGURE 2CRetreatment of tooth #3.6 with K3 nickel-titanium [NiTi] files

Varible Tip Varible Taper (VTVT) system. The K3 file sequence after the
two Orifice Openers/Body Shapers is: #35/.06, #30/.04, #25/.06,
#20/.04. In the majority of cases, the #25/.06 or the #20/.04 will
reach the desired working length on the first pass. If not, the sequence is
repeated from the beginning. (Courtesy of Dr. Fred Barnett.)
The ROOT ZX runs on AA

alkaline or lithium batteries
(mixing types is to be avoided)
and will shut itself off after twenty minutes. There is a bar graph
on the face of the unit which indicates residual battery power. The
question of the accuracy of signals sent through the electrode is
in doubt if the battery power
level drops below the first three
or four bars (authors observation) [Fig. 7].
A paper point measurement,
foramenal detection technique has
August 2004
21
been advocated by Rosenberg.12 It

is designed to determine the point
positional location of the apical
foramen as well as three-dimensional information regarding the
slope of the foramen. A trial paper
point is placed 1mm short of the
EFL determined length. If the
point is retrieved dry, it is
advanced further until fluid is
noted. The length of the segment
of the point that is dry is noted.
This sequence is repeated as
evidenced in Figs 6A, B & C and
the maximum length of the point
FIGURE 3The subtraction approximation technique; the average disparity of

0.5 to 1mm between the radiographic
apex or terminus (RT) and the cavosurface point of exit of the root canal space
used as the standard for length determination is fraught with inaccuracy.
FIGURE 4BLookup matrix generated

from in-vivo studies (x-axis capacitance,
y-axis resistance, vertical z-axis is resultant displayed location in the canal).
(Courtesy of Dr. William Watson.)
that can be placed into the canal

and remain dry reflects the orientation of the cavosurface of
the apical foramen (Fig. 6D).
FIGURE 4AFourth Generation foramenal locator (Elements Diagnostic,

SybronEndo, Orange CA).
There are several basic conditions that ensure accuracy of

usage for all generations of foramenal locators;
1) preliminary
debridement
should remove most tissue or
debris obstructions,
2) cervical leakage must be
eliminated and excess fluid
removed from the chamber as
this may cause inaccurate
readings,
3) extremely dry canals may result in low readings [long
working length],
4) long canals can produce high
readings [short working
lengths],
4) lateral canals may give a
false foramenal reading, and
5) the use with open apices is contraindicated. The residual fluid
in the canal should possess a
low conductivity value. In descending order of conductivity
these are; sodium hypochlorite
(NaOCl 5.25 percent), EDTA
(17 percent), Smear Clear
(SybronEndo, Orange, CA),
52
oralhealth
FIGURE 5The graphic shows the technologic difference between the operation of
third and fourth generation foramenal locators.
saline, FileEze (Ultradent

Products, S. Jordan, UT), and
isopropyl alcohol.
It is advisable to use a crown
down canal preparation technique13 and take the preliminary
electronic measurement using a
file that is approximately big
enough to bind at the apical con-
August 2004
22
striction.14 A second working

length measurement is advisable
after flaring the coronal and middle thirds as shortening of working
length occurs when instrumenting
curved canals; this shortening can
vary from 0.22mm to 0.5mm. However, once coronal flaring has been
done little change in length
occurs.15,16 From a medico-legal
standpoint, a verification radiograph is recommended at this

juncture. It is also advisable to do
a final confirmation EFL reading
after drying the canal and prior
to obturation.
In the case of the third generation ROOT ZX (Fig. 7), the
working length of the canal
used to calculate the length of
the filling material is actually
somewhat shorter; the length of
the canal up to the apical seat
(i.e. the end point of the filling
material) is found by subtracting 0.5 to 1.0mm from the working length indicated by the 0.5
reading on the meter.
The meters 0.5 reading indicates that the tip of the file is in
the vicinity of the apical foramen (i.e. an average of 0.2 to
0.3mm past the entrance to the
apical constriction towards the
apex). The disparity between
the EFL reading of such units
as the Ultima EZ and the ROOT
ZX is demonstrated to be the
+.0.5/-0.5 position indicated by
the 0.5 reading on the meter.
This finding has been consistently verified by numerous
investigators.17,18
A recent investigation of the
fourth generation EFL, the Elements Diagnostic (Sybron Endo,
Orange, CA) demonstrated an
unprecedented level of accuracy
in usage. Length calibrations
were performed on teeth to be
extracted, the files cemented to
position and the teeth cleared for
microscopic examination.19 In 22
out of 22 cases where the reading
of the file was taken to 0.0 or into
the minus numbers and withdrawn to the 0.5 mark on the
scale, the file terminus was consistent with the position of the apical constriction (Fig. 8A).
When the file was cemented
after going down to the 0.5 mark,
in 20 out of 24 cases, the file was
positioned a distance of 0.5mm
FIGURE 6AThe paper point is introduced coronal to the level of the EFL
determination. As it is shy of the cavosurface of the canal terminus, it should
remain dry. (Courtesy of Dr. David Rosenberg.)
FIGURE 6BHydrostatics will cause periapical fluids to accumulate on the

overextended paper point. (Courtesy of Dr.
David Rosenberg.)
FIGURE 6CThe angle of the paper point

discolouration reflects the three dimensional orientation of the cavosurface of the apical foramen. (Courtesy of Dr. David Rosenberg.)
FIGURE 6DThe terminus of the canal is

not a point in space; it is a multidimensional, topographically diverse plane.
FIGURE 7The Root ZX is a fully automatic, self-calibrating root canal foramenal locator.
FIGURE 8AWhen the file glide path is

stopped at 0.5 on the digital display,
the units accuracy in determining the
apical foramen is less than 85 percent.
from the external foramen (Fig.

8B). Of note was the finding that
when the device displayed a
minus number, the file was
always beyond the apical constriction and in most cases out of
the root structure (Fig. 8C).
CONCLUSION
(Courtesy of Dr. David Rosenberg.)
Evolutionary technologic sophistication is the hallmark of all

scientific and clinical endeavour.
Endodontics is the bedrock of all
comprehensive care. As such, it is
imperative that predictable endoAugust 2004
23
oralhealth
53
FIGURE 8BWhen the file reaches the

periodontal ligament, the digital display
shows 0.0. When the file is withdrawn
0.5mm, an instrumentation terminus
point consistent with the apical constriction resulted 100 percent of the time.
dontic success is projected as

close to 100 percent as biologically possible. Outcome assessment
studies indicate that formenal
position is a pivotal factor if not
the pivotal factor in the most
favourable end result. New modes
of debridement and disinfection
are constantly arriving in the
endodontic armamentarium. The
Fourth Generation of foramenal
locators will ensure that their
usage in evolutionary endodontic
54
oralhealth
FIGURE 8CWhen the file glide

path is extended into a negative
reading on the display, the file
was out of the canal in all cases.
protocols is optimized.
OH
Drs. Serota, Vera, Barnett, Nahmias,

Watson and Glassman are members
of the cybercommunity ROOTS
www.rxroots.com.
Oral Health welcomes this original
article.
REFERENCES
1. Simon JHS. The apex: How critical is it? Gen Dent
1994 42:330-4.
2. Serota KS, Nahmias Y, Barnett F, Brock M, Senia ES.
Predictable endodontic success. The apical control
August 2004
24
zone. Dent Today. 2003 May;22(5):90-7.

3. Chugal NM, Clive JM, Spangberg LS. Endodontic
infection: Some biologic and treatment factors associated with outcome. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2003 Jul;96(1):81-90.
4. Ricucci D, Langeland K. Apical limit of root canal
instrumentation and obturation, Part II: A histological
study. Int Endod J 1998;31:394-409.
5. Dammaschke T, Steven D, Kaup M, Ott KH. Longterm survival of root-canal-treated teeth: A retrospective study over 10 years. J Endod. 2003 Oct;29
(10):638-43.
6. Kojima K, Inamoto K, et al. Success rate of endodontic treatment of teeth with vital and nonvital pulps. A
meta-analysis. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2004 Jan;97(1):95-9.
7. Basmadjian-Charles CL, Farge P, Bourgeois DM,
Lebrun T. Factors influencing the long-term results of
endodontic treatment: a review of the literature. Int
Dent J. 2002 Apr;52(2):81-6.
8. Vachey E, Lemagnen G, Grislain L, Miquel JL. Alternatives to radiography for determining root canal
length. Odontostomatol Trop. Sep 2003;26(103):15-8.
9. Friedman S, Abitbol S, Lawrence HP. Treatment
Outcome in Endodontics: The Toronto Study. Phase I:
Initial Treatment. J Endod December 2003;29
(12):787-793.
10. Pratten D, McDonald NJ. Comparison of radiographic
and electronic working lengths. 1996 J Endo April
1996;22(4):173-6.
11. Pommer O. In vitro comparison of an electronic root
canal length measuring device and the radiographic
determination of working length. Schweiz Monatsschr
Zahnmed. 2001;111(10):1165.
12. Rosenberg D. Paper Point Technique: Part II.
Endodontic Practice May 2004 7;(2):7-11.
13. Ibarrola JL, Chapman BL, Howard JH, Knowles KI,
Ludlow MO. Effect of preflaring on Root ZX apex locators. J Endod September 1999;25(9):625-6.
14. Nguyen HQ, Kaufman AY, Komorowski RC, Friedman
S. Electronic length measurement using small and
large files in enlarged canals. Int Endod J. 1996
Nov;29(6):359-64.
15. Davis RD, Marshall JG, Baumgartner JC. Effect of
early coronal flaring on working length change in
curved canals using rotary Nickel-Titanium versus
stainless steel instrumentation. J Endod 2002;
28:438-441.
16. Caldwell JL. Change in working length following instrumentation of molar canals. Oral Surg Oral Med Oral
Path 1976; 41:114-8.
17. Welk A, Baumgarnter C, Marshall G. An in vivo comparison of two frequency-based electronic apex locators. J Endod August 2003; 29(8):497-500.
18. Shabahang S, Goon WW, Gluskin AH. An in vivo evalution of ROOT ZX electronic apex locator. J Endod
November 1996; 22(11):616-8.
19. Vera J, Gutierrez M. Accurate working length
determination using a fourth generation apex locator (in press).
THE ELEMENTS DIAGNOSTIC

SYSTEM: GETTING DIALED IN
The Elements Diagnostic System:

Getting Dialed In
Rich Mounce, DDS
Orange, CA), there is an analogy to my board sailindsurfing can be an incredible rush when
ing days. When I am using the Elements unit, I feel
you are on the right sized board and sail, in
as though I am effortlessly dialing in the apex
great wind and everything is tuned correctly.
much like it feels on a sailboard when everything is
Its hard to describe the feel of the wind and speed
working right.
as youre literally flying across the water on a cushion of air. Its like strapping on a rocket.
Determination of workWindsurfers call this being
ing length should be a
dialed in where all the
multifactorial process inaspects of their equipment
corporating several methand body position are
ods to ensure accuracy in
tuned perfectly to give
case a single technique
maximum speed and balproves unreliable. Root
ance. Sailing well in such
canal systems should be
conditions is almost effortinstrumented to the minor
less. Like a windsurfer who
constriction of the apical
does not have their gear
foramen at the dentin
tuned correctly, having an
cementum junction (Fig.
unreliable apex locator or
1). The four methods for
one that is challenging to
determining the correct
use can be incredibly diffiworking length (the point
cult and frustrating in the
mentioned above) are: 1)
heat of the battle. As I am
Tactile sense 2) Radiousing the new fourth-gengraphic 3) Bleeding point
eration, state-of-the-art
and 4) Electronic Apex
combination apex locator
location. Practicing endoand electric pulp tester, the
Elements Diagnostic Unit- FIGURE 1The ideal termination point of a root canal fill- dontics without a reliable
EDU (SybronEndo, former- ing is B above, the apical constriction. Image provid- Apex locator would be like
windsurfing with only one
ly known as Analytic, ed by SybronEndo, Orange, CA.
42
oralhealth
December 2003
25
FIGURE 2The new fou rth-gene ration Elements Diagnostic

Unit from SybronEndo (Orange, CA). Image provided by
SybronEnclo, Orange, CA.
size sail. It might work in one wind condition, but

could be very dangerous in many others. Knowing
where one is at all stages of cleansing and shaping
the root canal system is essential to excellent
debridement and avoidance of a host of procedural
errors (ledges, zips, perforations, creation of blockages, etc.) that result from instrumenting without a
clear sense of where the operator is. The purpose of
this article is to discuss the new EDU, which is
based on new electric and mathematic criteria compared to its predecessors. Specific suggestions for
its use are also included.
FIGURE 3AThe Satellite portion of the machine can be

clipped to the patient napkin to save time having to look
away behind the operative field for the position of the file in
the canal.
much like the x/y axis chart from our high

school math. In other words, because the machine
determines the resistance and capacitance, it can
give the location of the file tip instantly without
all the calculations needed by the previous generation of machines leading to more accurate and
consistent readings with all types of fluids (blood,
pus, sodium hypochlorite, EDTA, water, etc.) in
the canal system.
Apex locators generally are very accurate but

for greatest success they must be used in conjunction with at least one of the other three methods of
working length determination listed above. A
working length confirmed by at least two methods
is generally very accurate, all things being equal.
Apex locators are invaluable in the treatment of
teeth, which are difficult to radiograph for a variety of anatomic reasons, in all patients where
reduction of radiation exposure is desirable (pregnancy) and for the disabled and those with a
heavy gag reflex.
The EDU (Fig. 2) has a separate monitor called a

Satellite which can be clipped on to the patients
napkin or whatever surface is desired for ease of use
(Figs. 3A & B). This ergonomic feature allows the
operator to look forward at the satellite and be more
focused on the area of treatment as compared to
conventional units, which make the operator look
backward to see the monitor screen. While the satellite is not autoclavable, all of the cords of the unit
are. Pinnacle Dental Products makes a 4x6
Cover-All (model #3700-C) custom-fit barrier
cover for the satellite to prevent cross-contamination. The satellite is attached to the machine by an
umbilical. Both the main monitor and the satellite
have non-glare surfaces, which are very easy to read
even from a distance.
Previous generations of Apex locators (thirdgeneration machines in particular) were able to

extract impedance from the signals used. This
required a great deal of mathematical calculation
by the units in order for them to give a reading
and often caused hang up much like a computer
with many programs opened at the same time,
causing either an inaccuracy in the reading or the
device to flutter. The EDU measures resistance
and capacitance directly allowing the machine to
reference an internal set of pre-computed values
The EDU has an auto power off function to

December 2003
26
oralhealth
43
save battery life. The batteries are rechargeable

and last several weeks on a single charge. The
unit is self-calibrating. In other words, it is ready
to use for every patient without an additional
step to customize it to the individual patient,
thus saving time. The unit comes with various
probes and tips to allow electric pulp testing and
apex location in a variety of clinical settings (it
comes with a crown tip, vitality tip, bifurcated
probe and file clip).
When the file is moving

down the canal, the unit
reads a length, which intuitively
feels right given the tactile
information one is sensing
in the fingertips.
There are several general suggestions I have for

using the system, some of which are germane for all
Apex locators and the EDU in particular:
FIGURE 3BPinnacle barriers to prevent cross-contamination

for the Elements Diagnostic Satellite.
1. Use the largest file which will fit to the

desired length in the canal. Small files left
dangling in large canals can introduce inaccuracy in readings.
length from this image. The Apex locator then

confirms the actual working length after instrumentation. Subsequently, working length is
often verified again by the presence of a small
bleeding spot on the tip of a paper point at working length prior to obturation (denoting apical
patency) and/or by pre-obturation master cone
radiographs. A case treated in a similar fashion
is presented in Figures 4 A-D. Dr. Dave Rosenberg of Vero Beach, FL, recently wrote an excellent article (Part 1 of 2) in Dentistry Today
(March 2003) on how to use paper points to aid
in determination of working length.
2. In large canals, attaching the file clip to a rotary

nickel titanium file after creation of a glide path
can actually give a moving assessment of where
the rotary file is as it progresses down the canal
system during instrumentation, especially in the
apical third.
3. All apex locators are most effective when the vast
majority of pulp tissue has been removed from
the root canal system. Using them prior to the
removal of the greatest volume of pulp tissue possible tends to pack the apical thirds of small
canals with bits of pulp, which may prove impassable or create a greater possibility for inaccurate
readings.
5. All apex locators can be expected to show some

inaccuracies with immature root end development.
Verification in such situations radiographically is
essential.
The EDU needs to be tested in a double blind,
university-based study against other similar machines on the market. I suspect it will compare very
favorably to its competition. Empirically, in my
hands, this apex locator is more stable, accurate and
easier to dial in than the older models I have used
previously. When the file is moving down the canal,
the unit reads a length, which intuitively feels
right given the tactile information one is sensing in
4. Although apex locators can be used in a myriad

of ways, many endodontists use an apex locator
only after they are essentially finished instrumenting the canal and to verify the final canal
length. Initially, at the start of the case, it is
common to expose a film with a file in the canal
and instrumentation is taken to the desired
44
oralhealth
December 2003
27
FIGURES 4A-DRecent case treated with the Elements Diagnostic System. Included
are the important cone fit confirmation radiograph and two final films including one
from an off angle to separate the mesial canals and evaluate each individual canal
obturation.
the fingertips. Hence the monitor

reads a length, which confirms
what the operator senses is actually going on in the canal as the
file moves apically. Ive never
seen or felt an apex locator perform this way before. The sound
upon locating the apex is adjustable which can be a pleasant
change from the squawking of
my previous machines. In the
past, it was very frustrating to be
well into a procedure and not be
able to get an accurate reading
for often unpredictable and
uncertain reasons. Ive not encountered this type of variability
with the EDU. The EDU performs consistently in my hands
and has been easy to learn how to
use. Unlike previous systems, I
didnt need to learn when the
machine was lying to me and
try to take evasive action as was
common before. In other words, it
does not require the interpretation so common with all the other
apex locators I have owned.
Every edge that we can possess to make our endodontic

treatment more efficient, accurate, enjoyable and practical is a
step in the right direction. Correct determination of working
length is a critical step in the performance of excellent endodontics. If youve not been using
an apex locator or your machine
has been less than truthful with
you, the EDU (while it cant
duplicate the rush of flying on a
sailboard!) is an opportunity to
help make your endodontics more
predictable and dialed in for the
best possible performance.
OH
Dr. Mounce is in private endodontic practice in Portland, OR. He lectures worldwide and is widely published. Dr. Mounce has no commercial interest in the Elements Diagnostic System or SybronEndo.
Reprinted with permission, Doctor
of Dentistry, Oregon/SW Washington.
28
December 2003
oralhealth
45
A PREDICTABLE PROTOCOL FOR THE

BIOCHEMICAL CLEANSING OF THE ROOT
CANAL SYSTEM
A Predictable Protocol
for the Biochemical Cleansing
of the Root Canal System
By Gary D. Glassman DDS, FRCD(C) and Kenneth S. Serota DDS, MMSc
he triad of biomechanical
preparation, chemotherapeutic sterilization and threedimensional obturation is the
hallmark of endodontic success.
The purpose of this article is to
provide the reader with a review
of the variables that are fundamental to the most sophisticated
irrigation protocol available in
order to achieve the highest standards of success and excellence
now possible in endodontics.
APICAL PATENCY
A study performed by Dr. Gary
Carr (personal communication) of
the PERF Institute (San Diego,
CA) assessed the level of penetration of commonly used irrigants
when optimized by the introduction of overproof/absolute (96% by
volume) ethyl alcohol into root
canals. Teeth were shaved sagittally leaving a thin layer of dentin
over the root canal space that
appeared transparent when wet. It
was possible to view the manner
by which the motion of the file
impacted on the flow of the irrigant along the length of the root
canal. In this model, it was
observed that the irrigant did flow
into the apical area after the file
was removed. However, it was
noted with even more significance
that as sodium hypochlorite
(NaOCl) was alternated with
absolute alcohol, the irrigant would
flow into the apical area as if a file
were being used, provided apical

patency had been established.
Absolute ethyl alcohol reduces
the dentinal surface tension and
enables the irrigant to flow unimpeded through the entire length of
the root canal and into the vaguaries and intricacies that exist in the
root canal system. The conclusion
reached by this experiment was
that the failure to get irrigant into
the apical third of the root canal
when patency files were not used
was more of a surface tension issue
than a mechanical one.
A recent study by Gamberini1
demonstrated that the use of 1%
Triton X-100 (Sigma Corp., St.
Louis, MO), a tensioactive agent,
would enhance debridement when
used in combination with NaOCl
and 17% EDTA. It would appear
that surfactants of one form or
another will play a increasingly
important role in the endodontic
irrigation protocol.
At this juncture however, the
authors conclusion is that it is
reasonable to include overproof
ethyl alcohol during the irrigation
protocol to enhance the penetrability of other irrigants throughout the root canal system and
dentinal tubules.
IRRIGANT DELIVERY
It has been shown clearly that the
deeper penetration afforded by

side irrigation needles such as the
Maxi-i-Probe (MPLTechnologies,
Franklin Park, IL, Monoject - BD,
Franklin Lakes, NJ, Endo-Eze,
Ultradent
Products,
South
Jordan, Utah) with diameter sizes
as small as .032 inches leads to
more effective irrigation.2 Indeed,
there are studies that suggest
that effective irrigation may not
occur unless the canals are
enlarged to at least the diameter
of a No. 40 instrument. Other
studies have shown that no apical
flushing will occur until proper
flaring of the canal and an apical
diameter of a #25 instrument has
been achieved.3,4 The use of apical
patency files must be used to
allow penetration of the root
canal irrigants to working length.
Numerous case reports describing extreme pain, edema,
and hematoma formation following the inadvertent extrusion of
sodium hypochlorite into the soft
tissues. This occurs when end
vented irrigating needles are
used by injecting the irrigating
solutions under pressure. This
adverse affect is easily avoided
by introducing side vented irrigating needles into the root canal
and delivering the solutions in a
passive manner avoiding any
binding of the needle in the canal
whatsoever. When delivered in
this manner the incidence of
July 2001
29
ORAL HEALTH
19
reported cases of so called irrigating accidents will decrease

dramatically.
SODIUM HYPOCHLORITE
Three percent hydrogen peroxide
solution has long been out of
favour in the endodontic irrigation protocol; its inclusion did not
increase the solvent action of
NaOCl.5 Furthermore, It has been
well documented for more than
100 years that sodium hypochlorite (hypochlorous acid) alone will
remove pulpal remnants, organic
debris and predentin from instrumented and uninstrumented surfaces of the root canal space. Only
recently have researchers determined theoretically how chlorine
derivatives disinfect by their
action on gram-negative bacteria.
They act by attacking the bacterial cell wall, altering it physically,
chemically and bio-chemically
thereby terminating the cells
vital functions and killing the
microorganism.
A possible sequence of events during
chlorination would be:
1) disruption of the cell wall barrier by reactions of chlorine with
target sites on the cell surface
2) release of vital cellular constituents from the cell
3) termination of membrane-associated functions
4) termination of cellular functions within the cell
During the course of these
events, the microorganism dies,
meaning it is no longer capable of
growing and causing disease.
Shuping et al6) have recently
shown that when using 1.25%
NaOCl, the apical portion of the
root canal must be enlarged to at
least a diameter 0.279mm for it
to be more effective in eliminating microorganisms than saline.
The question of concentration has
been addressed by Baumgartner
and Cuenin.7 While varying dilutions were still effective in
removing organic debris, a full
strength solution (5.25%) of
20
ORAL HEALTH
NaOCl delivered with either an

endodontic irrigation needle or an
ultrasonic device proved most
effective with no perceptible
injury of the peripheral attachment apparatus.
Of note; one of the primary disadvantages of NaOCl (Chlorox) has
been its smell. The introduction of
fresh scent sodium hypochlorite
(Clorox) has eliminated that problem. Harrison et al.8 demonstrated
that formulary changes involved in
the manufacture of the fresh
scent sodium hypochlorite had no
apparent effect on its antimicrobial
properties.
THERMO-ACCELERATION
A study by Cunningham et al.9
demonstrated that while the in
vitro bactericidal action of sodium
hypochlorite solution was comparable at room temperature (22C)
and at body temperature (37C),
sterility was achieved in significantly less time at 37C. A study
by Berutti et al (10) compared the
effect of 5% sodium hypochlorite
solution at 21C and at 50C. The
findings demonstrated that in the
middle third of the root canal
space, where NaOCl had been
used at 50C, the smear layer was
thinner and made of finer, less
well-organized particles than
where it had been used at 21C.
In the apical third, the smear
layer was of almost the same
thickness in the two groups of
specimens, although the particles
were finer where the NaOCl had
been used at 50C.
Irrigation syringe warmers are
now commercially available (Vista
Dental, Racine WI). Thermo-acceleration of an irrigation solution
would logically speed up the dissolution of organic debris in much
the same way that sugar dissolves
in hot water quicker than in cold
water. Alternatively, the solution
can be microwaved before the procedure and coffee cup warmers
can be used to hold the solution
container during the procedure.
July 2001
30
ANTIMICROBIAL EFFECT OF
IRRIGANT COMBINATIONS
WITHIN DENTINAL TUBULES
The most effective irrigation sequence for removing the smear
layer and other debris is the alternating sequence of sodium hypochlorite (NaOC1) and ethylenediamine tetra acetic acid (EDTA).
NaOC1 will dissolve and aid in
the removal of the organic component and EDTA will aid in the
removal of the inorganic calcific
component of the smear layer (the
combined organic and inorganic
layer that is produced during
canal instrumentation left behind
on the root canal walls, which
may occlude accessory canals and
dentinal tubules). The inclusion of
absolute ethyl alcohol in the
sequence will increase the penetrability of both irrigants. The
inclusion of CHX (chlorhexidine)
in this sequence has been demonstrated to further synergize its
effectiveness. Many studies have
noted a significant decrease in
cleaning efficiency as the apical
end of the canal was approached.
This was corrected in a study by
wherein it was demonstrated that
30 second ultrasonic pulses of the
irrigant between file sizes particularly as the apical terminus was
approached would effect almost
total smear layer removal.11
EFFICACY OF THE CROWN DOWN

APPROACH IN RESERVOIR CREATION
It is generally appreciated that
various techniques for root canal
instrumentation may have different effects in cleaning curved root
canals, especially their apical portions.12 The consensus indicates
that the balanced-force technique
produced a cleaner apical portion
of the canal than did the other
techniques studied. The Balanced
Force or Crown Down technique
first advocated by Roane13 creates
a reservoir of increasing diametral size that facilitates the ionic
exchange demonstrated by EDTA
to work and enhances the reactivity of the constantly replenished
and heated NaOCl. This same
effect can be achieved by practicing a crown-down shaping

approach using variable tapered
Ni-Ti instruments.
CHLORHEXIDINE
A study by Leonardo et al14 suggests that 2% chlorhexidine prevents microbial activity in vivo
with residual effects in the root
canal system up to 48 h. In a study
by Vahdaty15 solutions of 0.2% and
2% chlorhexidine, 0.2% and 2%
sodium hypochlorite (NaOCl) and
normal saline were tested for their
efficacy in disinfecting dentinal
tubules following root canal irrigation in vitro. The results indicated
that chlorhexidine and NaOCl
were equally effective antibacterial agents at similar concentrations
against the test microorganism.
They significantly reduced the
bacterial counts in the first 100
microns of dentinal tubules.
Studies16,17,18 have demonstrated
that the 2% CHX concentration
instilled greater and longer lasting antimicrobial activity then the
0.12% CHX concentration.
TIME
The duration of irrigation remains
the most important variable contributing to an effective and efficient cleansing action of the prepared root canal system.19 The
longer the irrigant is in contact with
the root canal, the greater the
antimicrobial, tissue dissolving and
smear layer removal effectiveness
will be. The advent of NiTi rotary
instruments has proven to be more
effective in the tapering design of
the root canal space than traditional hand instrumentation. However,
the cutting speed of NiTi instrumentation may reduce the time
component that under the circumstances may prove to be disadvantageous to a successful end result.
The variables of heat, ultrasonic
vibration, and variable irrigant
combinations must be factored into
the equation to compensate for time
adjustment that may be decreased
by using NiTi instrument systems.
ULTRASONIC INSTRUMENTATION
Perhaps the most dramatic study
conducted on the debridement
efficacy of the ancillary usage of
ultrasonics in canal preparation is
the work of Archer et al.20 This
study evaluated two groups of
mandibular molars. Group I was
prepared using a traditional
instrumentation technique and
intermittent irrigation with 5.25%
NaOCl. In Group II, 3 minutes of
ultrasonic instrumentation was
performed per canal after instrumentation. The results were
assessed at mm levels from the
apical terminus. At every point of
comparison, the cleanliness levels
with the ultrasonic usage were as
much as 30% higher in Group II.
Of particular significance was the
dramatic percentage differential
in the isthmus areas (the thin
areas of communication between
principal canals) of Group II.
Ahmad et al reported that the
physical mechanisms of ultrasound, namely cavitation and
acoustic streaming, in conjunction
with 2.5% sodium hypochlorite
solution demonstrated powerful
bactericidal activity.21 Studies22,23
demonstrated that ultrasonic irrigation with 5.25% NaOCl successfully eradicated bacteria from an
artificially created smear layer
while the introduction of 5.25%
NaOCl irrigation alone with a
syringe was insufficient. Ultrasonic irrigation with less concentrated NaOCl failed to eliminate
bacteria completely from reservoir channels in most samples.
OPTIMIZING CLINICAL SUCCESS

The authors recommend that
sodium hypochlorite solutions not
be stored from use to use. The
reservoir, especially if uncovered,
should be replenished with new
solution for each new procedure.
The stability of sodium hypochlorite is adversely affected by exposure to high temperature, light,
air, and the presence of organic
and inorganic contaminants. The
tissue-dissolving ability of 5.25%
sodium hypochlorite remains stable for at least 10 weeks. The tissue-dissolving ability of 2.62%
and 1.0% sodium hypochlorite
remains relatively stable for 1
week after mixing and then
exhibits a significant decrease in
tissue-dissolving ability at 2
weeks and beyond.24
The authors recommend that
sodium hypochlorite should be
heated to between 60C and 70C
to enhance the chemical reactivity of the solution during usage.
RC-Prep (Premier Dental Products, King of Prussia, PA) or any
other chelating agent that contains urea peroxide may be used
during the initial phase of instrumentation. The urea peroxide
allows emulsification of the dental
pulp that will help in the prevention of soft tissue compaction. A 2.5
cc NaOCl flush is recommended
after each instrument during this
phase to remove the accumulated
dentin debris. Replenishment of
the RC-Prep et al is recommended
before the next instrument usage.
Heated 5.25 % NaOCl and room
temperature 17% aqueous EDTA
may be used. The most effective irrigation sequence for removing the
smear layer and other debris is
EDTAC/NaOCl/EDTAC etc. This
should be performed during the
entire shaping protocol of the root
canal preparation in combination
with absolute ethyl alcohol.
A 2% solution of chlorohexidine
may be used to flush each canal at
this time to increase bacterial
elimination.
After completion of the canal
shaping, it is recommended that a 5
cc flush of 17% EDTA be used with
ultrasonic vibration in each canal
(performed with a file tip in many
proprietory ultrasonic devices) for
approximately 30 seconds, followed
with a 10 cc flush of each canal
using 5.25% NaOCl with ultrasonic vibration for 30 seconds.
July 2001
31
ORAL HEALTH
21
Absolute alcohol is then used to flush out the root

canal to allow drying and dehydration. Minimal
paper points will be required to absorb residual
moisture. Access to accessory and lateral canals as
well as dentinal tubules is maximized prior to obturation by following this protocol.
CONCLUSION
The future holds the possibility that lasers will be
used to sterilize the root canal system, heat the irrigants and weld the dentinal tubules shut. The NDYag laser and experimental procedures with the
Erbium Wavelength laser are being assessed for
these purposes.25,26 Other studies are evaluating the
use of electrolyzed neutral water which exhibits a
bacteriostatic/bactericidal action against isolates
obtained from infected root canals.27
As the biochemical cleansing protocol of the root
canal system evolves, the science of endodontics is
rapidly approaching a time when 100% predictable clinical success will be a reality rather than an objective. OH
Gary Glassman is the Endodontic board member for

Oral Health and examiner for the Royal College of Dentists
of Canada. He maintains a private practice limited to
endodontics in downtown Toronto. Dr. Glassman has
recently received a Fellowship in the Academy of Dentistry
International.
50(6):569-71, 1980.
10. Berutti E, Marini R. A scanning electron microscopic evaluation of the debridement
capability of sodium hypochlorite at different temperatures. J Endodon 22(9):467-70,
1966.
11. Abbott PV, Heijkoop PS, et al. An SEM study of the effects of different irrigation
sequences and ultrasonics. Int Endod J 24(6):308-16, 1991.
12. Ram Z. Effectiveness of Root Canal Instrumentation. Oral Surgery, Oral Medicine, Oral
Pathology 44(3):306-9, 1977.
13. Roane JB. Principles of Preparation using the Balanced Force Technique. In: Hardin
JF, ed. Clarks Clinical Dentistry. Philadelphia, PA, USA. JB Lippincott Co.
14. Leonardo MR, Tanomaru Filho M, et al. In vivo antimicrobial activity of 2% chlorhexidine used as a root canal irrigating solution. J Endodon 25(3):167-71, 1999.
15. Vahdaty A, Pitt Ford TR, et al. Efficacy of chlorhexidine in disinfecting dentinal tubules
in vitro. Endodontics & Dental Traumatology 9(6):243-8, 1993.
16. Cameron JA. The choice of irrigant during hand instrumentation and ultrasonic irrigation
of the root canal: a scanning electron microscope study. Aust Dent J 40(2):85-90, 1995.
17. Cameron JA. Factors affecting the clinical efficiency of ultrasonic endodontics: a scanning electron microscopy study. Int Endod J 28(1):47-53, 1995.
18. Ciucchi B, Khettabi M, et al. The effectiveness of different endodontic irrigation procedures on the removal of the smear layer: a scanning electron microscopic study. Int
Endod J 22(1): 21-8, 1989.
19. Wu MK, Wesselink PR. Oral Surgery, Oral Medicine, Oral Pathology. 79(4):492-6, 1995.
20. Archer R, Reader A, et al. An in vivo evaluation of the efficacy of ultrasound after stepback preparation in mandibular molars. J Endodon 18(11):549-52, 1992.
21. Ahmad M, Pitt Ford TR, et al. Effectiveness of ultrasonic files in the disruption of root
canal bacteria. Oral Surgery, Oral Medicine, Oral Pathology 70(3):328-32, 1990.
22. Huque J, Kota K, et al. Bacterial eradication from root dentine by ultrasonic irrigation
with sodium hypochlorite. Int Endod J 31(4):242-50, 1998.
23. Sjogren U, Sundqvist G. Bacteriologic evaluation of ultrasonic root canal instrumentation. Oral Surgery, Oral Medicine, Oral Pathology 63(3):366-70, 1987.
24. Johnson BR, Remeikis NA. Effective shelf-life of prepared sodium hypochlorite solution. J Endodon 19(1):40-3, 1993.
25. Hardee MW, Miserendino LJ, et al. Evaluation of the antibacterial effects of intracanal
Nd:YAG laser irradiation. J Endodon 20(8):377-80, 1994.
26. Fegan SE, Steiman HR. Comparative evaluation of the antibacterial effects of intracanal Nd:YAG laser irradiation: an in vitro study. J Endodon 21(8):415-7, 1995.
27. Horiba N, Hiratsuka K, et al. Bactericidal effect of electrolyzed neutral water on bacteria isolated from infected root canals. Oral Surg Oral Med Oral Pathol 87(1): 83-7, 1999.
Kenneth Serota is the Endodontic contributing consultant for Oral Health. He maintains a private practice limited to endodontics in Mississauga, ON.
The authors wish to thank the members of the Internet
discussion forum ROOTS roots@ls.canaden.com
(www.rxroots.com) for their contribution to this article.
The information contained within was derived from related email messages sent from over 400 practitioners from
around the world.
REFERENCES
1. Gambarini G. Shaping and cleaning the root canal system: a scanning electron
microscopic evaluation of a new instrumentation and irrigation technique. J Endodon
25(12):800-3, 1999.
2. Abou-Rass M, Piccinino MV .The effectiveness of four clinical methods on the removal
of root canal debris. Oral Surgery;Oral Medicine and Oral Pathology 54:323-8, 1998.
3. Salzgeber RM, Brilliant JD. An in vivo evaluation of the penetration of an irrigating
solution in root canals. J Endodon 3(10):394-398, 1977.
4. Mader CL, Baumgartner JC, Peters DD. Scanning electron microscopic investigatin
of the smeared layer on root canal walls. J Endodon 10(10):477-483, 1984.
5. The SD. The solvent action of sodium hypochlorite on fixed and unfixed necrotic tissue. Oral Surgery, Oral Medicine, Oral Pathology 47(6):558-61,1979.
6. Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria
using nickel-titanium rotary instrumentation and various medications. J Endodon
26(12):751-755, 2000.
7. Baumgartner JC, Cuenin PR. Efficacy of several concentrations of sodium hypochlorite for root canal irrigation. J Endodon 18(12):605-12, 1992.
8. Harrison JW, Wagner GW, et al. Comparison of the antimicrobial effectiveness of regular and fresh scent Clorox. J Endodon 16(7):328-30, 1990.
9. Cunningham WT, Joseph SW. Effect of temperature on the bactericidal action of
sodium hypochlorite endodontic irrigant. Oral Surgery, Oral Medicine, Oral Pathology
22
ORAL HEALTH
July 2001
32
DOES NITI NIRVANA EXIST?

D
E
T H E
R E P O R T
oes NiTi Nirvana Exist?
myriad of rotary
nickel
titanium
(RNT) file systems
have been introduced in the
past decade. Unfortunately,
there is no perfect rotary
nickel titanium instrumentation system (what I would
call NiTi Nirvana), but all
systems, if they are used Richard E. Mounce, DDS
Private Practice
appropriately, can be used to
Portland, Oregon
produce an excellent canal
shape. Systems vary widely with regard to tactile sense,
fracture resistance, cutting efficiency, flexibility, and
avoidance of transportation based on their design features.
With regard to these features, several of the following
instruments have been discussed in the dental
literature.1-5 This article provides the general
practitioner a clinical perspective on these systems
(correlating their design features to their clinical
handling) and explains which features influenced the
authors system selection.
At present, there are seven major brands of rotary
nickel titanium files available commercially in
North America: ProFile (ISO and Series 29)a,
ProSystemGT,a, ProTaper,a, LightSpeed,b,
RaCe,c, Quantecd, and K3d.
ProFile ISO and Series 29
The ProFile ISO possesses a fixed taper of .02,
.04, and .06, a U-shaped cutting blade, radial lands,
and is available in a variety of ISO tip sizes. In
addition, the ProFile is available in a Series 29
version with tips that successively increase 29% in
diameter in either a .04 or .06 taper. The symmetry
of this file with regard to the placement of radial
lands, equal land widths, flute widths, flute depths,
and symmetrical X-section lends itself to a
screwing-in action (Figure 1A). This tendency can
DENTSPLY Tulsa Dental, Tulsa, OK 75135; 800-662-1202

LightSpeed Technology, Inc., San Antonio, TX 78232; 800-817-3636
c
Brasseler USA, Savannah, GA 31419; 800-841-4522
d
SybronEndo, a division of Sybron Dental Specialties, Orange, CA
92867; 800-346-3636
a
ACE
Contemporary Endodontics
increase the chance of instrument fracture. It was

this factor, in my experience, that prompted me to
search for a different instrument design.
ProSystemGT Instruments
The ProSystemGT rotary instruments also
possess a U-shaped cutting blade (Figure 1B), tip
sizes of 20, 30, and 40, and fixed tapers of .04, .06,
.08, .10, and .12 (not all tip sizes are available in
every taper). Accessory ProSystemGT files for use
as orifice openers of .12 taper (35, 50 and 70, 90)
round out the line. This system is designed to be
used with matching gutta-percha and paper points
as well as GT obturators (carrier-based, warm
gutta-percha obturators). The ProSystemGT files,
in combination with the synergies achieved with
ProSystemGT obturators and matching guttapercha and paper points, consist of a logical and easy
system to use. That said, for me, the file does not cut
as effectively as the K3, ProTaper, or RaCe. I feel
like I am scraping dentin instead of cutting and
using more files than I would like to get to the same
end points. The perceived scraping is derived from
the negative rake (cutting angle) of the file,
analogous to using a safety razor at the wrong angle.
ProTaper Files
The ProTaper file has a bulging triangular cross
section (Figure 1C) and is variably tapered across
its cutting length. There are six files in this series,
three Shaper files (SX, S-1, and S-2) that are the
rough equivalent of orifice openers, and three
Finishing files (F1, F2, and F3) each with
different tip sizes. The file is designed so that the
bulk of the cutting is done on the area of greatest
taper, where the file is strongest. ProTaper files
cut well (because of the nonlanded triangular
cross section). However, because of the variable
taper, if the file tip becomes locked (even though
it is not designed to be engaged as such) these files
are susceptible to fractureespecially in the
absence of an adequate glide path (hand
Vol. 1, No. 1, 2004
33
T H E
Figure 1AProFile cross section, seen in

relation to its working surface.
Figure 1BProfile GT cross section, seen

in relation to its working surface.
instrumentation of the canal with #08 to #15 Ktype files). In addition, the F2 and F3 files have
very few indications for me clinically because of
their bulk and stiffness.
ACE
R E P O R T
Figure 1CProTaper cross section,

seen in relation to its working surface.
be prepared more easily with the LightSpeed (because

of less engagement of the canal walls) than many other
systems, potentially resulting in better apical cleaning
and irrigation. This hybrid technique is emerging and
others will certainly be written about as more clinicians
realize the value of larger apical diameters without
risking canal transportation or perforation.
Because the LightSpeed is smooth shafted, its
effectiveness as a coronal shaper is somewhat
diminished relative to other files. The upside to this
feature, though, is that it promotes larger tip sizes
introduced further apically with far less engagement of
the instrument with the canal walls than many other
brands of rotary files.
RaCe Files
The RaCe file (short for Reamers with
Alternating Cutting Edges) has a safety tip and
triangular cross section (Figure 1D). This file has two
cutting edges: a first cutting edge alternates with a
second that has been placed at a different angle. In
essence, this file possesses an alternating spiral and has
a cutting shank of 8 mm, giving variable helical angles
and a variable pitch. This enhances the files antiscrewing-in characteristic. The RaCe file is
recommended to be run at 500 rpm. The RaCe files
cut well. Given the higher rotational speed and the
concentration of forces on the shorter cutting shank,
this file requires a deft touch to prevent instrument
separation, especially if any lateral forces are put on the
file by the operator or the glide path is not ideal.
Quantec Files
The Quantec file (Figure 1E) is available in both
a cutting and noncutting tip with a standard 25 tip
size in the .12, .10, .08, .06, .05, .04, .03, and. 02
tapers. The .02 tapered Quantec is also available
in a 15-60 tip size. The Quantec system has a
positive blade angle and two wide radial lands
with surface reduction behind the lands. This
design allows for adequate strength and, at the
same time, reduces contact with the canal walls.
This reduction in contact minimizes the torque on
the instrument, resulting in less fatigue and
instrument separation. The flute space becomes
progressively larger distal to the cutting blade,
minimizing debris build-up, which can increase
torque and decrease cutting efficiency.
LightSpeed System
LightSpeed uses a U-shaped cross-sectional design,
but only on the tip, thus resembling a Gates Glidden
drill. The LightSpeed shaft diameter is always smaller
than its cutting surface. In essence, the shaft of the
instrument is smooth, with cutting flutes only on the
apical end. The LightSpeed system contains 22
various sizes ranging from 20 to 100 and, as a result of
the smaller tip, is optimally run at 1,700 to 2,000 rpm.
The LightSpeed can be used most effectively in a
hybrid technique in combination with the K3 or
another rotary system. The hybrid technique involves
using K3 files to prepare the coronal two thirds and the
LightSpeed to prepare the apical third. The value of
this hybrid technique is that larger apical diameters can
K3 Files
The K3 is an improvement on the Quantec in
that the K3 has three radial lands (Figure 1F). The
third radial land provides greater centering of the
file in the canal relative to the Quantec and the
Vol. 1, No. 1, 2004

34
T H E
ACE
R E P O R T
other instruments previously described. Because of

the positive cutting angle, the file does not exhibit
the scraping common with U-designed files. A
standard #25 tip size in the various tapers of the
Quantec can limit the file in that certain canal
anatomies might not be easily addressed. For
example, this limited range of file tip sizes would
have little relevance to a wide palatal canal with a
large apical diameter.
Among the above-mentioned systems, in my
hands, the K3 possesses the best blend of desirable
features relative to all of the instruments previously
described. The K3 system appeals to me in part
because it has almost universal applicability across a
wide range of clinical indications. It moves smoothly
down the canal with a robust sense of tactile control.
Since using the K3, fracturing of RNT files has
virtually been eliminated in my practice, yet the file
cuts efficiently and does not screw itself into the
canal. Another appealing feature is that (in the
absence of file deformation and with sound clinical
judgment) it can be used on more than one tooth in
all tapers, especially above a 25 tip size.
K3 System Features
The K3 canal shaping files are available with a

fixed taper of .02, .04, or .06. The .02 tapered K3
files are available in 15-45 tip sizes and 21-, 25-, and
30-mm lengths; the .04 and .06 tapered K3 files are
available in 15-60 tip sizes and 21-, 25-, and 30-mm
lengths. In addition, K3 shaping files have recently
been introduced with a taper of .08, .10, and .12.
These instruments can be used as canal shaping files,
orifice openers, and deep body shaping files. They
are available in a fixed 25 tip size, and 17-, 21-, and
25-mm lengths. The K3 (Figure 2) has:
a slightly positive rake angle providing the effective
Figure 1DRaCe cross section, seen in

10
cutting that the file possesses.

a variable core diameter that creates strength at the
tip, where many of the other files are weakest.
This tip strength, achieved by the variable core
diameter, means that this file can be used more
confidently in narrow canals with less concern
about snapping off the apical end of the file. This
is especially true in a canal that exits at an
acute angle several millimeters below the
pulpal floor.
a series of three radial lands with a relief behind
two of the three lands. The third radial land keeps
the file centered resulting in less canal transportation. The relief provides a place for debris to
be held until the file is removed from the canal
and wiped. It also reduces the contact area of the
file with the canal wall. This in turn reduces torque
and fatigue on the instrument. Less debris, less
torque, and less fatigue creates decreased loads on
the file, diminishing possible separation.
asymmetrically placed radial lands that prevent the
screwing-in effect and contribute to the robust
sense of tactile control that the file possesses.
an Axxess handle design (Figure 3), which shortens
the file handle by approximately 5 mm without
affecting the working length of the file. This is
especially helpful in difficult vertical access
situations, such as in a maxillary second molar.
a variable flute pitch and unequal flute depths,
promoting debris removal from the canal, greater
strength of the file nearer its tip, and a diminished
screwing-in effect.
color-coding, to distinguish between different tip
sizes and tapers, making the file easy to identify
and select from the storage container.
a safe-ended noncutting tip (Figure 4), which
diminishes the chance the file will create its own
Figure 1EQuantec cross section, seen in

Vol. 1, No. 1, 2004
Figure 1FK3 cross section, seen in

35
T H E
Figure 2Cross section of K3 with

various features appropriately labeled.
Figure 3Axxess handle design, which

shortens the file handle by approximately
5 mm without affecting the working
length of the file.
canal via transportation, or create a perforation or

the formation of a ledge.
ACE
R E P O R T
Figure 4Scanning electron microscopy

of K3 safe-ended tip.
roots of lower molars, palatal canals of upper

molars, etc) will require the .12 Shaper, medium
canals (upper second bicuspids, upper central
incisors, etc) will require the .10 Shaper, and smaller
canals will require the .08 Shaper for initial coronal
third enlargement. In small canals, after the .08
Shaper has been used, the operator can go back and
subsequently insert the .12 and .10 files successively
to further open the orifice. The Shaper files are used
to light resistance, which is usually about 3 mm to
4 mm apically or until resistance is met.
Recommended K3 Technique
Endodontic success and performance of the K3

RNT instrumentation system is enhanced by frequent
irrigation (with 5.25% sodium hypochlorite,
approximately 80 cc to 120 cc per average molar),
maintenance of apical patency, ethylenediaminetetraacetic acid (EDTA) gel used from the start in
vital pulp cases, and crown down instru-mentation
(where the coronal third is instrumented first, the
middle third second and apical third last).
K3 performance is also enhanced by slow, gentle,
smooth, and deliberate insertions into the canal with
no more than 4 mm of the file engaged at any given
time, if possible. An electric torque control motor
(Figure 5) (TCM Endo IIId) with auto reverse also
maximizes K3 performance at approximately 300 to
350 rpm.
While every tooth is different, the following is a
typical K3 technique for an average molar. Clinical
judgment is required to know when deviating from
this suggested method is appropriate.
After a comprehensive radiographic and clinical
evaluation of the tooth, including a mental
visualization of the anticipated final result, and
expected clinical challenges to be overcome during
the procedure, excellent anesthesia is a must. The
pulp chamber must be completely unroofed and the
common lateral dentinal triangle removed at the
cervical level in molars to achieve straight-line access.
Middle Third Shaping
If the Shaper advances easily, a glide path may not

always be required in the middle third. Many times,
the Shaper alone used in succession (.12 followed by
.10 and .08), will reach the junction of the middle
and apical thirds and the .06 and .04 files as
described below are unnecessary. If a glide path is
required at this level, after initially scouting the
canal with a #6-10 K file to the junction of the
middle and apical third, a middle third glide path is
created by instrumenting up to a #15 K file before
using the K3. Then, a .06/40 K3 (or the appropriate
Shaper) can often then be inserted to the mid root
or beyond after the middle third glide path has been
created. The apical third should not be entered at
this point. If the .06/40 K3 will not progress to the
junction of the middle and apical third, a smaller
.06 tapered K3 (or Shaper) can be used. The .06 K3
files are used in decreasing tip sizes until the middle
and apical third junction is reached. Specifically, a
.06/40 is used first, followed by a .06/35, .06/30,
etc, until the middle and apical third junction is
reached. Recapitulation and irrigation are alternated
after every file. In some narrow canals, .04 tapered
Coronal Third Shaping
When the orifices are located, they are initially

enlarged with the K3 Shaper. Larger canals (distal
Vol. 1, No. 1, 2004

36
11
T H E
ACE
R E P O R T
Figure 5TCM Endo III motor electric

torque control motor with autoreverse.
Figure 6The final shape imparted to the

canal by a given K3 file can be matched by
both a paper point and gutta-percha point
of the same taper.
files are used as described above for the .06

instruments.
Apical Third
Initial exploration of the apical third can be thought

of as a process of discovery. Because of the diversity of
apical anatomy (multiplanar curvatures, fins,
isthmuses, cul-de-sacs, etc), a delicate touch is required
to ascertain a road map to the clinical realities present
in this most challenging canal space. Entering the
apical third too quickly risks a myriad of iatrogenic
events (potentially causing ledges, perforations, apical
zipping, etc) all of which diminish possibilities for
endodontic success.
Adequate patience, time, and a gentle touch are
required in the apical third. Apical curvatures,
calcifications, patency, and ease of negotiation must be
carefully evaluated with #6 through #10 K files before
engaging a K3 RNT file in this region. Working with
a gentle intentionality, the operator should attempt to
reach the estimated working length as determined by
both the preoperative radiograph and as dictated by
tactile sense. These small K files are advanced passively
and never forced to the estimated length. The files
should advance apically just as far as they want to go.
The operator must bear in mind that achieving and
maintaining apical patency and leaving the apical
foramen at its original spatial relationship and size
relative to the root apex is essential. When a #10 to #15
K file reaches the estimated working length, a digital
image or radiograph (taken from multiple
horizontal angles) should be exposed and the true
working length verified by an apex locator. While
there are several electronic apex locators to chose
from (including Root ZX,e and Mark Vf) my
J. Morita USA, Inc, Irvine, CA 92618; 800-752-9729
Miltex Instruments Co, Inc, Bethpage, NY 11714; 800-645-8000
e
f
12
Vol. 1, No. 1, 2004
Figure 7ACases completed with the K3

RNT system and the System B Continuous
wave of condensation.
preference is the Elements Diagnostic Unitd. It is a

fourth-generation state-of-the-art electronic apex
locator that measures both resistance and
capacitance as the file is advanced. The reading
obtained initially can be verified again by a second
measurement after instrumentation is finalized and
confirmed with a bleeding/moisture point
measurement obtained with paper points.
In addition, true working length should be
confirmed again with a gutta-percha master cone-fit
radiograph when that stage of the procedure is
reached.
With true working length obtained, a glide path for
subsequent K3 files is created to approximately a size
15 K file to true working length. In other words, canal
is instrumented with K files to at least a 15 K file to
true working length before K3 RNT insertion in the
apical third. Again, irrigation and recapitulation should
be performed frequently, ideally after every file.
One of the attributes of the K3 system is the
option to introduce the .02/15 or .02/20 after glide
path creation. The .02/15 and .02/20 can further
accentuate and define the glide path, as well as
accelerate its creation to make way for subsequent
K3 files used in a crown down manner. Specifically,
after a glide path has been created by hand files to a
15-20 K file, insertion of the .02/15 and .02/20 can
often, with a gentle motion, reach true working
length. When used to true working length, this
refines the glide path and opens the canal more
efficiently for subsequent K3 use.
After the .02/15 and .02/20 K3s, subsequent K3
files are then introduced in a crown down sequence,
varying either the tip size (with subsequently smaller
K3 tip sizes of the same taper) or varying the taper
(mixing the tapers of the instruments as the tip size
diminishes). Regardless of whether the tip size or
37
T H E
Figure 7BCases completed with the K3

Figure 7CCases completed with the K3

taper is varied, K3 files are inserted from larger to

smaller tip sizes in a coronal to apical direction until
true working length is reached. Each subsequently
smaller taper and/or tip size, entered in the sequence
recommended, will reach a deeper apical level in the
canal. Varying the tip size, .06 K3 files are generally
inserted from a 40 tip size (or larger) to a 20 or 15
tip size (canal size, curvature, initial diameter of the
apical foramen, and apical-curvature dependent)
and the sequence repeated until the desired apical
diameter is achieved. When varying the tip size in
smaller canals, the .04 K3 can be used in the same
manner. Varying the tip size and/or taper ensures a
crown down instrumentation as each successively
smaller file advances further apically. In some canals
with dramatic pigtail three-dimensional curvatures in
the apical third, it may be necessary to prepare the
entire apical third by hand without RNT
instrumentation. Good clinical judgment is essential.
Before deciding to what tip size and taper the master
apical file should be instrumented, it is often necessary
to gauge the apex. In other words, it is necessary to
determine the apical diameter of the prepared canal.
This is best described by example. If a 20 K file resists
displacement through the apical foramen at the true
working length, then an appropriately tapered K3 25
or 30 tip size (canal-morphology dependent) can be
used to finalize canal preparation. This technique
allows shape to be created coronally to the foramen
while maintaining its size, location, and patency.
Paper and gutta-percha points of the same taper as
the prepared canal are available (Autofit gutta perchad)
(Figure 6). If a paper point will passively slide to the
true working length without kinking, then after the
canal is dried, cone fit with a gutta-percha point of the
same taper is generally very simple to obtain. A gutta-
ACE
R E P O R T
Figure 7DCases completed with the K3

percha cone-fit radiograph taken before obturation can

confirm both working length and appropriate
preparation shape. After cone fit is confirmed, System
B obturation can be completed for a multirooted molar
in a matter of minutes without the necessity of leaving
a carrier, as required in carrier-based obturation
techniques (Figures 7A through 7D).
Summary
As a practicing clinician, the K3 RNT system has
won out as my bread-and-butter rotary instrumentation
system. Although not perfect, this system is currently
my NiTi Nirvana. The file design allows for it to be
robust yet smooth, cut well yet resist fracture, and has
virtually enabled universal indication with confidence
across the broadest spectrum of clinical cases.
References
1.
2.
3.
4.
5.
6.
Bergmans L, Van Cleynenbreugel J, Beullens M, et al.

Progressive versus constant tapered shaft design using NiTi
rotary instruments. Int Endod J. 2003;36:288-295.
E. Shafer, Florek H. Efficiency of rotary nickel-titanium K3
instruments compared with stainless steel hand K-Flexofile.
Part 1. Shaping ability in simulated curved canals. Int Endod
J. 2003;36:199-207.
Schafer E, Schlingmann R. Efficiency of rotary nickeltitanium K3 instruments compared with stainless steel hand
K-Flexofile. Part 2. Cleaning effectiveness and shaping
ability in severely curved root canals of extracted teeth. Int
Endod J. 2003;36:208-217.
Martin B, Zelada G, Varela P, et al. Factors influencing the
fracture of nickel-titanium rotary instruments. Int Endod J.
2003;36:262-266.
Bystrm A, Sundqvist G. Bacteriologic evaluation of the
efficacy of mechanical root canal instrumentation in
endodontic therapy. Scand J Dent Res. 1981;89: 21-328.
Bystrm A, Sundqvist G. Bacteriologic evaluation of the
effect of 0.5 per cent sodium hypochlorite in endodontic
therapy. Oral Surg Oral Med Oral Path. 1983;55:307-312.
Vol. 1, No. 1, 2004

38
13
MANAGEMENT OF THE CORONAL THIRD

PROGRESSIVELY AND PASSIVELY
78
ENDODONTICS
Management of the Coronal Third
Progressively and Passively
or many, entry into and instrumentation of the coronal third of root canal
systems has almost been taken for
granted or considered simple, especially
with the advent of rotary Ni-Ti (RNT) orifice
openers. Fortunately, while this is true on
many occasions, it is not uncommon to have a
coronal third that challenges even the most
talented clinician. Especially in these problematic cases (which will be defined below),
diligence in canal location, coronal third negotiation, and instrumentation can make all the
difference between perforations, canal blockage, non-negotiability, frustration, and wasted
time (amongst other problems), and achieving
an efficient and desired result. Said differently, at times, the coronal third can be much
more complex than anticipated, especially
radiographically.
F
Richard
Mounce, DDS
Gary Glassman,
DDS
Figures 1a and b. These roots most likely can be initiated with an orifice opener in the coronal and middle thirds first and would generally not need hand file exploration prior to rotary use in the coronal two
thirds of the canal.
CRITICAL FACTORS
What factors are critical for creating excellence in orifice and coronal third management and initial enlargement of root canal
systems?
First, it is suggested that the clinician
take 3 angles of radiographs (buccal, mesial,
and distal) to assess carefully the position of
the orifice and the angle at which the canal
exits the pulpal floor. Caution is advised.
Metal crowns obscure some chamber floors
and coronal thirds, and there may be no visual clues as to cervical anatomy. In these cases,
it may be anyones guess as to what type of
cervical canal anatomy is present. While
many canals are large enough that they can
be easily located and exit relatively vertically
from the chamber floor, many do not. It is not
uncommon to find narrow canals that exit at
an acute angle from the pulpal floor, and if
this is not appreciated, placement of a Gates
Glidden drill or RNT orifice opener into the
narrow diameter of such a canal lumen can
rapidly cause chips to be generated that will
occlude the canal. In such an event, subsequent negotiation, even with small K-files,
can be difficult, and even impossible in
extreme cases. Leaving such significant
uncleaned and unfilled space (if the clinician
becomes blocked out entirely in the coronal
third before canal instrumentation commences) severely diminishes the prognosis, as
the entire contents of the canal will become
nonvital (if they were not already), risking
long-term failure. Such a blockage can be very
challenging in terms of achieving patency,
even if the canal should later prove negotiable
with a concerted effort.
The given angle of exit from the pulpal
floor and the size of the canal at the orifice
level make all the difference in terms of how
DENTISTRY TODAY DECEMBER 2005
Figures 2a and b. A tooth in which the first file entering the tooth should ideally be a small K-file
(6 to 10) with which to negotiate and determine patency.
Figure 3. The cervical dentinal triangle, which

places unnecessary torsional and cyclic fatigue
forces on files, reduces visibility and predisposes a tooth to iatrogenic events if not removed.
the canal will be negotiated initially. If the

canal is wide open and easily negotiable, it is
acceptable to place a RNT orifice opener into
the canal as the initial instrument, especially
if copious irrigation is carried out after each
pass of the instrument. Upper anterior teeth,
lower molar distal roots, and the palatal roots
of upper molars that are not calcified in any
way are often easily negotiable with orifice
openers and generally do not risk blockage. If
an orifice opener does not progress apically
for whatever reason, it should never be forced.
Alternatively as a precaution, if the clinician
wishes to establish patency with small K-files
39
Figure 4. After removal of the cervical dentinal

triangle, true straight-line access is achieved
from the cusp tip to the initial curvature of the
canal.
before using any orifice opener, especially in

the coronal and middle thirds and irrespective of the orifice and canal size, it is certainly acceptable to do so (Figures 1a through 2b).
If the clinician doubts that the orifice
openers will easily negotiate the coronal third
after careful examination of the anatomy, the
most efficient course of action is to use new 6
or 8 K-files (21 mm ideally) that are gently
inserted both progressively and passively (at
this stage in the process) to a depth no greater
than the junction of the middle and apical
third. The purpose of this examination with
continued on page 80
80
ENDODONTICS
Management of the Coronal Third...
continued from page 78
Figure 5. The Line Angle burs from SybronEndo, which

can help create straight-line access, act as orifice
openers and remove the cervical dentinal triangle.
small K-files is to assess the

ease of negotiation of the
canal in the coronal and middle thirds, canal curvature,
and canal diameter. Ideally,
all of these K-files will be gently curved by hand before

insertion. The tactile information derived from the file
can be extensive in this nego-
tiation and exploration. If the

K-file comes out severely
curved from the canal in the
coronal and/or middle thirds,
or the file will not easily
progress apically, it can be
assumed that the anatomy
present is complex, potentially problematic, and will risk
an iatrogenic event if not
managed correctly. Caution is
advised, as roots possess multiplanar curvatures, and even
if a canal may not look curved
in a mesial to distal direction
radiographically, it may be
very curved in a buccal to lingual dimension that will not
be easily visible, if at all,
unless the tooth is rotated.
It is noteworthy that
management of the coronal
third begins with straight-
FREEinfo, circle 48 on card

DENTISTRY TODAY DECEMBER 2005
40
line access that is large

enough to permit unrestricted access into any canal that
is essential for subsequent
negotiation of the canal system. Access that is too small
will almost certainly diminish the control possible over
the orifice and will put the
clinical case at risk for subsequent iatrogenic events. Ideally,
coronal access preparation,
once completed, will be large
enough that a file can stand
vertically in the canal without touching the adjacent
wall of the opening.
AFTER CORONAL ACCESS

After coronal access and
before attempted canal location, negotiation, and initial
instrumentation, it is essen-
tial for the clinician to flush

the chamber with irrigant,
ideally 5.25% sodium hypochlorite, to remove any chips
and pulp tissue. Alternatively, 2% chlorhexidine (Vista
Dental) can be used for this
flushing. Chlorhexidine and
sodium hypochlorite should
never be used in tandem
because of the precipitate that
will form when they are combined. Water or a liquid EDTA
should be used to rinse one of
these 2 solutions before the
other is introduced. Water can
be utilized to clear the pulp
chamber of debris, as described above, before canal
location and negotiation. However, if the desired goal is to
eliminate bacteria from the
coronal access to set the stage
for future canal disinfection
(and sterilization) to the
greatest degree possible, an
antibacterial solution is ideal
for this initial flushing as well
as during canal irrigation.
It is noteworthy that if
the tooth is vital, it is optimal
for the clinician to have a viscous EDTA gel placed into the
chamber before instrumentation below the orifice commences (eg, FileEze [Ultradent], Glide [DENTSPLY Tulsa
Dental], or RC Prep [Premier
Dental Products]). This will
help emulsify the vital tags of
pulp tissue, avoid their apical
compaction (and hopefully
prevent formation of dense
blockages of pulp tissue in
the form of dentin mud), and
facilitate their flushing. Such
an EDTA gel can of course be
used in nonvital cases as indicated and if desired. Once
instrumentation begins, this
viscous EDTA gel should ideally be utilized until the bulk
of the pulp is removed from
the tooth and/or negotiation
of the apical third is ready to
be undertaken. At this point,
the clinician can then switch
to chlorhexidine, sodium hypochlorite, or both (flushing
between solutions as previously noted) for irrigation of
the apical third.
Removal of the cervical
dentinal triangle (CDT) is
essential. If the CDT is left in
place, it will necessarily place
both a torsional force and
cyclic fatigue force on files.
Iatrogenic problems of all
types can result from leaving
this easily removed obstacle.
Removal is very straightforward if done under a surgical
continued on page 82
EFFECTIVE ROTARY NICKEL TITANIUM FILE USE:

MASTERING THE RIGHT TOUCH
Endodontics
Mounce.qxd
4/26/06
4:42 PM
Page 110
Effective rotary nickel titanium file use:

Mastering the right touch
Rich Mounce, DDS | Gary Glassman, DDS, FRCD(C)
Strategies for creating efficiency and safety in the clinical use of rotary nickel titanium
instruments are presented with an emphasis on using the correct tactile touch.
Received: April 4, 2005
Final revisions: June 16, 2005
Rotary nickel titanium files have been

widely accepted in contemporary endodontics.1-3 Multiple studies indicate
that rotary nickel titanium files demonstrate more effectiveness than hand instruments in a measured parameter; conversely, some studies show no difference
in the measured parameter.4-19 The way
that rotary nickel titanium files are utilized is more important than their individual design characteristics in terms of
both their efficiency and their iatrogenic
potential. The authors maintain that
some rotary nickel titanium file designs
have less iatrogenic potential than others,
provided they are used correctly (Fig. 1
and 2). Mastering the correct touch for
rotary nickel titanium files is closely related to specific strategies to prevent the
files separation. This article discusses the
tactile and digital touch that most rotary
nickel titanium files require for greatest
efficiency and least separation morbidity.
A discussion of how a given rotary
nickel titanium file may be used for greatest efficiency and safety should include a
discussion of both how they should and
should not be used. For example, rotary
nickel titanium files should not be used
like a toiler plunger. Doing so risks locking or engaging too many flutes of the file
in the canal at any given time and putting
the file at significant risk for torsional failure. Torsional failure results when a rotary nickel titanium is subjected to forces
that exceed the molecular attraction of
the given metal. Rotary nickel titanium
files should not be used with a pecking
motion, with the exception of the Lightspeed file (Lightspeed Technology Incorporated, San Antonio, TX; 800.817.3636),
whose manufacturers traditionally have
recommended a pecking motion.
Before a rotary nickel titanium file is
placed into the middle and apical third,
110
General Dentistry
Accepted: July 8, 2005
the canal should be explored by K files

and a glide path must be created to accommodate a 15 K file. Placing a rotary
nickel titanium file into any canal third
without first obtaining an accurate true
working length puts the entire procedure
at risk and could result in instrument
fracture, canal transportation, overenlarged foramen, and/or production of excessive debris that can be compacted into
the apical third (and could create an impassable blockage of dentin mud). The
literature supports the creation of a glide
path.20-22
Placing a rotary nickel titanium file
into the apical third before removing restrictive dentin in the coronal two-thirds
risks engaging too much of the file into
dentin at any given time, which could result in fracture. In addition, if a well-defined glide path has not been established,
it is entirely possible that the tip of a rotary nickel titanium file can become
locked in a delta canal or a canal aberration, causing the canal to fracture. If the
tip becomes locked while the file has the
torque to rotate at its greatest diameter,
the file can separate in an instant because
the relatively weak tip has little resistance
to fracture while the largest file diameter
is rotating in the canal.
Using the same tip sized file in successively larger tapers also is not advised.
For example, if a .04 tapered 25 file is taken to true working length and followed
by a .06 tapered 25 file, this second file
will be most fully engaged in dentin, especially in the absence of having first removed the restrictive dentin in a crowndown fashion (instrumentation of the
coronal third first, middle third second,
and apical third last). Preparing the
coronal third first, the middle third second, and the apical third last will remove
restrictive dentin in the coronal two-
www.agd.org
41
thirds first, providing the apical third

with the greatest tactile sense.
The dentist should resist the temptation to force a rotary file in the presence
of torque control, due to the mechanism
cited above. Relying upon an audible
alarm or an auto-reverse mechanism to
indicate when the file must be disengaged
creates the risk of fracture.
A smooth and feather touch is necessary when utilizing rotary nickel titanium
files. If the canal will not accept the file, it
shouldnt be forced; instead, a file that is
larger or smaller than the chosen file
should be used. Forcing a file to a predetermined length to follow an advocated
rigid technique that may not be applicable
clinically may cause the file to separate.
When using a rotary nickel titanium
file, the file should be rotating as it enters
the canal. Jerking or uncontrolled hand
motions are counterproductive and
might accidentally place the file tip in a
delta canal or predispose the file to overengagement. Rotary nickel titanium
files should be used only after the file is
inspected visually for deformations.
When deformations are discovered, the
file should be discarded.
If resistance can be overcome with the
gentlest of touches, the file may be advanced further; however, if resistance increases upon insertion, the file should be
removed and a different file should be
chosen.
The files should be placed on the
sponge in the order of expected use as
well as in the expected length of the
canal. The laser markings on the 25 mm
K3 rotary nickel titanium files (SybronEndo, Orange, CA; 800.346.3636) can be
read easily using a surgical microscope.
The length actually makes placement of
the tip easier (especially in constricted
cases) because of the improved visualization for tip placement (Fig. 3). By contrast, visualization of the smaller rotary
nickel titanium files can be blocked by
the head of the handpiece.
When using a rotary nickel titanium
file, the dentist must always be aware of
Mounce.qxd
4/26/06
4:42 PM
Page 111
Fig. 1. An example of the shapes possible when rotary nickel titanium

file are used.
Fig. 2. An example of a separated rotary nickel titanium file.
Fig. 3. Laser markings on the K3 rotary nickel

titanium file system.
Fig. 4. Left: An example of glide path creation resulting from correct use of nickel titanium files.
Right: An example of maintenance of apical patency resulting from nickel titanium files.
the length of the canal; the tip size, taper,

and length of the rotary file; which third
of the canal is being instrumented at the
given stage of the procedure; what instrumentation has preceded the given file;
and which file will be utilized next. Failing to do so can lead to unnecessary insertions, wasted time, and iatrogenic potential. The dentist must remain focused
so that the file will advance to the desired
level in the process, regardless of whether
the file can be advanced further. For example, if the apical third of the canal has
not been explored with a hand file, the
temptation to place a rotary nickel titanium file to the apical extent must be
avoided. Advancing the rotary nickel titanium file into the apical third before
exploring with K files and glide path replacement risks apical transportation (of
both the canal and the foramen) as well
as instrument separation. As simple as it
might seem, it is essential to keep a mental focus on what the given file is meant
to achieve in the canal. If the file is the

first to be inserted into a given third of a
canal, caution is advised regardless of
whether hand exploration and glide path
creation are complete.
Creation and maintenance (through
frequent recapitulation) of apical patency, in combination with copious and effective irrigation, can help to prevent
dentin mud (debris) from building up in
the apical third and contribute to the prevention of iatrogenic outcomes.
The rotational speed of a rotary nickel titanium file will determine how efficiently it will advance. According to the
literature, slower rotational speeds are
most desirable.23-25 Manufacturer-recommended speeds for rotary nickel titanium
files generally range from 250500 RPM.
A files ability to advance is related directly to its cutting efficiency and depends on
its rotational speed, the torque applied by
the dentist, and the curvature of the
canal. A power drill rotating at a lower
42
speed cuts less effectively than one with a

faster rotation.
Bassed on personal experience, the
primary author advocates higher rotational speeds than those typically recommended by manufacturers or by the literature. For example, with the K3, the
Shaper files (equivalent to orifice openers) can be rotated at 1,0001,500 RPM
without torque control in a canal that
will easily accept them. Any K3 file of any
taper and tip size can be rotated at either
600 or 900 RPM. The higher speeds require adhering to the various recommendations contained within this article.
These speeds exceed the manufacturers
recommended maximum speed but they
can increase the efficiency of the file in
combination with the strategies advocated in this article. Failing to use the
method advised above risks separation
and other iatrogenic events as well as a
loss of efficiency in rotary nickel titanium
file use (Fig. 4).
May-June 2006
111
Mounce.qxd
4/26/06
4:42 PM
Page 112
Summary
The method by which a rotary nickel titanium file is used is more important than
the files particular design. Smooth, gentle, slow, and passive insertion of the rotary nickel titanium file can minimize engagement to 1.02.0 mm per insertion
and help to reduce iatrogenic outcomes
of all types. Higher rotational speeds are
possible if the dentist adheres to all
strategies designed to prevent rotary
nickel titanium file separation. Apical
patency and creation of a glide path coincident to adequate irrigation and recapitulation are key strategies for improving
efficient rotary nickel titanium file utilization.
6.
7.
8.
9.
Disclaimer
The authors have no commercial interests in any products mentioned in this
article.
10.
Author information
Dr. Mounce is in private endodontic
practice in Portland, Oregon. Dr. Glassman is in group endodontic practice in
Toronto, Ontario and is endodontic consultant for Oral Health.
11.
12.
References
1. Xu Q, Lin JQ, Chen H, Wei X. [Clinical
evaluation of Nickel-titanium rotary instruments Hero 642 in root canal preparation]
(Article in Chinese). Shanghai Kou Qiang
Yi Xue 2005;14:2-5.
2. Peters OA. Current challenges and concepts in the preparation of root canal systems: A review. J Endod 2004;30:559-567.
3. Arbab-Chirani R, Vulcain JM. Undergraduate teaching and clinical use of rotary
nickel-titanium endodontic instruments: A
survey of French dental schools. Int Endod
J 2004;37:320-324.
4. Tharuni SL, Parameswaran A, Sukumaran
VG. A comparison of canal preparation using the K-file and Lightspeed in resin
blocks. J Endod 1996;22:474-476.
5. Chen JL, Messer HH. A comparison of
stainless steel hand and rotary nickel-titanium instrumentation using a silicone im-
112
General Dentistry
13.
14.
15.
16.
pression technique. Aust Dent J 2002;47:

12-20.
Barbizam JV, Fariniuk LF, Marchesan MA,
Pecora JD, Sousa-Neto MD. Effectiveness
of manual and rotary instrumentation
techniques for cleaning flattened root
canals. J Endod 2002;28:365-366.
Ahlquist M, Henningsson O, Hultenby K,
Ohlin J. The effectiveness of manual and
rotary techniques in the cleaning of root
canals: A scanning electron microscopy
Schafer E, Schlingemann R. Efficiency of
rotary nickel-titanium K3 instruments
compared with stainless steel hand K-Flexofile. Part 2. Cleaning effectiveness and
shaping ability in severely curved root
canals of extracted teeth. Int Endod J 2003;
36:208-217.
Szep S, Gerhardt T, Leitzbach C, Luder W,
Heidemann D. Preparation of severely
curved simulated root canals using enginedriven rotary and conventional hand instruments. Clin Oral Investig 2001;5:17-25.
Tan BT, Messer HH. The quality of apical
canal preparation using hand and rotary instruments with specific criteria for enlargement based on initial apical. J Endod
2002;28:658-664.
Schafer E, Schulz-Bongert U, Tulus G.
Comparison of hand stainless steel and
nickel titanium rotary instrumentation: A
clinical study. J Endod 2004;30:432-435.
Bertrand MF, Pizzardini P, Muller M,
Medioni E, Rocca JP. The removal of the
smear layer using the Quantec system. A
study using the scanning electron microscope. Int Endod J 1999;32:217-224.
Reddy SA, Hicks ML. Apical extrusion of
debris using two hand and two rotary instrumentation techniques. J Endod 1998;
24:180-183.
Portenier I, Lutz F, Barbakow F. Preparation of the apical part of the root canal by
the Lightspeed and step-back techniques.
Int Endod J 1998;31:103-111.
Sonntag D, Guntermann A, Kim SK, Stachniss V. Root canal shaping with manual
stainless steel files and rotary Ni-Ti files
performed by students. Int Endod J 2003;
36:246-255.
Deplazes P, Peters O, Barbakow F. Comparing apical preparations of root canals shaped
by nickel-titanium rotary instruments and
nickel-titanium hand instruments. J Endod
2001;27:196-202.
www.agd.org
43
17. Prati C, Foschi F, Nucci C, Montebugnoli L,

Marchionni S. Appearance of the root canal
walls after preparation with NiTi rotary instruments: A comparative SEM investigation. Clin Oral Investig 2004;8:102-110.
18. Schafer E, Zapke K. A comparative scanning electron microscopic investigation of
the efficacy of manual and automated instrumentation of root canals. J Endod
2000;26:660-664.
19. von Fraunhofer JA, Fagundes DK, McDonald NJ, Dumsha TC. The effect of root
canal preparation on microleakage within
endodontically treated teeth: An in vitro
20. Roland DD, Andelin WE, Browning DF,
Hsu GH, Torabinejad M. The effect of preflaring on the rates of separation for 0.04
taper nickel titanium rotary instruments. J
Endod 2002;28:543-545.
21. Berutti E, Negro AR, Lendini M, Pasqualini
D. Influence of manual preflaring and
torque on the failure rate of ProTaper rotary instruments. J Endod 2004;30:228230.
22. Blum JY, Machtou P, Ruddle C, Micallef JP.
Analysis of mechanical preparations in extracted teeth using ProTaper rotary instruments: Value of the safety quotient. J Endod 2003;29:567-575.
23. Yared GM, Dagher FE, Machtou P, Kulkarni GK. Influence of rotational speed,
torque and operator proficiency on failure
of Greater Taper files. Int Endod J 2002;
35:7-12.
24. Dietz DB, Di Fiore PM, Bahcall JK, Lautenschlager EP. Effect of rotational speed on
the breakage of nickel-titanium rotary files.
J Endod 2000;26:68-71.
25. Martin B, Zelada G, Varela P, Bahillo JG,
Magan F, Ahn S, Rodriguez C. Factors influencing the fracture of nickel-titanium
rotary instruments. Int Endod J 2003;36:
262-266.
To order reprints of this article,
contact Jill Kaletha at 866.879.9144, ext. 168 or
jkaletha@fostereprints.com.
CREATION OF LARGER MADS:

THE HYBRID TECHNIQUE
xxxxxxx _ xxxxxxx
Creation of Larger MADs:

The Hybrid Technique
Author_ Richard Mounce, U.S.A. & Gary Glassman, Canada
The endodontic literature is unequivocal that the creation of larger master apical diameters
(MADs) is consistent with cleaner canals post instrumentation.110 Achievement of larger
MADs might be thought of as one piece of a larger set of best practices in endodontics.There
is a strong argument to be made that traditional MADs are too small. This article was written to
describe an easily achieved method for the creation of larger MADs as practiced by the authors.
Fig. 1
_Traditionally, there has been very little attention

given to matching the size of the apical preparation
to the anatomy of the specific root being treated. Virtually all of us were taught a step back (SB) sequence
in dental school, and that we should instrument
canals to three sizes larger than the first file to bind at
the apex. Globally, this technique is still the educational norm. The basis for this technique is empirical,
not supported by the literature. In this technique, anterior teeth are generally taken to about a 40 ISO tip
size (or larger) and the mesial roots of lower molars to
a 25, etc. Arbitrary tapers and tip sizes are unrelated
to individual canal anatomy and have more to do with
the limits of older instrumentation systems and little
if anything to do with modern capabilities. SB instrumentation methods often leave debris or push it apically, potentiate iatrogenic events, give reduced tactile sense, create less than ideal canal shapes and reduce effectiveness in obturation. Preparation of
larger MADs consistently removes necrotic tissue and
circumferential dentin in the apical third allowing

greater volumes of irrigation. More irrigation, especially in the apical third, produces cleaner canals by
flushing of debris, antibacterial action and tissue dissolution. Enhanced debris removal reduces the frequency and severity of potential iatrogenic events.
Larger MADs also make cone fit simpler (Figs. 1, 2).
There are three primary methods available (as
practiced by the authors) to safely and efficiently prepare canals to larger than traditional MADs:
_1 with the K3 system (SybronEndo, Orange, CA, USA)
alone (Fig. 3),
_2 with the LightSpeed system (LS) (LightSpeed Endodontics, San Antonio, TX, USA) (Fig. 4), or
_3 a combination of these two systems.
Fig. 1_Under prepared and transported canal (Mesial root 2 mm

from Apex).
Due to space limitations, it is not possible to describe all three methods in detail, but the third
approach, a combination or hybrid technique, will
be described in detail. The reader is directed to
roots
1
_ 2006
44
I 05
I xxxxxxx _ xxxxxxx
Fig. 2a
Fig. 2b
Figs. 2ab_Creation of a larger master apical diameter in cross section.
MounceEndo.com, SybronEndo.com and www.LightSpeedEndodontics.com for a variety of articles and

information about these systems as well as references 1140.
It is noteworthy to mention that LS files are fundamentally different in concept than other systems,
including K3. LS files are not formed by grinding, the
metal is stamped. Smooth shafted, the file cuts only
on its end, which is ISO tip sized. Having no taper in its
design, it generally drops easily to the true working
length as one moves up the sequence from the smaller
sizes to larger. Due to its non-tapered design, when LS
is over stressed, failure occurs coronally (non-tip
end), making the separated fragment much easier to
retrieve. The spade end of the instrument design,
with-out flutes or helical angles, eliminates clogged
flutes, allows significant room to accommodate cut
debris, reduces stress on the shaft and prevents selfthreading. The LS is used with a slow continuous push.
_Clinical technique described

_1. Creation of straight-line access and location of
canals
is accomplished first.
_2. Irrigation is copious at all times during instrumentation with sodium hypochlorite and/or 2%
chlorhexidine.
_3. The tooth is instrumented crown down (the
coronal third first, middle third second and the
apical third last). Hand files precede rotary files,
virtually always. Canals are first, in whichever
third, negotiated by hand, the patency of the canal
assured and a glide path created (the canal third is
taken to at least a 15 K file) before rotary files are
placed. Rotary nickel titanium (RNT) instrumentation follows glide path creation. The clinician instruments with RNT files from larger tapers to
smaller and from larger tip sizes to smaller. Such a
sequence is inherently crown down in that each
06 I roots
1_ 2007
45
instrument is able to progress further down the

canal than its predecessor. Irrigation and recapitulation follow instrument insertion and the sequence is repeated as many times as necessary.
The clinician does not move into the middle third
of the canal until the coronal third is ideally instrumented, etc.
_4. The coronal, middle and apical third are instrumented one after another to the true working
length (TWL) in the manner above. Typically, using
this sequence in average roots, the clinician will
achieve approximately a .06-tapered preparation
that will be approximately a 25 or 30.
_5. Before creating a larger MAD, the canal must be
gaugedthe diameter of the minor constriction
of the apical foramen determined. The K file that
binds and resists displacement at the TWL is the
diameter of the canal at the minor constriction.
The clinician can then determine the size down to
which he choses to instrument the canal. It must
be mentioned that all irrigation, instrumentation
and obturation should ideally be kept above the
level of the minor constriction of the apical foramen. Transporting, ripping, tearing or otherwise
altering the apical foramen will lead to untoward
clinical outcomes, which diminish clinical success.
Canals can be gauged with hand K files or with LS
files. Using the same LS files for gauging that are
used to perform the final shaping can reduce the
number of files needed.
_6. After gauging, the clinician can take the preparation to the chosen MAD by simply enlarging the diameter of the gauged canal with LS (the Hybrid
technique). If the canal gauges to a 30, the clinician would simply insert the LS files from a 30 to
a 50 or 60 (clinician decision dependent) using
them in order. It is possible to alternatively use K3
to finalize the preparation by simply taking the
canal to successively larger file sizes at the TWL.
For example, if the canal gauges to a 30, then a .02
xxxxxxx _ xxxxxxx
Fig. 3
tapered 35, 40 and 45 could be taken to TWL followed by a .04 tapered 40, 45, and 50 or a similar
sequence until the desired tip and taper is
achieved. K3 is more than sufficiently flexible to
negotiate curvatures of all types if used with the
correct tactile touch during its insertion.
_7. SmearClear is the final irrigation rinse used to
clear the smear layer and allow bonding the canal
with a material like RealSeal (both materials
SybronEndo, Orange, CA, USA), which diminishes
to a statistically significant degree the potential
for coronal microleakage.4150 Cone fit and obturation follow. While the authors do not utilize
the Simplifil system for obturation (LightSpeed
Endodontics), it is a valid technique for obturating
canals instrumented in this manner, albeit a cold
one.
_Common Questions
If I create a given taper (.04 or .06), how does that
influence the size to which I instrument the canal?
It doesnt. The creation of a larger MAD is simply a
method to circumferentially enlarge the canal in the
apical 34 mm of the root. The entire root does not
have to be enlarged in taper to compensate for the minor enlargement in the apical 34 mm.
Does such preparation create a parallel shape in
the apical 34 mm and in essence not create a continuous tapering funnel with narrowing cross-sectional diameters?
If the canal is prepared with K3 in the coronal and
middle thirds and finished off with LS apically, yes, in
fact several millimeters of the canal in the apical third
might be more parallel than it otherwise would be.
This is not of any consequence clinically. Cone fit is far
easier when a canal is instrumented to a larger MAD.
If the clinician insists on creating ideal taper in the
apical 34 mm, successively larger LS files can be
taken short of the TWL in .5 mm increments.
Fig. 4
How do I know to what size to instrument a canal

once Ive created the basic preparation and gauged
the canal?
Determination of ideal MAD is not an exact science.
That said, if a canal gauges to a 25-hand K file, it can easily and quickly be taken to a 50 apically with a LS file in
less than a minute by advancing successively larger LS
files. A canal that gauges to a 30 can be taken up to a 60
at the TWL in a similar time frame. In clinical practice, if
a .06 K3 is taken to TWL to a 30-tip size, a 30 LS will immediately drop to the same length and is followed by a
35, 40, 45, 50, 55 and 60. Usually, these successive LS files
will drop to the TWL with minimal resistance even
though debris will come out on the head of the LS file.
What do I need to get started?
K3 files (.12, .10, .08 Shapers, .06 15-60, .04 15-60)
25 mm length and LS files in sizes 2570 in a 25 mm
length. The 25 mm files are recommended because
the clinician can read the laser markings without the
use of a rubber stopper. Rubber stoppers can move
during insertion and thus allow inaccuracy for the
measurements taken. It is also noteworthy that LS
files are rotated at higher speeds than their K3 counterparts (2,000 rpm versus 350 rpm, respectively) and
the clinician will need to have electric motors and attachments that can make this change seamlessly.
Will I need to use all these files in every case? Isnt
that a lot of files?
No, the clinician will not need to use every file in
the above recommendations in every case. Alternative systems are often sold on the basis of having a
limited number of files (as if that is a positive attribute of the given file system, which in the authors empirical opinion it is not). In reality, the clinician may
only use a few K3 files, less than five or six in alternative systems, the difference being that one is limited
in clinical cases by a system that has a fixed and often
restrictive number of files. K3 is a complete system
that can handle any anatomy and can do so to a larger
MAD as needed, there is no limitation.
Fig. 3_The K3 rotary nickel titanium

file (SybronEndo, Orange, CA, USA).
Fig. 4_The LightSpeed rotary nickel
titanium file (LightSpeed Endodontics, San Antonio, TX, USA).
roots
1
_ 2006
46
I 07
I xxxxxxx _ xxxxxxx
Fig. 5b
Fig. 5a
Figs. 5ab_Clinical cases treated

with a hybrid technique utilizing K3
and LS files.
In actual fact, the clinician often uses no more

than five to six K3 files and, similarly, it is not necessary to use all the LS files either. In essence, even
though the files may be packaged differently, the actual number of files used in either system (K3 and LS
combination) or other systems is very much the
same with the big advantage being that either the
K3 alone or a K3-LS combination is a complete system suitable for all canal anatomies whereas many
of the other systems, especially those with a limited
number of files, are not.
How do I choose the taper to which I will instrument the canal?
Most canals encountered in clinical practice will
be instrumented to a .06 taper. Bigger roots may be
prepared to larger tapers and smaller and more
curved roots to smaller tapers. If a canal can be enlarged to a 15-hand file, with RNT files it can be enlarged beyond that diameter, irrespective of the curvature. It is not necessary to instrument especially
curved canals by hand with the vital caveat to that
statement being that the correct sequence, rotational speed, touch and RNT system is used.
The endodontic literature is very clear that the
creation of larger MADs is correlated with cleaner
canals. This paper has demonstrated one method of
creating cleaner canals that is safe, effective and reproducible.
Dr. Mounce and Dr. Glassman have no commercial interest in any of the products mentioned in this
article._
Literature
1. Int Endod J. 2000 May; 33(3): 2625. Lumley PJ.
2. J Endod. 2000 Dec; 26(12): 7515. Shuping GB, et al.
3. J Endod. 2002 Nov;28(11):77983. Card SJ, et al.
4. OOO, 2002 Sep;94(3):36671. Rollison S, et al.
5. J Endod. 2005 May;31(5):35963. McGurkin-Smith R, et al.
08 I roots
1_ 2007
47
6. J Endod. 2002 Sep;28(9):65864.Tan BT, et al.

7. J Endod. 2004 Jun;30(6):4258.Albrecht LJ, et al.
8. Portenier I, Lutz F, Barbakow F. Preparation of the apical part
of the root canal by the Lightspeed and step-back techniques. Int Endod J. 1998 Mar;31(2):10311.
9. Khademi A, Yazdizadeh M, Feizianfard M. Determination of
the minimum instrumentation size for penetration of irrigants
to the apical third of root canal systems. J Endod. 2006 May;
32(5): 41720.
10. Peters CI, Koka RS, Highsmith S, Peters OA. Calcium hydroxide dressings using different preparation and application modes: density and dissolution by simulated tissue
pressure. Int Endod J. 2005 Dec;38(12):88995.
11. Schafer E,Erler M,Dammaschke T.Comparative study on the
shaping ability and cleaning efficiency of rotary Mtwo instruments. Part 2. Cleaning effectiveness and shaping ability in
severely curved root canals of extracted teeth. Int Endod J.
2006 Mar;39(3):20312.
12. Schafer E,Erler M,Dammaschke T.Comparative study on the
shaping ability and cleaning efficiency of rotary Mtwo instruments. Part 1. Shaping ability in simulated curved canals. Int
Endod J. 2006 Mar;39(3):196202.
13. Miyai K, Ebihara A, Hayashi Y, Doi H, Suda H,Yoneyama T. Influence of phase transformation on the torsional and bending properties of nickel-titanium rotary endodontic instruments. Int Endod J. 2006 Feb;39(2):11926.
14. Yao JH,Schwartz SA,Beeson TJ.Cyclic fatigue of three types
of rotary nickel-titanium files in a dynamic model. J Endod.
2006 Jan;32(1):557.
15. Jodway B, Hulsmann M. A comparative study of root canal
preparation with NiTi-TEE and K3 rotary NiTi instruments.
Int Endod J. 2006 Jan;39(1):7180.
16. Guelzow A, Stamm O, Martus P, Kielbassa AM. Comparative
study of six rotary nickel-titanium systems and hand instrumentation for root canal preparation. Int Endod J. 2005
Oct;38(10):74352.
17. Yoshimine Y, Ono M,Akamine A.The shaping effects of three
nickel-titanium rotary instruments in simulated S-shaped
canals. J Endod. 2005 May;31(5):3735.
18. Patino PV, Biedma BM, Liebana CR, Cantatore G, Bahillo JG.
xxxxxxx _ xxxxxxx
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
The influence of a manual glide path on the separation rate

of NiTi rotary instruments. J Endod. 2005 Feb;31(2):1146.
Masiero AV, Barletta FB. Effectiveness of different techniques for removing gutta-percha during retreatment. Int
Endod J. 2005 Jan;38(1):27.
Ayar LR, Love RM. Shaping ability of ProFile and K3 rotary
Ni-Ti instruments when used in a variable tip sequence in
simulated curved root canals. Int Endod J. 2004 Sep; 37(9):
593601.
Ankrum MT, Hartwell GR, Truitt JE. K3 Endo, ProTaper, and
ProFile systems: breakage and distortion in severely curved
roots of molars. J Endod. 2004 Apr;30(4):2347.
Prati C,Foschi F,Nucci C,Montebugnoli L,Marchionni S.Appearance of the root canal walls after preparation with NiTi
rotary instruments: a comparative SEM investigation. Clin
Oral Investig. 2004 Jun;8(2):10210.
Iqbal MK, Rafailov H, Kratchman SI, Karabucak B.A comparison of three methods for preparing centered platforms
around separated instruments in curved canals. J Endod.
2006 Jan;32(1):4851.
Knowles KI, Hammond NB, Biggs SG, Ibarrola JL. Incidence
of instrument separation using LightSpeed rotary instruments. J Endod. 2006 Jan;32(1):146.
Lam PP, Palamara JE, Messer HH. Fracture strength of tooth
roots following canal preparation by hand and rotary instrumentation. J Endod. 2005 Jul;31(7):52932.
Peters OA, Barbakow F, Peters CI. Analysis of endodontic
treatment with three nickel-titanium rotary root canal preparation techniques. Int Endod J. 2004 Dec; 37(12):84959.
Barbakow F. The LightSpeed system. Dent Clin North Am.
2004 Jan;48(1):11335.
Wei X, Cheung SP.The effects of three nickel-titanium rotary
instruments on root canal curvature. Shanghai Kou Qiang Yi
Xue. 2001 Dec;10(4):3335. Chinese.
Hulsmann M, Herbst U, Schafers F. Comparative study of
root-canal preparation using Lightspeed and Quantec SC
rotary NiTi instruments. Int Endod J. 2003 Nov; 36(11):
74856.
Alapati SB, Brantley WA, Svec TA, Powers JM, Mitchell JC.
Scanning electron microscope observations of new and
used nickel-titanium rotary files. J Endod. 2003 Oct;29(10):
6679.
Weiger R, Bruckner M, ElAyouti A, Lost C. Preparation of
curved root canals with rotary FlexMaster instruments compared to Lightspeed instruments and NiTi hand files. Int Endod J. 2003 Jul;36(7):48390.
Brantley WA, Svec TA, Iijima M, Powers JM, Grentzer TH. Differential scanning calorimetric studies of nickel-titanium rotary endodontic instruments after simulated clinical use. J
Endod. 2002 Nov;28(11):7748.
Wei X, Ling J, Zhang S. The shaping effects of three nickeltitanium rotary instruments on preparing curved canals in
posterior teeth. Zhonghua Kou Qiang Yi Xue Za Zhi. 2002
Sep;37(5):3335.
Bergmans L, Van Cleynenbreugel J, Beullens M, Wevers M,
Van Meerbeek B, Lambrechts P. Smooth flexible versus active tapered shaft design using NiTi rotary instruments. Int
Endod J. 2002 Oct;35(10):8208.
35. Tan BT, Messer HH.The quality of apical canal preparation

using hand and rotary instruments with specific criteria
for enlargement based on initial apical file size. J Endod.
2002 Sep;28(9):65864.
36. Peters OA, Schonenberger K, Laib A. Effects of four Ni-Ti
preparation techniques on root canal geometry assessed
by micro computed tomography. Int Endod J. 2001 Apr;
34(3):22130.
37. Mayer BE, Peters OA, Barbakow F. Effects of rotary instruments and ultrasonic irrigation on debris and smear layer
scores: a scanning electron microscopic study. Int Endod
J. 2002 Jul; 35(7):5829.
38. Deplazes P, Peters O, Barbakow F. Comparing apical preparations of root canals shaped by nickel-titanium
rotary instruments and nickel-titanium hand instruments.J
Endod. 2001 Mar;27(3):196202.
39. Tharuni SL, Parameswaran A, Sukumaran VG. Abstract A
comparison of canal preparation using the K-file and
Lightspeed in resin blocks. J Endod. 1996 Sep;22(9):
4746.
40. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing
of nickel-titanium endodontic instruments.J Endod.1997
Feb; 23(2):7785.
41. Miner MR, Berzins DW, Bahcall JK. A comparison of thermal properties between gutta-percha and a synthetic
polymer based root canal filling material (resilon). J Endod. 2006 Jul;32(7):6836.
42. Stratton RK, Apicella MJ, Mines P. A Fluid Filtration Comparison of Gutta-Percha versus Resilon, a New Soft Resin
Endodontic Obturation System. J Endod. 2006 Jul;32(7):
6425.
43. Shipper G, Lopez L. Clinical application of an adhesively
bonded fiber post and Resilon.Pract Proced Aesthet Dent.
2006 Apr;18(3):S127.
44. Teixeira FB. Ideal obturation using synthetic root-filling
systems: coronal sealing and fracture resistance. Pract
Proced Aesthet Dent. 2006 Apr;18(3):711.
45. Williams C, Loushine RJ,Weller RN, Pashley DH,Tay FR.A
comparison of cohesive strength and stiffness of Resilon
and gutta-percha. J Endod. 2006 Jun;32(6):5535.
46. Wang CS, Debelian GJ, Teixeira FB. Effect of intracanal
medicament on the sealing ability of root canals filled with
Resilon. J Endod. 2006 Jun;32(6):5326.
47. Aptekar A, Ginnan K. Comparative analysis of microleakage and seal for 2 obturation materials: Resilon/Epiphany
and gutta-percha. J Can Dent Assoc. 2006 Apr;72(3):
245.
48. de Oliveira DP, Barbizam JV, Trope M, Teixeira FB. Comparison between guttapercha and resilon removal using
two different techniques in endodontic retreatment. J Endod. 2006 Apr;32(4):3624.
49. Stuart CH, Schwartz SA, Beeson TJ. Reinforcement of immature roots with a new resin filling material. J Endod.
2006 Apr;32(4):3503.
50. Ezzie E, Fleury A, Solomon E, Spears R, He J. Efficacy of
retreatment techniques for a resin-based root canal obturation material. J Endod. 2006 Apr;32(4):3414. Epub
2006 Feb 17.
_authors
roots
Dr. Mounce,
is in private Endodontic
practice in Portland,
Oregon. He lectures globally and is widely published.
He can be contacted at
Lineker@aol.com.
Dr. Gary Glassman,

is in private endodontic
practice in Toronto, Ontario,
Canada. Dr. Glassman is an
Associate in Dentistry at
the University of Toronto,
School of Dentistry and the
endodontic editor of Oral
Health, a dental journal. He
can be reached through his
Web site www.rootcanals.ca.
roots
1
_ 2006
48
I 09
THE THERMOSOFTENED MILLENNIUM REVISITED:

CONTINUOUS WAVE OF CONDENSATION
Gary Glassman, DDS, FRCD(C), Fadi and Kenneth S Serota, DDS, MMSc Fadi
The Thermosoftened
Millennium Revisited: Continuous
Wave of Condensation
Gary D. Glassman, DDS, FRCD(C), FADI and Kenneth S. Serota, DDS, MMSc., FADI
RATIONALE
Until recently, the pursuit of
excellence in endodontics was
compromised by the incompatibility of the biologic demands and
technical limitations of the armamentarium available. The availability of increasingly innovative
nickel-titanium rotary instrumentation systems that allow a
crown-down apex last shaping
approach, continues to reinforce
the inappropriateness of the stepback technique for the shaping of
the root canal space. Endodontics
succeeds through the internal
sculpting of the root canal space
to provide a reservoir for the irri-
gants to clean the anatomy and

the vagaries of the root canal system. Each portal of exit along the
root face is biologically significant; this includes bifurcations,
trifurcations, canals exiting at the
base of infrabony pockets as well
as apical termini. The cleaning
and subsequent obturation of
these portals of exit is imperative
for biologic endodontic success.
In order to affect a thorough
shaping and cleaning of the root
canal system and seal it permanently with a biologically
inert obturating material, the
operators focus must shift to
the apical shape achieved that

enables the containment of the
obturating material that provides
a three dimensional seal.
APICAL CONTROL ZONE

Integral to nickel-titanium instrumentation and thermo-softened obturation is the deep shaping effect that produces the Apical
Control Zone (Figs. 1A, B & C).
The Apical Control Zone is an
area located in the apical one
third of the root canal system that
FIGURES 1A, B, CAPICAL CONTROL ZONE. The Apical Control Zone is an area located
in the apical one third of the root canal system that demonstrates an exaggerated
taper from the clinician defined apical constriction.
December 2002
49
ORAL HEALTH
FIGURE 2TOUCH N HEAT (SYBRON ENDO, ORANGE, CA). The Touch

N Heat supplies a precise amount of heat for a precise
length of time. A gloved finger can activate an omni directional contact ring trigger switch.
demonstrates an exaggerated
taper from the clinician defined
apical constriction. This greater
rate of taper is needed as a control zone to provide resistance
against the condensation pressures of obturation. This increases the retention/resistance
form and insures against extrusion of the filling material.
EVOLUTION
Clinical experience with warm
gutta-percha obturation techniques has always been influenced by the efficacy of the heat
source used. The original heat
source was a carrier inserted into
a butane or propane flame. This
variability in the control of the
degree of heat applied to the
gutta-percha was a significant
technical drawback to the vertical
condensation of warm gutta-percha technique. In addition,
patients often would experience
increased anxiety when they
would see a flaming red instrument come toward their mouth
after it was heated in a gas flame!
With the advent of electric heat
carriers, the thermodynamic
properties of gutta percha has
been taken advantage of and with
10
ORAL HEALTH
FIGURE 3OBTURA II. This thermoplasticized injection-molded

delivery system allows for the placement of thermosoftened guttapercha within the root canal space at an approximate temperature of up to 200C. The viscosity gradient of gutta-percha
decreases rapidly as the gutta-percha cools to body temperature.
good suction of fumes generated,

patients barely perceive that a
hot instrument is being used.
The development of the Touch
N Heat electric heat source
(SybronEndo, Orange County, CA)
(Fig. 2) has enabled the operator
to optimize the thermolabile properties of gutta-percha in the
three-dimensional obturation of
the root canal space. The shaping
of the heat carrier tips enables
their use as pluggers, simultaneously softening and condensing
the gutta percha. High volume
suction eliminates the smell of
the warming gutta percha and
the capability of its activation
away from the sight of the patient
has allowed the technique to gain
wide spread acceptance as an
integral component in predictable
clinical success.
Dr. L. Stephen Buchanan
developed the Continuous Wave
of Condensation1,2 technique during the past decade. The down
pack segment of the technique
requires a Touch N Heat electric heat source with a narrow
posterior or anterior plugger
inserted (.5mm diameter). The
December 2002
50
backfill of the canal space is readily done with an Obtura II

gutta percha injection system
(Obtura/Spartan, Fenton, MO)
(Fig. 3) and a variety of Obtura or
Schilder pluggers (Dentsply/
Tulsa, Tulsa, OK).
The procedural possibilities
that arise from these conceptual
and technological advances are
significant. The Continuous Wave
of Condensation technique requires a non-standardized cone to
be prefit in the root canal space.
This is consistent with the apical
control zone requirements of the
traditional Schilder technique of
Vertical Condensation.3 It is actually quite difficult to pull the master cone out as the technique is
accomplished with the apically
directed vectoring of a single
instrument. In addition, the deadsoft stainless steel heat pluggers
are quite flexible, allowing for
deeper, more effective condensation of warm gutta-percha in narrow, curved canals. This is in
marked contrast to the use of
inflexible conventional pluggers.
Ideal three dimensional obturation can therefore be achieved
without gross and dangerous over-
enlargement of the cervical half

of canals, an invitation to strip
perforation and root fracture.
CONTINUOUS CENTERED WAVE

VS. INTERRUPTED VERTICAL WAVE
COMPACTION
This technique allows a singletapered electric heat plugger
to capture a wave of condensation at the orifice of a canal
and ride it, without release, to
the apical extent of downpacking in a single, continuous
movement. This is in contrast
to heating and packing the
gutta percha through three,
four or five interrupted waves
of condensation in the traditional technique of Vertical
Condensation.3 Because the tip
moves through a viscosity-controlled material into a taperedlike canal form, the velocity of
the thermosoftened gutta percha and sealer moving into the
root canal system actually
accelerates as the down packing progresses, moving softened gutta percha into
extremely small ramifications
(Figs. 4A & B). Interrupted
waves of condensation build a
pressure wave that is lost each
time the gutta percha cools, starting and stopping its movement
into canal irregularities.
CENTERED CONTINUOUS
WAVE DOWNPACK
The apical control zone shaping
facilitates the fit of a suitably
sized gutta-percha cone, preferably fine-medium or medium. The
intimacy of diametrical fit between the cone and the canal
space is confirmed radiographically (Fig. 5). The Touch N Heat
.5 mm plugger should fit to within 4 to 6mm from most canal termini (Fig. 6). Difficulties in
achieving adequate plugger depth
are due to deficient deep shape in
the canal preparation (inadequate enlargement 3mm to 4mm
shy of the terminus).
Stainless steel Schilder plug-
FIGURES 4A, & BGutta percha and sealer can move into extremely small canal
ramifications by virtue of the vertical
and lateral forces created during the
simultaneous warming and condensation of the gutta percha.
FIGURE 5CONE FIT.

A non-standardized
(fine, fine-medium, or
medium) gutta-percha
cone is fit into the
tapered root canal
preparation making
sure that apical tugback has been
achieved 1 mm to
2 mm short of the
working length
(distance from apical
reference point will
vary with canal curvature and size).
gers (Tulsa/Dentsply, Tulsa, OK)

or Obtura pluggers (Obtura/
Spartan, Fenton, MO) are prefit
into the canals to their binding
point. Rubber stoppers are adjusted on these pluggers to the
occlusal reference point corresponding to 2 mm short of the apical binding point. These pluggers
are placed aside to be used later
in the back fill phase of canal
obturation (Fig. 7). The Touch N
Heat plugger is prefit to its
binding point in the canal, and
the rubber stop is adjusted adjacent to a reference point (Fig. 6).
The canal is dried and measured
one last time with feather-tipped
paper points, and the master cone
is cemented in the canal with
sealer (Fig. 8).
The omni directional trigger
switch is made active. The plug-
FIGURE 6TOUCH
N HEAT PLUGGER
FIT. It is essential
that the narrow
.5mm posterior or
anterior plugger is
prefit into each
canal to its binding point. A rubber stop must be
placed and adjusted to the appropriate coronal reference point for
each canal.
ger is driven through the center

of the gutta percha in a single
motion (about one second), to a
point about 3-4 mm shy of its apical binding point (Figs. 9 & 10).
While maintaining pressure on
the plugger, the trigger switch is
released and the plugger slows
its apical movement as the plugger tip cools (about one second)
to within 2 mm from its apical
binding point. After the plugger
stops, short of its binding point
apical pressure on the plugger is
sustained until the apical mass
of gutta percha has set (five to
ten seconds), taking up any
shrinkage that occurs upon cooling (Fig. 11).
After the apical mass has set, the
touch switch is made active again,
for a one-second surge of heat.
Pause for one-second after this sepDecember 2002
51
ORAL HEALTH
11
FIGURE 7SCHILDER OR OBTURA PLUGGERS FIT. Stainless steel

Schilder pluggers (Tulsa/Dentsply) are prefit into the canals to
their binding point. Rubber stoppers are adjusted on these pluggers to the occlusal reference point corresponding to 2 mm
short of the apical binding point.
FIGURE 8MASTER
CONE CEMENTATION.
The master cone is
cemented in the
canal with sealer.
FIGURE 11SUSTAINED APICAL CONDENSATION.

The omni directional trigger switch
should be released once within 3-4 mm of
the apical binding point. The plugger
should slow and stop within 2 mm short of
the binding point. Apical pressure is maintained for a full 10 second sustained push
to prevent the cooling gutta-percha mass
from shrinking.
13
12
FIGURES 12 & 13
SEPARATION BURST.
The heat source is
activated for one
second then the
omni directional
trigger switch is
released. The plugger is held in position for one second after the
switch is released, and the plugger is removed with the down
pack surplus of gutta percha, leaving the apical seal intact. All
portals of exit may be sealed, primarily with gutta-percha or a
combination of gutta-percha and sealer, and the canal is ready
for backfilling.
aration burst, and then remove the heated plugger

and the surplus gutta percha (Fig. 12). Because these
pluggers heat from their tips, this separation burst of
12
ORAL HEALTH
December 2002
52
10
FIGURES 9 & 10INITIATION OF DOWN PACK.

With the omni directional trigger
switch activated, the prefit, preheated
plugger is smoothly driven through the
mass of gutta-percha to within 4-6 mm
of the binding point.
heat allows for quick, sure severance of the plugger from the already condensed and set apical
mass of gutta percha, minimizing the possibility
of pulling the master cone out. Be certain to limit
the length of this heat burst, as the goal is separation from the apical mass of gutta percha without reheating it (Fig. 13).
Clinicians must be very alert during the first
second of the downpack so that the binding
point is not reached before completion of the
downpack. If heat is held for too long, the plugger drops to its binding point in the canal and
then cannot maintain condensation pressure on
the apical mass of gutta-percha during cooling,
possibly allowing it to pull away from the canal
walls. If binding length is reached by mistake,
the heat plugger should be removed immediately and the small end of the nickel-titanium
Continuous Wave hand plugger (Sybron Endo,
Orange, CA) should be used to condense the
apical mass of gutta-percha until set.
A final downpacking nuance is required for
ovoid or canals that join into a common apical
foramen (apically contiguous). These two canal
forms can allow for venting of condensation
backpressures during a Continuous Wave downpack and less then ideal filling of canal irregularities. In both canals, a secondary gutta-percha cone is first to butt into the master cone
short of the canal terminus and the fat end of
the Continuous Wave had plugger is used to hold it in
place during the downpack. For ovoid canals, the
hand plugger is placed at the orifice alongside the
14
15
17
18
FIGURES 14-20BACK FILLING. Applicator tips for the Obtura

II(tm) system are available in sizes #20, #23, and #25
gauges. Additional root canal sealer may be placed in the
coronal aspect of the root canal with a hand file prior to
back filling. 4-6 mm aliquots of gutta percha are injected
into the canal space then immediately condensed with the
pre-fitted Schilder or Obtura pluggers in sequence using
the sequentially larger pluggers as the coronal aspect of
the canal is approached. As thermosoftened gutta-percha
is deposited in the canal, backpressure is produced and
the applicator is forcibly extruded from the canal space. It
is essential that the operator continue injecting as the
applicator tip is retrieved from the canal in order to avoid
inadvertent removal of the newly deposited gutta percha
mass prior to condensation.
16
19
20
gutta-percha mass. This

sequence of thermosoftened gutta-percha injection and progressive compaction is continued until
the obturation of the
entire root canal space is
achieved (Figs. 14-20).
THE FUTURE
With each improvement
and modification of the
technical limitations of the
technique, the thermosoftened millennium will continue to expand the horizons of endodontic success and
elevate the standard of care and pursuit of excellence
in clinical treatment. As the future unfolds, it is
inevitable that sealers will be chemically altered to
achieve the dentin bonding adherent effects consistent
with the current generation of restorative materials.
The most anticipated event however, remains the elimination and replacement of gutta-percha as the primary obturating material. This particular development
may be expected within the next few years.
OH
heat plugger. For apically contiguous canals, the

hand plugger is held at the orifice of the other canal.
BACKFILLING
The Obtura II (Obtura/Spartan, Fenton, MO)
thermosoftened injection molded delivery system is
used to backfill the canal space. A 23 gauge applicator tip is suitable for most root canals; a 25 gauge
applicator tip and Flow 150 gutta-percha which
has a reduced density is now available for longer
more tortuous canals. The applicator tip is placed
into the root canal space until it penetrates the
coronal aspect of the apical plug of gutta-percha.
An aliquot of 5 to 6 mm of gutta-percha is then
deposited. As gutta-percha is extruded from the
applicator tip, the viscosity gradient of the back
pressure produced will push the tip coronally from
the root canal space.
Dr. Glassman is the endodontic Editorial Board member for Oral Health.
Dr. Serota is the endodontic Contributing Consultant for
Oral Health.
The technique sensitivity requires that when this

sensation occurs, the operator must sustain pressure on the trigger mechanism as the applicator tip
moves from the canal. The prefit Schilder or Obtura
condensers are then used in sequence to maximize
the density and homogeneity of the compressed
REFERENCES
1. Buchanan LS. The Continuous Wave of Condensation Technique: A Convergence of
Conceptual and Procedural Advances in Obturation. Dentistry Today 1994; 13(10):
80, 82, 84-5.
2. Buchanan LS. The continuous wave of obturation technique: centered condensation of warm guta-percha in 12 seconds, Dent Today 15:60, 1996.
3. Schilder H. Filling Root Canals in Three Dimensions. Dent Clin North Amer 1967; 723-44.
December 2002
53
ORAL HEALTH
13
ELEMENTS OBTURATION UNIT

Sybron Endo
product evaluation
The Elements Obturation Unit

replaces multiple devices while
taking up approximately one-third
the space of separate machines.
Elements Obturation Unit
incisal edge
Sybron
Endos new
filling
machine does
the work of
two separate
devices.
Dr. Gary D.
Glassman
puts it to the
test.
Until now, continuous wave of condensation techniques have required

two separate devices: an electric
heat source for down packing (like
Sybron Endos own System-B) and
an injection system (the Touch n
heat unit) for three-dimensional
backfilling. Incorporating advanced
technologies in software, metallurgy, and electronics in a compact
industrial design, the Elements
Obturation Unit has combined both
an electric heat source and backfilling injection system in a single
state-of-the art unit. It is a multifunctional, multitasking achievement of modern engineering. It
seamlessly integrates down packing, backfilling, hot-pulp testing,
and heat cauterization in a single
dynamic unit that takes up only
one third of the space of two separate machines.
The left side of the unit incorporates the controls and handpuece
from System-B, while the right
side incorporates the extruder sys-
56
tem and its controls. Both the

System-B and extruder handpieces
have autoclavable aluminum
sheaths with silicone coatings at
the active end that prevent heat
transfer to the clinicians fingertips
and protect the patients soft tissues. The sheaths are installed by
lining up the index marking and
sliding them into place until a click
is felt and heard. The activation
switches are easy to reach, smooth
to the touch, and signal with an
audible tone when deployed. Two
sheaths are provided for each
handpiece so that one can be in use
while the other is being autoclaved.
The digital and graphical display for
the System-B controls incorporates
four functions each with its own
preset default temperatures and
durations. If a temperature setting
other than the preset is desired for
any of the functional modes, the
temperature function can be used to
change the temperature in 5-degree
increments. Pressing and holding
54
the current mode buttons for 4

seconds will set that temperature
for that particular function. This
new temperature preset is retained
until manually changed or the
defaults are renewed. The preset for
the down-pack control function is
200C, the backfill function is
100C, the heat-cautery function is
600C, and the hot-pulp test function is 200C.
The System-B handpiece is activated by depressing the button with a
gloved finger. The tip will heat
instantly and the LED indicator on
the handpiece will illuminate. The
tip will remain heated only as long
as the button is depressed. A
time-out feature assists the clinician by shutting off the energy to
the tip after an appropriate
amount of time for each of the four
functions. This avoids overheating
of the tooth and/or tissue. The
time-outs are four seconds for
the down-pack function, 15 seconds for the backfill function, 60
seconds for the hot-pulp test function, and five seconds for the heatcautery function. During activation, the tip temperature is continuously maintained and displayed.
The handpiece will need to be reactivated to resume heating beyond
the preset duration. During down
packing, the unit emits an automatic timer beep at five seconds
and 10 seconds to indicate readiness for the separation burst.
The pluggers are available in 0.04,
0.06, 0.08, 0.10, and 0.12 tapers.
They replicate the canal shape and
maximize condensation forces to
messy cleanup of plungers and bushings found in other units a thing of

the past, and the needles are extra
long (by 4mm), facilitating access to
posterior teeth with unprecedented
visibility and greater control and
accuracy. The cartridges are offered
in 20-, 23-, and 25-gauge sizes that
have plastic locknuts color-coded gray
for RealSeal and black for gutta percha. Made of silver for excellent heat
conductivity, the cartridges load and
disengage easily from the handpiece
with the specialized tool provided
with the unit.
The extruder handpiece has a
CONVENIENT CARTRIDGE DELIVERY

Proprietary disposable cartridges of
gutta percha or RealSeal minimize the
possibility for cross contamination and
eliminate cleanup. Made of silver for
excellent heat conductivity, the cartridges load and disengage easily.
move the filling material and sealer

into all areas of the root canal system, including lateral and accessory
canals, to ensure a complete and
homogenous fill. They have a new
hex-nut attachment that allows
quick insert and release, thereby
eliminating the need for a pinvise nut
that is found in both the original
System-B and Touch n Heat. The
new 0.04 taper has a 40% smaller
tip diameter that allows access into
smaller canals and provides the same
thermo-feedback as the other
System-B pluggers, but is closer to
the size of a Touch n Heat tip.
Proprietary disposable cartridges of

gutta percha or RealSeal makes the
MEDICAL
GRADE
CONNECTIONS
Ensure Longevity
and Accuracy
mechanical indicator on the opposite

side of the activation buttons that
shows the amount of material
remaining in the cartridge. If the
extruder is deactivated before the
cartridge is empty, the plunger will
retract slightly to prevent excess filling material from discharging. When
the heat-select and heat-activated
buttons are deployed, the preset temperature is reached in approximately
45 seconds and shuts off automatically in 15 minutes to prevent overheating of the filling material. There are
two activation buttons on the extruder handpiece that allow the clinician
to choose between two speeds for the
extrusion of filling material.
Conclusion
There are several advantages of the
new System-B electric heat source
in the Elements Obturation Unit
over the previous standalone
System-B unit and Touch n Heat
unit. Autoclavable removable
sheaths, multifunctional preset heat
settings, an audible time-out feature to prevent overheating of tooth
55
For practitioners who are firsttime users of electric heat

sources and thermo-softened
injection delivery systems, or
for those who are purchasing
additional equipment, it would
be beneficial to consider acquiring one unit that incorporates
both devices to take advantage
of the multitude of features and
small footprint. For those who
possess two independent devices
already, as maintenance and
repair costs become formidable
it may be more economically
prudent to replace them with a
single unit.
The Elements Obturation unit
represents the next generation
in thermo-softened filling material delivery devices, incorporating the latest in technology,
ergonomics, and ease of compliance with Occupational Safety
and Health Administration standards to facilitate a more thorough three-dimensional obturation
of the root canal systems.
57
incisal edge
The extruder system is micromotor

driven and automates the backfill
process, eliminating the fatiguing
manual action required by the other
thermo-softening injection units. Its
advanced insulation technology allows
the extruder to stay dramatically
cooler than other units throughout
treatment.
structure, detachable cord for servicing, and hex-nut attachment

for the pluggers are several examples. The extruder system has several feature enhancements compared to standalone extruders
including disposable color-coded
cartridges of either RealSeal or
gutta percha available with different gauged tips (no messy cleanup),
preset one-touch heat settings for
RealSeal and gutta percha, audible
heat ready tones, dual-speed feature, fatigue-free activation button,
automatic plunger retraction, and
autoclavable/ removable
shields/sleeves.
BONDED ENDODONTIC OBTURATION:

ANOTHER QUANTUM LEAP FORWARD FOR
ENDODONTICS
C A S E
P R E S E N T A T I O N
Bonded Endodontic Obturation:

Another Quantum Leap Forward
for Endodontics
Rich Mounce, DDS and Gary Glassman, DDS, FRCD(C)
he surgical operating microscope and the advent of rotary

nickel titanium instrumentation have both provided a quantum leap forward towards a higher standard of endodontics. Adhesion has done much the same
for restorative dentistry. Blending
the best of adhesion into endodontic obturation has now become
reality. In the authors opinion,
adhesion in canal obturation represents another quantum leap forward for the specialty. Recently,
Resilon Research LLC, (Madison,
CT) has introduced Resilon obturating points (a soft resin) and
resin sealer which when used in
combination with a self etch
primer after smear layer removal,

allow creation of a solid monoblock (a material which is contiguous from its resin tags in
cleared dentinal tubules through
sealer to the core canal filler). The
material not only fully obturates
canal anatomy (especially through
the compaction possible with
warm obturation techniques); it
diminishes coronal microleakage
through bonding to the cleared
dentinal tubules. Resilon Products
(RP) are marketed as RealSeal
(SybronEndo, Orange, CA). and
Epiphany (Pentron, Wallingford,
CT) (Figs. 1-2). The authors experience is with the RealSeal brand
and will reference it throughout
the report. It is hard to overstate

the advance that this represents
(detailed in this paper) relative to
gutta percha.
FIGURE 1Resilon and Epiphany

Sealer (R/E) (Resilon Research LLC,
Madison, CT).
FIGURE 2RealSeal (R/S) (SybronEndo, Orange, CA).
FIGURE 3Gap present between gutta

percha and AH 26 sealer 650X.
Gutta percha, despite its many

advantages (non toxic, biocompatible, thermoplastic and retreatable) and status as a time honored standard for endodontic
obturation possesses one significant limitation. Gutta percha cannot prevent coronal microleakage
which places the entire procedure
at risk in the event of recurrent
caries or subsequent microleakage if either the patient does not
have the tooth restored or the
subsequent restoration is not sat-
July 2004
56
oralhealth
13
C A S E
FIGURE 4Smear layer produced by

instrumentation before removal.
FIGURE 5Smear layer removal with SmearClear (SybronEndo, Orange, CA).
FIGURE 6Graphic illustration of Dentinal

tubules after smear layer removal.
FIGURE 7Graphic illustration of Resilon

primer penetration.
FIGURE 8Graphic illustration Resilon

sealer penetration and Resilon point creating a monoblock of resin.
FIGURE 9Resilonmonoblock 40X.
FIGURE 10Resilon monoblock 650X.
FIGURE 11Sealer tags and Resilon

1000X.
isfactory (and microleakage occurs). Gutta percha (with or without sealer) provides a relatively
poor to non existent barrier to
prevent the coronal to apical
migration of bacteria after obturation as gutta percha (with and
without sealer) does not bond to
canal walls, it can only adapt1-4
(Fig. 3). In addition, even if the
standard of endodontic therapy is
excellent, a lack of coronal seal or
recurrent decay significantly
diminish the possibilities for
endodontic success over the long
term as bacteria can migrate in a
coronal to apical direction and ini-
tiate failure. Ironically, coronal

seal is a major indicator of the
potential for endodontic success
or failure aside from the quality of
the endodontic treatment or the
presence of gutta percha.5,6 As a
result, gutta percha has been
more of a filler that took up
space within the root canal system. While imperfect, gutta percha has been the best material
clinicians have had up to this
point in time.
14
oralhealth
These significant limitations

are overcome by RealSeal. By
removal of the smear layer (Figs.
July 2004
57
4-5), produced during instrumentation, it is now possible to

bond the obturating material
into the dentinal tubules and
create (as mentioned above) a
monoblock of resin sealer and
resin core filling material (Figs.
6-11). The root canal system can
now be sealed to some degree
(technique and clinician dependent) along the entire length of
the canal (from orifice to apex)
preventing microbial migration.
One strategic advantage that
this gives the clinician is that if
the patient does not get a coronal
restoration as they should (assuming that the treatment has been
performed correctly), Resilon is
significantly resistant to leakage
along its length and one of the key
factors responsible for endodontic
failure has been eliminated or dramatically reduced. A recent study
by Shipper, et al found that comparing bacterial leakage using
Streptococcus mutans and Enterococcus faecalis through both
gutta percha and Resilon over a 30
day period demonstrated that
Resilon showed minimal leakage
which was statistically significant
C A S E
FIGURE 12CONE FIT. An

appropriate RealSeal cone is
fit into the tapered root canal
preparation making sure that
apical tug-back has been
achieved 1 mm to 2 mm
short of the working length
(distance from apical reference point will vary with
canal curvature and size).
FIGURES 13A, B & CHAND PLUGGERS FIT. Stainless steel Schilder pluggers (Tulsa/Dentsply),
Obtura pluggers (Obtura/Spartan, Fenton, MO), or Buchanan Hand Pluggers (SybronEndo,
Orange, CA) are prefit into the canals to their binding point. Rubber stoppers are adjusted on
these pluggers to the occlusal reference point corresponding to 2 mm short of the apical binding point. The reason the rubber stoppers are adjusted short of the apical binding point is to
provide the clinician a marker to prevent direct engagement of the plugger on the canal walls.
FIGURE 14ASystem-B Supplies a

precise amount of heat for a precise
length of time. A gloved finger can
activate an omni directional contact
ring trigger switch.
FIGURE 14BSystem-B
BUCHANAN PLUGGER
FIT. It is essential that the
plugger is prefit into each
canal to its binding point.
A rubber stop must be
placed and adjusted to
the appropriate coronal
reference point for each
canal.
FIGURE 15MASTER CONE

CEMENTATION. The master cone is cemented in
the canal with sealer.
July 2004
58
FIGURE 16INITIATION OF
DOWN PACK. With the
omni directional trigger
switch activated, the prefit, preheated plugger is
smoothly driven through
the mass of RealSeal to
within 4-6 mm of the
binding point.
oralhealth
15
C A S E
FIGURE 17COMPLETION
OF DOWN PACK. With the
switch activated, the prefit,
preheated plugger is smoothly driven through the mass of
RealSeal to within 4-6 mm of
the binding point.
FIGURE 18SUSTAINED APICAL CONDENSATION. The

switch should be released
once within 3-4 mm of the
apical binding point. The
plugger should slow and stop
within 2 mm short of the binding point. Apical pressure is
maintained for a full 10 second sustained push to prevent the cooling RealSeal
mass from shrinking.
FIGURES 19 & 20SEPARATION BURST. The heat source is activated for one second then the omni directional trigger
switch is released. The plugger is held in position for one second after the switch is released, and the plugger is removed
with the down pack surplus of RealSeal, leaving the apical
seal intact. All portals of exit may be sealed, primarily with
RealSeal or a combination of RealSeal and resin sealer, and
the canal is ready for backfilling.
compared to gutta percha.7 In essence, now,

Resilon endodontic obturating material can significantly diminish microleakage, a property not possessed by gutta percha.
RealSeal is a thermoplastic synthetic resin
material based on the polymers of polyester and
contains a difunctional methacrylate resin, bioactive glass and radio opaque fillers. RealSeal sealer contains UDMA, PEGDMA, EBPADMA and
BisGMA resins, silane treated barium borosilicate
glasses, barium sulfate, silica, calcium hydroxide,
bismuth oxychloride with amines, peroxide, photo
initiator, stabilizers and pigment. RealSeal
Primer is an acidic monomer solution in water.
RealSeal is non toxic, FDA approved and non mutagenic. With its radio opaque fillers, RealSeal is a
highly radio opaque material. The sealer is
resorbable. Aside from its capacity to be thermoplasticized, RealSeal can be dissolved with chloroform and retreated. There are unsubstantiated
statements on the internet that RealSeal shrinks
substantially less than gutta percha but this fact
cannot be verified from the literature at this time.
16
oralhealth
FIGURE 21OBTURA II. This thermoplasticized injectionmolded delivery system allows for the placement of thermosoftened RealSeal within the root canal space at an
approximate temperature of up to 150C-175C. The viscosity gradient of RealSeal decreases rapidly as the RealSeal
cools to body temperature.
One remarkable feature about RealSeal is that in

virtually all handling characteristics, it handles and
feels like gutta percha. In other words, it can be used
with all the common present forms of endodontic
obturation (vertical compaction of warm gutta percha, cold lateral condensation, lateral/vertical combinations) and there is virtually no learning curve to
its use. This allows the clinician to use this new technology with only two added steps relative to common
July 2004
59
C A S E
22
24
23
25
FIGURES 22-28BACK FILLING. Applicator tips for the Obtura II system are available in sizes #20, #23, and #25 gauges.
Additional root canal sealer may be placed in the coronal aspect of the root canal with a hand file prior to back filling. 4-6
mm aliquots of RealSeal are injected into the canal space then immediately condensed with the pre-fitted Schilder or Buchanan
hand pluggers in sequence using the sequentially larger pluggers as the coronal aspect of the canal is approached. As thermosoftened RealSeal is deposited in the canal, backpressure is produced and the applicator is forcibly extruded from the canal
space. It is essential that the operator continue injecting as the applicator tip is retrieved from the canal in order to avoid inadvertent removal of the newly deposited RealSeal mass prior to condensation.
26
27
endodontic treatment regimens,

clearing the smear layer and placing the self etch primer (to be
described). RealSeal points are
available in introductory kits of
various configurations and as
individual components (.02, .04,
.06 tapered cones with a variety of
tip sizes along with accessory
28
points ranging in size from x-fine

to large). RealSeal cones are very
flexible and pellets of the material
are available for the Obtura gun
(Spartan Obtura, Fenton, MO). At
present, no carrier based product
exists that possesses Resilon technology and none is on the horizon
to the authors knowledge.
Because root canal therapy

removes some amount of dentin within the tooth, the potential exists to weaken the tooth
to some degree and make the
tooth more susceptible to vertical root fracture. Gutta percha has no potential to
strengthen the roots after
treatment. RealSeal in contrast has the potential to
strengthen roots. In vitro,
Teixeira, et al. found that the
resistance to root fracture
found with Resilon was superior (P=0.037) to gutta percha/AH 26 sealer (Dentsply
Maillefer) using both lateral
and vertical condensation.8 In
essence, Resilon used in the
manner tested increased the
fracture resistance of single
canal endodontically treated
teeth as compared to other common gutta percha techniques.
While this might be considered a
secondary benefit as compared to
its potential to reduce coronal to
apical leakage of bacteria, it is
not in any way inconsequential.
July 2004
60
oralhealth
19
C A S E
CLINICAL TECHNIQUE
Canal Preparation: The canal
is prepared with the protocol normally used. Canal preparation
techniques do not need to be
altered to facilitate the use of the
material.
Smear
Layer
Removal:
Throughout the entire instrumentation protocol an alternating
sequence of 17% EDTA and sodium hypochlorite must be used to
remove the smear layer. The
smear layer is the layer of organic
and inorganic debris that is created along the walls of the canals
during instrumentation. While
17% liquid EDTA can be used as a
final canal rinse, the author recommends SmearClear (SybronEndo, Orange, CA) as a final rinse
where the liquid is allowed to soak
into the tubules throughout the
entire canal system for 1-2 minutes. SmearClear contains surfactants which enhance wetting of
the canal walls and provide optimal smear layer removal. It is
important not to use either sodium
hypochlorite or absolute alcohol as
the final rinse to dry the canal
after the smear layer is removed.
Sodium hypochlorite will disrupt
the sealer bond and absolute alcohol will act as a drying agent. The
walls need not be completely dry
as the sealer is hydrophilic.
Placement of the Primer:
After the canal is dried with
paper points, a brush provided by
the manufacturer can be used to
bring the self etch primer into the
coronal third of the canal.
Alternatively, a paper point of an
appropriate taper can be super
saturated with the adhesive that
has been introduced into a plastic
bonding well. The primer should
be dispersed evenly on the canal
walls yet not extrude apically.
Under a surgical operating microscope, one may see if any primer
remains in the canal or if the
excess has been removed.
Mixing of the Resin Sealer:
20
oralhealth
July 2004
61
Next, the dual syringe (containing the sealer) is used to express

the sealer onto the mixing pad.
The dual syringe has tips which
mix the sealer as it is expressed.
As an aside, it is possible to forgo
the use of the mixing tip provided
in the kits and hand mix the sealer with a spatula (express a small
amount of both sealer components onto the pad without the
mixing tip) and save a significant
amount of sealer from every dual
syringe although the mixing tips
eliminate one step relative to
hand spatulation. Cone fit (Fig.
12) and placement of the sealer
can be performed as per the clinicians present technique. While
preferred methods for sealer
placement vary widely, the
author is not in favor of use of a
lentulo spiral to introduce sealer
of any type and this personal
preference extends to the resin
sealer used with RealSeal due to
the unwarranted risk of apical
extrusion as well as potential for
lentulo separation.
Obturation: Stainless steel
Schilder pluggers (Tulsa/Dentsply,
Tulsa, OK), Obtura pluggers
(Obtura/Spartan, Fenton, MO),or
Buchanan Hand Pluggers (SybronEndo, Orange, CA) are prefit
into the canals to their binding
point. Rubber stoppers are adjusted on these pluggers to the occlusal reference point corresponding
to 2 mm short of the apical binding
point. These pluggers are placed
aside to be used later in the back
fill phase of canal obturation (Figs.
13A, B & C). The The System-B
Buchanan plugger is prefit to its
binding point in the canal, and the
rubber stop is adjusted adjacent to
the appropriate reference point
(Fig. 14a,b). The canal is dried and
measured one last time with feather-tipped paper points, and the
master RealSeal cone is cemented
in the canal with sealer (Fig. 15).
The omni directional trigger
switch on the System B handpiece is made active. The plugger
C A S E
is driven through the center of the

RealSeal cone in a single motion
(about one second), to a point
about 3-4 mm shy of its apical
binding point (Figs. 16 & 17).
While maintaining pressure on
the plugger, the trigger switch is
released and the plugger slows its
apical movement as the plugger
tip cools (about one second) to
within 2 mm from its apical binding point. After the plugger stops,
short of its binding point apical
pressure on the plugger is sustained until the apical mass of
RealSeal has set (five to ten seconds), taking up any shrinkage
that occurs upon cooling (Fig. 18).
After the apical mass has set,
the touch switch is made active
again, for a one-second surge of
heat. Pause for one-second after
this separation burst, and then
remove the heated plugger and
the surplus RealSeal (Fig. 19 &
20). Because these pluggers heat
from their tips, this separation
burst of heat allows for quick,
sure severance of the plugger
from the already condensed and
set apical mass of RealSeal, minimizing the possibility of pulling
the master cone out. Be certain to
limit the length of this heat burst,
as the goal is separation from the
apical mass of RealSeal without
reheating it. Clinicians must be
very alert during the first second
of the downpack so that the binding point is not reached before
completion of the downpack. If
heat is held for too long, the plugger drops to its binding point in
the canal and then cannot maintain condensation pressure on the
apical mass of gutta-percha during cooling, possibly allowing it to
pull away from the canal walls. If
binding length is reached by mistake, the heat plugger should be
removed immediately and the
small end of the nickel-titanium
Buchanan hand plugger (Sybron
Endo, Orange, CA), or Obtura
pluggers (Obtura/Spartan, Fenton,
MO) should be used to condense
the apical mass of gutta-percha
until set. A final downpacking

nuance is required for ovoid or
canals that join into a common
apical foramen (apically contiguous). These two canal forms can
allow for venting of condensation
backpressures during a Continuous Wave downpack and less
then ideal filling of canal irregularities. In both canals, a secondary RealSeal cone is first to
butt into the master cone short of
the canal terminus and the fat
end of the hand plugger is used to
hold it in place during the downpack. For ovoid canals, the hand
plugger is placed at the orifice
alongside the heat plugger. For
apically contiguous canals, the
hand plugger is held at the orifice
of the other canal.
BACKFILLING
The Obtura II (Obtura/Spartan, Fenton, MO) thermosoftened
injection molded delivery system
is used to backfill the canal space
at a temperature of between
150C-175C. A 23 gauge applicator tip is suitable for most root
canals (Fig. 21). A thin layer of
sealer is applied to the root canal
walls with a paper point before
backfilling. The applicator tip is
placed into the root canal space
until it penetrates the coronal
aspect of the apical plug of
RealSeal. A bolus of 5 to 6 mm of
RealSeal is then deposited. As
thermosoftened RealSeal is extruded from the applicator tip,
the viscosity gradient of the back
pressure produced will push the
tip coronally from the root canal
space.The technique sensitivity
requires that when this sensation
occurs, the operator must sustain
pressure on the trigger mechanism as the applicator tip moves
from the canal. The prefit hand
condensers are then used in
sequence to maximize the density
and homogeneity of the compressed gutta-percha mass. This
sequence of thermosoftened
gutta-percha injection and progressive compaction is continued
until the obturation of the entire
62
July 2004
oralhealth
21
C A S E
root canal space is achieved

(Figs. 22-28).
Post Preparation or Curing
the Coronal third: If required,
a post space may be prepared at
the time of obturation only
after the canals are first filled to
the level of the orifices. If any
lateral/accessory canals and/or
dentinal tubules have not been
sealed during the down pack,
perhaps they may be sealed on
the back fill. If post space needs
to be prepared after the material has set up and the monoblock
created, ideally, a small amount
of chloroform can be introduced
and the RealSeal dissolved to
the desired depth in the canal
and post preparation accomplished. A curing light can also
be used to help cure several mm
of the material in the coronal
third and the material will self
cure within one hour.
Empirically, the authors
have found the transition from
gutta percha to RealSeal to be
virtually seamless and without
a learning curve and are using
this material exclusively. The
added step of placing the primer
is virtually negligible with regard
to the amount of time it takes in
the context of the entire procedure and the benefits derived
(Figs. 29A & B).
With certainty, this material
will be extensively studied, tested and reported in the literature
in the years to come. Technique
nuances with regard to its handling and creation of the greatest
possible efficiency in its use may
emerge. This said, in the authors
opinion, over the next decade, as
studies in all probability will
continue to validate this material, it is very possible that gutta
percha will become obsolete until
another material can be found
which will give greater clinical
benefit with less patient risk
than RealSeal. In the authors
opinion, this material truly is a
22
oralhealth
FIGURES 29A & BClinical RealSeal cases. Compaction and handling characteristics
of RealSeal are virtually identical to gutta percha.
quantum leap forward in the

modern era of endodontics and
worthy of consideration for use
as an obturating material in
place of gutta percha.
OH
Dr. Mounce is in private endodontic practice in Portland, Oregon, USA.

Dr. Glassman in a Fellow of the
Royal Endodontic in Canada, endodontic consultant for Oral Health
Dental Journal and is in a group
endodontic practice in Toronto, Ontario,
Canada. Dr. Mounce has no commercial
interest in any products of any kind.
Resilon, Epiphany and RealSeal
have received regulatory clearance from
the FDA and has the proper documentation to allow placement of the CE
mark for European sales. At the time of
this publication Resilon, Epiphany and
RealSeal are undergoing the approval
July 2004
63
process by Health Canada.

article.
REFERENCES
1. Barrieshi KM, Walton RE, Johnson WT, Drake DR.
Coronal leakage of mixed anaerobic bacteria after
obturation and post space preparation. Oral Surg
1997;84:310-4.
2. Torabinejad M, Ung B, Kettering JD In vitro bacterial
penetration of coronally unsealed Endodontically treated teeth, J. Endod. 1990 Dec; 16(12):566-9.
3. Saunders WP, Saunders EM Assessment of leakage in
the restored pulp chamber of Endodontically treated
multirooted teeth Int. Endod J. 1990 Jan;23(1):28-33.
4. Chailertvanitkul P, Saunders WP, Saunders EM,
MacKenzie D, An evaluation of microbial coronal
leakage in the restored pulp chamber of root canal
treated multirooted teeth Int Endod. J 1997
Sept;30(5):318-22.
5. Swartz DB, Skidmore AE, Griffin JA. Twenty years of
Endodontic success and failure. J Endod. 1983;9:
198-202.
6. Ray HA, Trope M. Periapical status of Endodontically
treated teeth in relation to the technical quality of the
root filling and the coronal restoration. Int Endod. J
1995;28:12-18.
7. Shipper G, Orstavik D, Teixeira FB, Trope M, An evaluation of microbial leakage in roots filled with a thermoplastic synthetic polymer based root canal filling
material (Resilon), J Endod, 2004 May; 30(5):342-7.
8. F.B. Teixeira, E.C. Teixeira, J. Y. Thompson, M. Trope.
IADR/AADR/CADR 82nd General Session, March 1013, 2004.
C A S E
root canal space is achieved

(Figs. 22-28).
Post Preparation or Curing
the Coronal third: If required,
a post space may be prepared at
the time of obturation only
after the canals are first filled to
the level of the orifices. If any
lateral/accessory canals and/or
dentinal tubules have not been
sealed during the down pack,
perhaps they may be sealed on
the back fill. If post space needs
to be prepared after the material has set up and the monoblock
created, ideally, a small amount
of chloroform can be introduced
and the RealSeal dissolved to
the desired depth in the canal
and post preparation accomplished. A curing light can also
be used to help cure several mm
of the material in the coronal
third and the material will self
cure within one hour.
Empirically, the authors
have found the transition from
gutta percha to RealSeal to be
virtually seamless and without
a learning curve and are using
this material exclusively. The
added step of placing the primer
is virtually negligible with regard
to the amount of time it takes in
the context of the entire procedure and the benefits derived
(Figs. 29A & B).
With certainty, this material
will be extensively studied, tested and reported in the literature
in the years to come. Technique
nuances with regard to its handling and creation of the greatest
possible efficiency in its use may
emerge. This said, in the authors
opinion, over the next decade, as
studies in all probability will
continue to validate this material, it is very possible that gutta
percha will become obsolete until
another material can be found
which will give greater clinical
benefit with less patient risk
than RealSeal. In the authors
opinion, this material truly is a
22
oralhealth
FIGURES 29A & BClinical RealSeal cases. Compaction and handling characteristics
of RealSeal are virtually identical to gutta percha.
quantum leap forward in the

modern era of endodontics and
worthy of consideration for use
as an obturating material in
place of gutta percha.
OH
Dr. Mounce is in private endodontic practice in Portland, Oregon, USA.

Dr. Glassman in a Fellow of the
Royal Endodontic in Canada, endodontic consultant for Oral Health
Dental Journal and is in a group
endodontic practice in Toronto, Ontario,
Canada. Dr. Mounce has no commercial
interest in any products of any kind.
Resilon, Epiphany and RealSeal
have received regulatory clearance from
the FDA and has the proper documentation to allow placement of the CE
mark for European sales. At the time of
this publication Resilon, Epiphany and
RealSeal are undergoing the approval
July 2004
64
process by Health Canada.

article.
REFERENCES
1. Barrieshi KM, Walton RE, Johnson WT, Drake DR.
Coronal leakage of mixed anaerobic bacteria after
obturation and post space preparation. Oral Surg
1997;84:310-4.
2. Torabinejad M, Ung B, Kettering JD In vitro bacterial
penetration of coronally unsealed Endodontically treated teeth, J. Endod. 1990 Dec; 16(12):566-9.
3. Saunders WP, Saunders EM Assessment of leakage in
the restored pulp chamber of Endodontically treated
multirooted teeth Int. Endod J. 1990 Jan;23(1):28-33.
4. Chailertvanitkul P, Saunders WP, Saunders EM,
MacKenzie D, An evaluation of microbial coronal
leakage in the restored pulp chamber of root canal
treated multirooted teeth Int Endod. J 1997
Sept;30(5):318-22.
5. Swartz DB, Skidmore AE, Griffin JA. Twenty years of
Endodontic success and failure. J Endod. 1983;9:
198-202.
6. Ray HA, Trope M. Periapical status of Endodontically
treated teeth in relation to the technical quality of the
root filling and the coronal restoration. Int Endod. J
1995;28:12-18.
7. Shipper G, Orstavik D, Teixeira FB, Trope M, An evaluation of microbial leakage in roots filled with a thermoplastic synthetic polymer based root canal filling
material (Resilon), J Endod, 2004 May; 30(5):342-7.
8. F.B. Teixeira, E.C. Teixeira, J. Y. Thompson, M. Trope.
IADR/AADR/CADR 82nd General Session, March 1013, 2004.
ADHESIVE BONDING IN ENDODONTICS:

AN IDEA WHOSE TIME HAS COME
CPD
Clinical
Figure 3
Figure 5
Figure 5:
Figure 4:
Dr Mounce is in private endodontic practice in Portland, Oregon,

USA.
Dr Glassman is a Fellow of the Royal Endodontic in Canada,
endodontic consultant for Oral Health Dental Journal and is in a
group endodontic practice in Toronto, Ontario, Canada.
Dr McCarty is a general practitioner in Lewisburg,
Pennsylvania, USA
Dr Mounce, Dr Glassman and Dr McCarty ha ve no commercial
interest in any of the products discussed in this article.
Endodontic therapy, ideally, should duplicate the net

effect of extraction. Extraction removes the entire
diseased pulp and as a result the patient heals. To the
greatest degree possible, the more pulp that is removed
during endodontic therapy (mimicking extraction), the
higher the chance of clinical success. In practical terms,
the mechanical goal of endodontic therapy to achieve
this is the cleansing, shaping and obturation of the root
The goal of endodontic treatment
separate units are combined into one ergonomic,

practical and affordable machine. A description of how
Elements Obturation can be instrumental in most fully
utilizing RealSeal will be detailed in the technique
section of this article. The Elements obturation unit is
the first that is designed to work with RealSeal bonded
technology as well as GP.
Figure 4
Figure 2
ENDODONTIC PRACTICE MAY 2005
Adhesive bonding has come to endodontics. It is now

possible to bond a biocompatible and retreatable
obturating material into canal systems. This is a
watershed event in the history of endodontics on a par
with the advent of the surgical microscope, ultrasonics,
warm gutta percha (GP) techniques and rotary nickel
titanium instrumentation.
Resilon Research LLC (Madison, CT) has introduced
soft-core resin obturating points named Resilon, along
with a resin sealer and a self-etch primer. These
materials, after smear layer removal, create a resin-based
obturation that is continuous from resin tags (which
penetrate the dentinal tubules) through to the core
filling material, occupying the body of the canal.
Resilon Research refers this obturation as a monoblock.
This bonding into the dentinal tubules significantly
reduces coronal microleakage in a way never possible
with GP, as GP has no significant ability to resist
coronal microleakage. Resilon products are labeled and
sold as RealSeal (SybronEndo, Orange, CA) and
Epiphany (Pentron, Wallingford, CT) (Figures 1 to 5).
The authors collectively have extensive clinical
experience with RealSeal and it will be referred to as
such in this article.
Coincident to this quantum leap forward toward
endodontic excellence, a new instrument has recently
been introduced, the Elements Obturation Unit, which
combines, refines and enhances the best features of the
SystemB heat source (SybronEndo, Orange, CA, USA)
and other means of gutta percha extrusion. Now these
Figure 1
Figure 3:
Figure 2:
Figure 1:
17
RealSeal
and Epiphany (RE)
(Pentron, Wallingford,
CT)
RealSeal
(RS) (SybronEndo,
Orange, CA)
Gap
present between
gutta percha and AH
26 sealer 650X
Smear
layer produced by
instrumentation
before removal
Smear
layer removal with
SmearClear
(SybronEndo,
Orange, CA)
Richard Mounce, DDS, Gary Glassman, DDS, FRCD(C), and David McCarty,
DMD, share their experiences of using RealSeal and discuss the research
published to date on this new material
Adhesive bonding in endodontics:

An idea whose time has come
This article is equivalent to one hour of

verifiable CPD. See page 3 for details
65
Graphic
illustration of
dentinal tubules
after smear layer
removal
Graphic
illustration of
RealSeal primer
penetration
Graphic
illustration of
RealSeal sealer
penetration and
Resilon point
creating a
monoblock of resin
RealSeal
monoblock 40X
RealSeal
monoblock 650X
Sealer
tags and RealSeal
1000X
18
Figure 11:
Figure 10:
Figure 9:
Figure 8:
Figure 7:
Figure 6:
Figure 8
Intuitively, it makes sense that removal of root dentin

creates the possibility that endodontic therapy might
weaken a tooth, making it somewhat more susceptible
to fracture, especially vertically. RealSeal has the
potential to strengthen roots; gutta percha does not. It
has been found that relative to gutta percha and AH26
(Dentsply Maillefer) testing, both lateral and vertical
condensation, RealSeal had a statistically significant
better resistance to root fracture (P=0.037) in vitro
(Teixeira FB, Teixeira ECN, Thompson JY, Trope M,
2004).
In vivo, using a dog model to compare RealSeal
versus gutta percha and AH 26 in obturated roots to
prevent apical periodontitis after coronal inoculation
with oral microorganisms (incorporating both positive
Additional relevant published

research
From the MSDS sheets provided by the manufacturer,

it is noted that:
1) Resilon contains a difunctional methacrylate resin,
bioactive glass and radio-opaque fillers
2) The sealer is made up of UDMA, PEGDMA,
EBPADMA and BisGMA resins, silane-treated barium
borosilicate glasses, barium sulfate, silica, calcium
hydroxide, bismuth oxychloride with amines, peroxide,
photo initiator, stabilizers and pigment
3) The primer is an acidic monomer solution in water.
In addition, RealSeal core material is filled
approximately 65% by weight and RealSeal sealer is
filled approximately 70% by weight. Given its chemical
components, RealSeal sealer is bacteriostatic.
As previously mentioned, the brand of Resilon the
authors have extensive clinical experience with is
RealSeal. RealSeal is used exactly like GP, feels like GP
and handles like GP. This has the advantage that the
operator does not need to modify their present
obturation technique (warm or cold) to incorporate
RealSeal into practice. This material is not available at
this time for any of the carrier-based products that only
come with GP as the thermosoftened component.
RealSeal is available commercially as .02, .04 and .06
tapered cones and as accessory cones with sizes from
x-fine to large.
Figure 10
Figure 9
canal system from the canal orifice to the minor

constriction of the apical foramen in three dimensions.
Even with ideal three-dimensional cleansing, shaping
and packing, with previously available methods and
materials, GP never had an inherent ability to limit or
prevent coronal microleakage, especially in a coronal to
apical direction; a desirable but heretofore unachieved
objective. In theory, ideal endodontic obturation should
seal off bacteria that cannot be removed during cleaning
and shaping procedures, and prevent the orthograde
and retrograde percolation of fluids into the canal
system (Sundquist G et al, 1998; Swanson K et al, 1987;
Madison S et al, 1988).
In addition, as mentioned, GP exposed to salivary
contamination due to a lack of coronal seal or caries
allows the apical migration of bacteria from crown to
apex, causing apical inflammation and infection
(Barrieshi KM, Walton RE, Johnson WT, Drake DR,
1997; Torabinejad M, Ung B, Kettering JD, 1990;
Saunders WP, Saunders EM, 1990). GP only adapts to
canal walls and, even with a resin sealer, gaps are often
present between the GP and the sealer. As a result, if
adequate coronal seal is not achieved after endodontic
procedures, the risk of treatment failure rises (Swartz
DB, Skidmore AE, Griffin JA, 1983; Ray HA, Trope M,
1995; Torabinejad M et al, 1990; Khayat et al, 1993).
Resilon-bonded obturation goes a long way towards
removing the inherent limitations of GP. After smear
layer removal with an EDTA solution like SmearClear
(SybronEndo, Orange, CA, USA) a homogenous
monoblock of Resilon points and sealer can be created,
in theory sealing the canal from the orifice to the minor
constriction of the apical foramen (Figures 6 to 11).
How much sealing is actually achieved is, to a large
degree, controlled by the clinician and strict adherence
to the recommended technique. It has been shown in an
in vitro comparison of GP to Resilon that Resilon was
statistically more resistant to leakage (Shipper G,
Orstabik D, Teixeira FB, Trope M, 2004).
Resilon is non-toxic, non allergenic, FDA-approved,
non-mutagenic, highly radio-opaque and resorbable,
and can be retreated with chloroform. Resilon is a
thermoplastic synthetic resin based on the polymers
of polyester.
Figure 11
Figure 7
Figure 6
Clinical
66
Figure 12
Figure 13
6. Coronal obturation after the downpack

Post space is inherently created after the SystemB
downpack. If desired, a post can be immediately placed.
Alternatively, if the clinician would like to backfill the
canal and then make post space (remove as much
RealSeal as needed for the post space) in order to have
two opportunities to obturate the canal (in the downpack
and the backpack); this can certainly be done.
The Elements Obturation unit is the state-of-the-art
machine for providing the heat required for the
SystemB downpack and backpack. While a
5. Obturation technique
The authors utilize the continuous wave of condensation
obturation technique commonly known as SystemB
obturation. A complete description of the technique is
available elsewhere (Buchanan LS, 1998).
4. Sealer placement
The RealSeal sealer is marketed in a dual syringe that is
fitted with a new mixing tip for every sealer extrusion.
It is possible simply to express the sealer onto the
mixing pad without the mixing tip and to mix it by
hand. Such hand spatulation will provide more
applications per unit syringe. There are no special cone
fit requirements for RealSeal and only the thinnest layer
of sealer is needed (Figure 12). Sealer can be placed via
the clinicians present method, although lentulo spirals
are not recommended because of their potential for
separation, as well as the potential for unwarranted
apical extrusion of the sealer. Only RealSeal sealer
should be used with RealSeal core material.
3. Self-etch primer placement

After smear layer removal, the canal is dried with paper
points. There are several acceptable methods for
placement of the primer, none of which has been shown
via the literature to be superior but all of which
empirically appear to be satisfactory. A brush provided
by the manufacturer (soaked in the primer) can be used
to place primer down the canal and inserted into the
full depth of the canal with paper points. It is also
acceptable to super-saturate a paper point with primer
and introduce primer in this manner. Judicious use of
paper points can prevent extrusion of the primer
apically. Placement of the primer is made far easier if
done under the visualization made possible by the
surgical microscope.
2. The smear layer is removed

The smear layer is the inorganic and organic material
that adheres to canal walls after instrumentation that is
not removed by sodium hypochlorite alone. While there
are differing protocols for smear layer removal, one
appropriate method is the alternative rinse of 17%
EDTA and sodium hypochlorite during the entire
instrumentation sequence. The authors recommend
SmearClear (SybronEndo, Orange, CA) for smear layer
removal (in lieu of 17% EDTA alone) because the
solution contains surfactants that allow a greater degree
of wetting of the canal walls and deeper penetration of
the solution, hence a greater potential for adhesion of
the sealer to create mechanical locks of resin into
tubules. A final soak of SmearClear should be left
in the canal for 1-2 minutes, irrespective of whether
liquid EDTA was used prior to the final rinse or not.
Sodium hypochlorite or absolute alcohol should not
be used as the final solution in the canal, as
hypochlorite can disrupt the bond of the sealer and
absolute alcohol is not needed because the RealSeal
sealer is hydrophilic.
As an aside, if the clinician is using chlorhexidine
for irrigation with or without sodium hypochlorite,
it is essential, as mentioned, that SmearClear be the
last solution used to irrigate the canal. In addition, if
both chlorhexidine and sodium hypochlorite are used
in the tooth in the same procedure, one should not
use either of the two sequentially due to the
formation of a precipitate that is avoidable by
clearing either the chlorhexidine or sodium
hypochlorite with water or SmearClear before the next
solution is used.
1. Instrumentation is completed with the clinicians

regular protocol
It is important for the operator to visualize the final
prepared canal as a means to create the shapes into
which irrigants can flow to remove both canal debris
and, subsequently, the smear layer that results from
canal preparation. In other words, the use of rotary files
is one of the first steps in creating the platform upon
which open tubules can be achieved. Protocols that
subscribe to the goal of keeping the apical foramen in
its original size and position and keep the entire canal
at its original position are desirable. Methods of canal
instrumentation, bearing these goals in mind, do not
need to be altered to use RealSeal.
Clinical technique
and negative controls into the study

design), histologically mild
inflammation was observed
statistically more with gutta percha
and AH 26 versus roots filled with
RealSeal and roots in the negative
control (P<0.05). In essence,
RealSeal consistently demonstrated
less apical periodontitis because of
its ability to resist coronal
microleakage (Shipper G, Teixeira
FB, Arnold RR, Trope M, 2005).
Numerous other research projects
are going on currently around the
world and are pending publication.
Clinical
Figure 13:
Figure 12:
19
Elements
Obturation Unit
(SybronEndo,
Orange, CA, USA).
This state-of-the-art
combination unit
combines and
enhances the best
features of previous
heat sources and
obturation units
RealSeal
cartridges for the
Elements Obturation
unit (SybronEndo,
Orange, CA).
Cartridges are
available for both
gutta percha and
RealSeal and come
in various needle
diameters
20
14b:
Clinical cases
obturated with
RealSeal
(SybronEndo,
Orange, CA, USA)
courtesy of Dr David
McCarty
Figures 14a and
Chailertvanitkul P, Saunders WP, Saunders EM, MacKenzie D (1997) An
Endod Prac. 1(4): 7-18
Buchanan LS (1998) Continuous wave of condensation technique.
preparation. Oral Surg 84: 310-4
leakage of mixed anaerobic bacteria after obturation and post space
Barrieshi KM, Walton RE, Johnson WT, Drake DR (1997) Coronal
References
publication there are no university-based double-blind

studies published that refute the findings above, nor are
there any published studies of any kind that refute the
contentions about RealSeal made in this article. In
addition, there are no published clinical reports in
dental trade journals (non-refereed journals) that
disparage the material.
The authors believe it likely that in the coming
decades RealSeal will become (and/or certainly has the
potential to become) the world standard in obturation.
It is difficult to envision that any material will be more
studied and referenced in the literature in the coming
decade, and it will be instructive to carefully evaluate
the literature as it unfolds to evaluate these initial
results. The demonstrated advantage actually to seal
root canal systems, strengthen roots and reduce apical
inflammation are qualities that GP never had and never
will have.
As mentioned previously, the authors collectively
have extensive experience with RealSeal. The transition
from GP to RealSeal has been seamless as RealSeal
handles virtually identically to GP and can be very
quickly and easily introduced into clinical practice
routine and regimen. Taking the time to place the
primer is the only additional labor-intensive step
required for RealSeal. The time and effort required to
place the primer are of no consequence in relation to
the advantages that are derived from the clinical use of
the material. The costs involved in RealSeal use, while
more than GP (and less than carrier based products),
are more than compensated for by the benefits of the
material. With some exception, the authors have
abandoned GP in their endodontic practices. It is our
mutual belief that until there is a material that is both
retreatable and completely impervious to coronal
leakage, RealSeal will become and remain the
benchmark by which all future contenders will be
judged upon.
Figure 14b
Two questions are commonly asked in relation to

retreatment:
1. Can the material be retreated easily? Yes, with
chloroform; the material dissolves almost exactly like
gutta percha.
2. Can RealSeal be removed from the dentinal tubules?
No, but it is academic for two main reasons. One is that
retreatment usually involves enlarging the canal slightly,
which will remove a significant amount of RealSeal core
material and sealer impregnated into the dentinal
tubules, and most endodontic failure is a result of
missed canal systems and coronal microleakage. Not
being able to remove every tag of resin in a canal system
is unlikely to predispose any retreated root to a
subsequent failure.
It is worth mentioning briefly that at the time of
Retreatment
comprehensive description of the Elements Obturation

unit is beyond the scope of this paper, it is worthy to
address the synergies possible with Elements utilization
in conjunction with RealSeal obturation. The Elements
unit has a heat source on one side that enhances and
refines the capabilities of the SystemB heat source and
has an extruder on the other that provides extrusion of
gutta percha or RealSeal via cartridges for backpacking
canals (Figures 12 and 13).
In clinical technique, backpacking canals can be
accomplished with aliquots of material injected
segmentally or in one squirt. It is a matter of clinical
opinion which of these two methods is preferable and
in the authors opinion is case dependent. Cartridges of
RealSeal are available in 20 and 23 gauge sizes that are
self-contained and one cartridge can easily fill a
four-rooted molar and perhaps more, depending on how
efficiently it is used. The buttons on the extruder
component of the Elements Obturation Unit are quite
sensitive and, literally as the material is extruded, the
needle can back itself out of the canal to obturate the
space without voids. The temperature on the extruder
component of the Elements Obturation Unit used to
backfill canals should be 170C. While preferences will
differ, a 23-gauge cartridge will be suitable for most
cases. With the extrusion of RealSeal, the authors have
found few, if any, voids and that the material has
excellent flow characteristics during compaction while
thermosoftened. Cases obturated with RealSeal and the
Elements Obturation unit are demonstrated (Figure 14).
Figure 14a
Clinical
67
inflammation after coronal microbial inoculation of dog roots filled
Which of the following comments regarding irrigation and

smear layer removal is correct?
a) Smear layer removal allows for greater adhesion of resin
sealer locking resin into the tubules
b) EDTA should be used as the final rinse for 1-2 minutes
c) SmearClear should be used as the final rinse for 1-2
minutes
d) Using sodium hypochlorite and chlorhexidene
alternatively is the ideal way to prevent any precipitate
developing on the canal wall
e) Primer is best placed before smear layer removal
Q4
The term monoblock refers to which of the following

aspects of obturation?
a) Resin sealer bonds to the canal wall and dentinal tubules
b) Resin filling points bond to the canal wall and dentinal
tubules
c) Resin filling points bond to the resin sealer
d) GP filling points bond to the canal wall with a resin sealer
e) Monoblock relies on smear layer removal
Q2
Which of the following comments regarding conventional

obturation techniques are correct?
a) Gutta percha exposed to saliva contamination allows apical
migration of bacteria
b) Adaptation of gutta percha to canal walls is inadequate
even with a resin-based sealer
c) Ideal obturation should entomb bacteria that cannot be
removed during cleaning and shaping procedures
d) None of the above
e) All of the above
Q1
CPD
Resilon research has highlighted which of the following

properties of the material?
a) The material is as strong as gutta percha in strengthening
remaining tooth structure
b) The material is stronger than gutta percha in strengthening
tooth structure
c) Resilon obturation demonstrates less apical periodontitis
than gutta percha after apical inoculation of bacteria
d) Resilon obturation demonstrates less apical periodontitis
after coronal inoculation of bacteria.
e) Mild inflammation apically is noted equally with Resilon
and gutta percha obturation
Q3
unsealed endodontically treated teeth. J Endod 16: 566-9
This article is equivalent to one hour of verifiable CPD. To

receive credit, complete the multiple choice test after each
article and return for processing. Answers can be posted to
Endodontic Practice Verifiable CPD, FMC Ltd, NAT2688,
Shenley WD7 9BR (no stamp required within the UK), faxed
on 01923 851778 or emailed to debbie.levey@fmc.co.uk.
Please include your name, address, subscriber number, GDC
registration number and the reference code MOUNCE/MAY/05.
Shipper G, Teixeira FB, Arnold RR, Trope M (2005) Periapical
Torabinejad M et al (1990) In vitro bacterial penetration of coronally
polymer based root canal filling material (Resilon). J Endod 30(5):

342-7
of coronally unsealed endodontically-treated teeth. J. Endod 16(12):

566-9
microbial leakage in roots filled with a thermoplastic synthetic
Torabinejad M, Ung B, Kettering JD (1990) In vitro bacterial penetration
material. JADA 135: 646-652
Shipper G, Orstavik D, Teixeira FB, Trope M (2004) An evaluation of
resistance of roots endodontically-treated with a new Resin filling
Int. Endod J. 23(1): 28-33
Teixeira FB, Teixeira ECN, Thompson JY, Trope M (2004) Fracture
success and failure. J Endod. 9: 198-202
Swartz DB, Skidmore AE, Griffin JA (1983) Twenty years of endodontic
endodontically-treated teeth. Part 1. Time Periods. J Endod 13: 56-9
Swanson K et al (1987) An evaluation of coronal microleakage in
Oral Surg Oral Med Oral Pathol 85: 86-93
endodontic treatment and the outcome of conservative retreatment.
restored pulp chamber of endodontically treated multirooted teeth.
Saunders WP, Saunders EM (1990) Assessment of leakage in the
coronal restoration. Int Endod. J 28: 12-18
teeth in relation to the technical quality of the root filling and the
Ray HA, Trope M (1995) Periapical status of endodontically treated
endodontically-treated teeth. Part III. In vivo study. J Endod 14: 455-58
Madison S et al (1988) An evaluation of coronal microleakage in
obturated root canals. J Endod 19: 458-61
Sundquist G et al (1998) Microbial analysis of teeth with failed
of root canal treated multirooted teeth. Int Endod. J 30(5): 318-22

Khayat A et al (1993) Human saliva penetration of coronally unsealed
with gutta percha or Resilon. Journal of Endodontics 31(2): 91-96
evaluation of microbial coronal leakage in the restored pulp chamber
Clinical
21
ENDODONTIC OBTURATION: ONE GIANT

LEAP FOR ENDODONTICS
DENTAL TRIBUNE
Trends & Application 17
Asia Pacific Edition
Endodontic Obturation:
One Giant Leap for Endodontics
Richard Mounce, U.S.A. & Gary Glassman, Canada
Just as mans first step on the
moon changed human existence
forever so has bonded endodontic obturation changed the face
of root canal treatment. With the
development of new technique
and technology, the root canal
system can now be bonded from
orifice to apex. As a result, bacterial leakage can be diminished
with more significance than ever
before. Gutta percha, while time
honoured, is destined for slow
obsolescence.
It also is axiomatic that all
obturation, especially gutta percha
is dependent upon the quality of
cleansing and shaping. Excellent
cleansing and shaping can set the
stage for three-dimensional obturation, irrespective of the obturating material. There is significant
value in creating an obturation that
does more than just fill space in
the root canal system, as does gutta
percha. Gutta percha only takes up
space in the root canal system in
lieu of having another function.
Bonded obturation stands in distinction. It provides coronal seal
to a statistically significant greater
degree than gutta percha; bonds to
the canal wall entombing bacteria
and in doing so prevents the ingress
of tissue fluids when viewed over
the totality of the canal space.
At the very least, a bonded obturation has the potential to achieve
these functions if performed properly. Gutta percha simply does not.
Viewed from a different perspective, if cleansing and shaping is less
than ideal, bacteria that challenge
a root canal system from coronal
microleakage will be able to overcome the gutta percha as well as
add to the potential for failure due
to the bacteria left after root canal
therapy. Bonding the obturation
adds a layer of protection in that
even if cleansing and shaping is
not ideal, diminishing the amount
of coronal leakage possible, entombing bacteria and reducing the
amount of tissue fluid ingress can
only increase the chances that the
body will be able to handle the bacteriological challenge.
Creation of the potential for
bonding is made possible by removal of the smear layer. The
smear layer can be removed in
clinical Endodontics by the use
of a liquid EDTA solution such as
SmearClear (SybronEndo, Orange,
CA, USA). Dentinal tubules are
largest and most plentiful in the
coronal third and least plentiful and
smallest in the apical third. Dentinal tubules in the middle third of
root canal systems are intermediate between the two. Tubules found
in older teeth tend to be fewer
and smaller than those in younger
teeth. The net effect is that bonding
is most effective in the coronal half
of roots and least effective in the
apical half of roots. Studies of leakage comparing gutta percha versus
bonded products must be done so
along the entire length of the root.
To only study the apical 2 mm of
a given root canal system is virtually irrelevant because this does not
compare leakage resistance, as it
would be present clinically.
In addition, it is important
to mention that bonding may not
be circumferential at all levels in
the canal despite the number of
tubules. Bonding can and does occur at all levels of the canal system.
Despite what may be a lack of bonding in one small and specific location of a canal, there is very likely to
be bonding to other areas around
these spots where the smear layer
was not cleared appropriately or
there were not abundant tubules.
Before looking at the state of the
art in Endodontic obturation, it is
instructive to evaluate the historical backdrop and materials considerations that have made gutta
percha the traditional standard:
Gutta percha sold commercially is approximately 20% gutta
percha. The dried juice of the
Taban tree (i.e., Isonandra percha.)
It occurs naturally as 1,4-polyisoprene.1 Gutta percha is (or can be):
1) Present in an alpha and beta
phase (beta phase when unheated, in the heated or alpha
phase it will flow and can be
compacted)
2) Thermosoftened
3) Chemically softened and removed with chloroform
4) Used only with a sealer to fill
voids in the canal not occupied
by the core material
5) Non toxic, non allergenic, non
mutagenic
6) Well tolerated and biocompatible
7) Composition dependent, resorbable
8) Can be placed cold or warm
It is instructive to evaluate the
properties of an ideal obturating
material which include:
1) Ability to flow into canal irregularities and can seal the entire
canal space with/without a
sealer
2) It is provided sterile or can be
made sterile before insertion
3) Non toxic, non mutagenic, non
allergenic
4) Cost effective
5) Will not corrode or be affected in
any way by blood or tissue fluids
6) Easy to use clinically providing
enough working time
7) Can be stored under normal
atmospheric conditions
8) Antibacterial
9) Resorbable if extruded apically
but not resorbable inside the
canal space
10) Retreatable
11) Clearly visible on radiographs
(opaque)
12) Easily sized to fit conventional
canal preparations
13) Will not change dimensions
upon setting in canals after
insertion (whether due to exposure to moisture or from
shrinkage after cooling)
14) Does not discolour the tooth
over time after insertion
It is noteworthy that the three

Principle functions of the root canal
filling include:
1) To entomb most surviving bacteria
2) To stop the influx of periapical
tissue-derived fluid from reaching surviving bacteria in the root
canal system
3) To act as a barrier, thereby preventing re-infection of the root
canal, i.e. provide a coronal and
apical seal.
It bears questioning whether
gutta percha, despite its positive attributes achieves these objectives.
The simple answer is no. Gutta
percha:
1) Has never had any ability to
bond to canal walls
2) Has always been dependent on
sealer to create any form of
seal with the canal walls
3) Has no ability to reproducibly
diminish or prevent the migration of bacteria in a coronal to
apical direction
4) Cannot bond to any sealer
presently available
5) Can only form an adaptation to
canal walls irrespective of the
sealer with which it is used
6) Is almost entirely dependent on
the placement of a coronal seal
to protect it from microbial contamination
7) When exposed to coronal microbial contamination for even
a short period, days to weeks for
sure, must be retreated so as
to remove the microbes to the
greatest extent possible to enhance the possibilities of clinical success.
touched by the use of shaping

files of all types, be they Gates
Glidden drills, hand files,
and/or rotary nickel titanium
(RNT) files.
10) Shrinks 57% upon cooling
Resilon Research, Wallingford
CT, USA introduced Resilon in
2003. RealSeal was licensed by
SybronEndo (Orange, CA, USA) to
use Resilon technology. Resilon
technology is also present today
in the form of Simplifil Carriers
(LightSpeed Technology, San
Antonio, TX, USA), coated Fibrefill
(Pentron, Wallingford CT, USA),
InnoEndo (Heraeus Kulzer, Armonk, NY, USA). The primary author (RM) has extensive clinical
experience with RealSeal, having
used it exclusively for the past
two years and it will be synonymous with Resilon in this paper
(Fig. 1).
RealSeal is:
1) A thermoplastic synthetic polymer based root canal filling material
2) Polymers of polyester
3) Bioactive glass, bismuth oxychloride and barium sulfate
4) Overall filler content ~ 65% by
weight
RealSeal Sealer is:
1) Dual cure dental resin composite sealer
2) Mixture of BisGMA, ethoxylated
BisGMA, UDMA and hydrophilic
difunctional methacrylates
3) Fillers of calcium hydroxide,
barium sulfate, barium glass and
silica
Fig. 2: Gap between the canal walls and gutta percha.
8) When placed with cold lateral

condensation is completely dependent on sealer to take up any
voids that may occur where
gutta percha is absent in the
canal.
9) In single cone techniques, the
clinician is wholly dependent
on the movement of sealer to
be dispersed by the placement
of the single cone as it is placed.
In essence, there is no means
to assure with certainly that
the sealer will be distributed
into all of the ramifications of
the pulp space, especially fins,
cul de sacs and isthmuses
which are likely to be un-
68
Fig.1: RealSeal Kit (SybronEndo,

Orange, CA, USA).
RealSeal core material chemically bonds to the hybrid layer created through the sealer application
and extends into the dentinal
tubules continuously. Resilon Research describes this obturation as
a monoblock to denote the chemical similarity of the various components to the obturation. RealSeal
points are available in various tip
sizes and tapers. The points look,
handle, feel and behave virtually
identical to gutta percha. The clinician does not need to change their
clinical technique to use the material (Figs. 28).
Extensive research has been performed and published on RealSeal.
Extensive future research is planned
for the material. The vast majority
of the findings have been positive
in some measured parameter (dye
leakage, apical inflammation in dogs
teeth, resistance to vertical fracture,
etc) both in vitro and in vivo.
Fig.3: Graphic representation of the bond between the canal

walls the core filling material.
4) Total filler content in the sealer ~

70% by weight
RealSeal self-etching primer is:
1) Water
2) HEMA
3) Sulfonic acid-terminated functional monomer
4) Polymerization initiator)
In addition: RealSeal is:
1) FDA approved in the United
States
2) Non cytotoxic
3) Non mutagenic
4) Well tolerated and biocompatible
5) Non allergenic
Simply stated, bonded obturation has resolved many of gutta

perchas limitations while not possessing any additional problems
that diminish its effectiveness. In
a statistically significant manner
bonded obturation has been shown
to diminish coronal to apical migration of bacteria in a number of
studies and research designs, both
in vivo and in vitro.213 It bears
mention that while many RealSeal
samples demonstrate no leakage
when studied, RealSeal does not
provide an absolute seal in every
canal, simply that in a statistically
DT page 18
DENTAL TRIBUNE
18 Trends & Application
DT page 17
Figs. 48: Bonding between the canal wall and the

sealer and core material of RealSeal (SybronEndo,
Orange, CA, USA).
Fig. 7
significant manner, it seals much

better than gutta percha, which has
no inherent ability to seal canals.
A search of Pubmed finds several studies that are not supportive
of RealSeal. Ironically, two of the
same authors appear on all of these
papers.14 20 It is not possible because of space limitations to evaluate all such papers. It has value
though to look at one of the studies
in detail to evaluate if there is any
evidence that RealSeal is not the
advance that all of the other varied
researchers and parties believes
it to be. The study in question is
Ultrastructural evaluation of the
apical seal in roots filled with a polycaprolactone-based root canal filling material. Tay FR, et al. JOE, 2005
Jul; 31(7): 514-519.
The reader is encouraged to
read the article and then evaluate
the questions below. A research
paper should carefully explain the
methodology in which variables
have been meticulously excluded.
Experimental groups should be
evaluated by a blinded investigator
and results statistically compared
to eliminate bias. Variables that invalidate this particular paper are
numerous. The net effect of not
controlling these variables biases
the study against RealSeal. The
authors concluded, a complete
hermetic apical seal cannot be
achieved with either root filling
materials but they:
Dont describe tooth selection
adequately.
Dont explain using 2.6% NaOCl
or if all samples got the same irrigant volume.
Dont assure the smear layer was
cleared by their EDTA regimen.
Dont measure leakage in a clinically relevant coronal to apical
direction. Bonding in the coronal
and middle thirds is more prevalent due to larger and more numerous tubules. This advantage
of Resilon isnt measured as the
study tests leakage in the reverse
direction.
Dont describe primer application
in a manner that assures distribution throughout the canal.
Dont apically gauge. The size 35
master apical file used may be
Fig. 6
Fig. 5
Fig. 8
irrelevant to the apical anatomy

present.
In addition,
Why did they establish TWL 1 mm
short of the foramen? If the apical
4 mm showed leakage after TEM,
has not 25% of the canal been left
untouched relying solely upon
irrigation for disinfection?
Why use a lentulo for Resilon
sealer application? How much
sealer was used? After downpack,
was sealer re-applied, as it should
have been before backfill? Sealer
was placed on the GP master
cone. Why different than the Resilon group?
The size for ESEM evaluation
group (2) is too small.
There is no description of how the
gaps were measured. How many
gaps were observed per mm? Gap
size? There is no data, no statistics
and obviously no statistical significance.
No case is made for TEM as testing
medium (after stating there is
no single, universally accepted
model of leakage testing in
Endodontics). Despite this, they
conclude that TEM proves a complete hermetic seal cannot be
achieved with either root filling
materials.
TEM testing was 3 hours. Why
so short?
Master cones were placed within
1 mm of TWL (1 mm short of the
foramen). In essence, the apical
4 mm had possibly 2 mm of empty
space before downpack. This is
not clinically relevant.
ESEM showed excellent coupling of Resilon to epiphany
sealer. This alone is a significant
advance over GP and not noted.
How experienced was the clinician who performed the SystemB
obturation and RealSeal use?
Specimens were sectioned longitudinally (we are not told how)
and the exposed surfaces were
polished, etched and deproteinized. Couldnt this cause
gaps?
Given the number of issues and
concerns and the fact that all of the
papers have two authors in com-
mon it is difficult, in the empirical

opinion of the author to give credibility to their claims.
Dr. Mounce has been using
RealSeal exclusively for two years
clinically. Thus he has several observations that can be shared:
1) RealSeal has excellent flowing
characteristics. While the material can be placed with virtually
any gutta percha technique
(such as the vertical compaction
of warm gutta percha, the PAC
MAC, cold lateral condensation)
except carrier based techniques,
the author uses SystemB obturation within the Elements Obturation unit (SybronEndo, Orange,
cartridges prevent cross contamination, as they are single

use. A single cartridge can fill
approximately 56 canals. In the
SystemB downpack, the material
moves well into the narrowing
cross sectional diameters of the
root canal system and can be
moved with precision in each
apical compaction. The Elements Obturation unit is the only
warm obturation device commercially available that extrudes
both gutta percha and RealSeal.
The material is down packed at
200 degrees C and the elements
obturation has a setting that automatically heats the cartridges
to 170 degrees C. Once the power
switch to heat the cartridge is
engaged it takes approximately
45 seconds for the cartridge to
become fully heated and ready
for obturation. Turning the heat
on as the clinician performs the
first downpack in the molar can
save time. Once the extruder of
the Elements obturation unit is
engaged, it takes approximately
20 seconds for the material to appear at the tip. While the material
can be extruded at two speeds,
engaging the button to expel
material as soon as the extruder
is picked up and carried into the
Fig. 9: The Elements Obturation Unit (SybronEndo, Orange, CA, USA).
CA, USA) with 20 gauge cartridges of RealSeal (Fig. 9). SystemB

is simple (needed equipment is
easily obtained, inexpensive and
not challenging to use and the
technique is straightforward to
learn and achieve), efficient
(with SystemB obturation, a
5 canalled molar can be obturated in 5 minutes or less after
cone fit, the technique blended
with RealSeal is efficient and
predictable), effective (the literature has validated the technique), economical (The material is more expensive than
gutta percha applied in cone
form but significantly less than
carrier based techniques). Such
69
mouth can save time and create

efficiency. A detailed description
of the SystemB technique and its
use with RealSeal is included at:
http://www.oralhealthjournal.com/
issues/ISarticle.asp?id=152890
&story_id=23669151352
2) The material can be light cured
in the coronal third of the canal
if desired, the material will self
cure within an hour. If the clinician wishes to bond composite
against the coronal plug of RealSeal, it is possible to do so.
3) The material retreats easily.
With chloroform, it dissolves
without difficulty and behaves
very much like gutta percha in
its removal. The sealer that is
bonded into the tubules in RealSeal obturation is unlikely to be

removed in some locations of the
canal and subsequent second
bonding of the canal but this is
a minor limitation if at all. Root
canal treatment fails for major
reasons, untreated space within
the canal system, coronal microleakage and vertical fracture.
For the first two reasons, should
a tooth bonded with RealSeal
need retreatment, and the cause
of the failure be addressed,
whether bonding was absolute
due to removal of all the sealer in
the tubules, is academic. In addition, when a tooth is retreated,
especially if the canals are prepared to a larger taper as they
often are, such instrumentation
will circumferentially prepare
the canal to a larger diameter
and as such remove such tags of
resin in the tubules.
4) For the majority of clinical cases,
a .06 tapered size 20 and 25 cone
(either case dependent) can be
easily modified to create a master cone of almost any apical tip
size through snipping the end of
the cone. Such a cone as the bulk
and taper to match the overwhelming majority of clinical
cases if it is trimmed appropriately. Clinically, this would involve gauging the final prepared
canal shape and after deciding
to what size the canal would be
prepared, the cone would be
trimmed the number of mm required to give tugback. Trimming cones to achieve tugback is
a skill that can save time and
money relative to having a large
number of various cone sizes.
With practice is can be possible
to create tugback with 1 size
master cone for the vast majority
of cases.
5) The system is easily transitioned
to because the clinician does not
need to learn a new technique.
Aside from clearing the smear
layer, the technique requires
only that the clinician place the
self-etching primer prior to
usual obturation techniques.
6) Sealer can be placed as per normal obturation techniques. The
author coats the master cone
and downpack the canal as per
the SystemB technique and ideally, the canal is recoated again
with sealer before the backfill
with the cartridges of the Elements Obturation unit are used.
Ideally, the canal is recoated
again with sealer before the
backfill with the cartridge of
RealSeal in the Elements Obturation Unit.
7) Placement of the primer is predictable. Under a surgical microscope it is easy to see that the
canal has primer fully dispersed
throughout it. As an aside, paper
points which can wick up the
excess primer are often soaked
with the primer after several dryings, insuring that the canal is
fully coated. It has value to perform such wicking from larger
paper points to smaller so as to
diminish the possibilities for extruding the primer apical.
8) Empirically, the author has not
seen more post operative discomfort with the material than
gutta percha. While it cannot
be quantified, if anything, the
amount of postoperative discomfort has diminished relative
to gutta percha.
DENTAL TRIBUNE
In summary, a discussion of the
significant advance that bonded
obturation in the form of RealSeal
offers over gutta percha has been
presented with an eye toward advancing the state of the art in clinically relevant way. DT
Dr. Mounce would like to thank Dr. Martin Trope, Dr. Fabricio Tiexiera for the
images shown in the Figures 28.
Literature
1. Pathways of the Pulp, 9th edition,
Elsevier Publishers.
2. A Fluid Filtration Comparison of
Gutta-Percha Versus Resilon: A New
Soft Resin Obturation System. Stratton et. al., Abstract #20, 31(3), March
2005. JOE
3. Apical Leakage of a New Obturation Technique, Abstract #42, 31(3),
March 2005. JOE Gambarini G, et al.
4. Interfaces in Soft Resin Obturated
Root Canals ABSTRACT: 2005 IADR/
AADR/CADR 83 rd General Session &
Exhibition D.J. Alongi, et al.
5. Bonding of Self-Etching Primer/
Polycaprolactone-Based Root-filling Material to Intaradicular Dentin,
ABSTRACT: 2005 IADR/AADR/CADR
83rd General Session & Exhibition,
F.R. Tay, et al.
6. Bondability of Resilon to a Root
Canal Sealant ABSTRACT: 2005
IADR/AADR/CADR 83rd General
Session & Exhibition W. Jia, S.
Gagliardi, and S. Jin, Pentron Corporation, Wallingford, CT USA.
7. Antimicrobial Potential of Epiphany
RCS System ABSTRACT: 2005
IADR/AADR/CADR 83rd General
Session & Exhibition Y. Li, W. Zhang,
O. Onyago, W. Jia, and S. Gagliardi,
Loma Linda University, Ca, Pentron
Corporation, Wallingford, CT.
8. Characterization of Tubule Penetration Using Resilon: A Soft-Resin
Obturation System, ABSTRACT:
2005 IADR/AADR/CADR 83rd General Session & Exhibition L.P. Benzley, J.C.-H. Liu, and A.E. Williamson,
University of Iowa, Iowa City, USA.
9. An Evaluation of Microbial Leakage
in Roots Filled with a Thermoplastic Synthetic Polymer-Based Root
Canal Filling Material (Resilon)
Journal of Endodontics, Vol. 30, No.
5, May 2004
10. Fracture resistance of roots endodontically treated with a new
resin filling material, JADA, Vol. 135,
May 2004
11. Predictable Endodontic Success:
Part II Microstructural Replication
Oral Health, December 2003 .
12. Bonded Endodontic Obturation:
Another Quantum Leap Forward for
Endodontics, Oral Health, July 2004
13. ResilonThe Missing Link in Sealing the Root Canal. Compendium,
Vol. 25, No.10A, October 2004.
14. Periapical Inflammation after Coronal Microbial Inoculation of Dog
Roots Filled with Gutta-Percha or
Resilon. Journal of Endodontics,
Vol. 31, No. 2, February 2005.
15. Tay FR, Hiraishi N, Pashley DH,
Loushine RJ, Weller RN, Gillespie
WT, Doyle MD. Bondability of resilon to a methacrylate-based root
canal sealer. J Endod. 2006 Feb;
32(2): 1337.
16. Gesi A, Raffaelli O, Goracci C, Pashley DH, Tay FR, Ferrari M. Interfacial
strength of Resilon and gutta-percha
to intraradicular dentin.
17. J Endod. 2005 Nov; 31(11): 80913.
18. Tay FR, Pashley DH, Yiu CK, Yau JY,
Yiu-fai M, Loushine RJ, Weller RN,
Kimbrough WF, King NM. Susceptibility of a polycaprolactone-based
root canal filling material to degradation. II. Gravimetric evaluation of
enzymatic hydrolysis. J Endod. 2005
Oct; 31(10): 73741.
19. Tay FR, Loushine RJ, Monticelli F,
Weller RN, Breschi L, Ferrari M,
Pashley DH. Effectiveness of resincoated gutta-percha cones and a
dual-cured, hydrophilic methacrylate resin-based sealer in obturating
root canals. J Endod. 2005 Sep; 31(9):
65964.
20. Tay FR, Pashley DH, Williams MC,
Raina R, Loushine RJ, Weller RN,
Kimbrough WF, King NM. Suscep-
Trends & Application 19
tibility of a polycaprolactone-based
root canal filling material to degradation. I. Alkaline hydrolysis. J Endod. 2005 Aug; 31(8): 5938.
21. Tay FR, Loushine RJ, Lambrechts P,
Weller RN, Pashley DH. Geometric
factors affecting dentin bonding in
root canals: a theoretical modelling
approach. J Endod. 2005 Aug; 31(8):
5849.
22. Tay FR, Loushine RJ, Weller RN,
Kimbrough WF, Pashley DH, Mak
YF, Lai CN, Raina R, Williams MC.
Ultrastructural evaluation of the
apical seal in roots filled with a polycaprolactone-based root canal filling material.
23. J Endod. 2005 Jul; 31(7): 5149.
Contact Info
Dr. Richard Mounce is in private
endodontic practice in Portland,
Oregon, USA. Dr. Mounce is the author of a comprehensive DVD on
cleansing, shaping and packing the
root canal system for the general
practitioner. The material is also
available as audio CDs and as a web
cast pay per view.
For information:
Comfort@MounceEndo.com
Dr. Gary Glassman is in private

endodontic practice in Toronto,
Ontario, Canada. Dr. Glassman is
an Associate in Dentistry at the
University of Toronto, School of
Dentistry and the endodontic editor
of Oral Health dental journal.
Drs. Mounce and Glassman have no
commercial interest in any of the
products mentioned in this paper.
AD
Dentsply Asia
70
SEQUELAE OF ENDODONTIC THERAPY

THE BIOLOGIC RATIONALE FOR POSTOPERATIVE PAIN
71
72
73
74
75

Book One

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Book One

Uploaded by

Copyright:

Available Formats

Gary D.

CURRICULUM VITAE: SYNOPSIS

PHIL SHEDLETSKY, DDS, MS

entists are trained to thoroughly review medical

FIGURE 1This human skull demonstrates several important

FIGURE 2This table serves to reveal the enormous health and

FIGURE 3A radiograph of a maxillary first bicuspid showing

plates of bone have been invaded by a lesion.2 If a

duce an additionally $1,000,000 of dentistry.4

FIGURE 4AA photograph reveals significant swelling secondary to a LEO that

FIGURE 4BA photograph demonstrates

ETIOLOGY OF PULPAL BREAKDOWN

three-step diagnostic process comprised of the

The dental pulp is a dynamic tissue whose status at

THE ENDODONTIC EXAMINATION

FIGURE 5A surgical photograph of an

ination includes, but is not

FIGURE 6AA photograph shows discoloration of the clinical crown of the

FIGURE 6BA clinical photograph of the

a tooth exhibits a coronal fracture, then light will

The intraoral hard tissue exam reveals missing

FIGURE 7A radiograph suggests the

angle and perpendicular to the

FIGURE 8A radiograph suggests this

FIGURE 9A radiograph of a maxillary

The diagnostic quality of a

FIGURE 11AA radiograph of an endodontically involved mandibular first

When performing the radiographic examination,

FIGURE 11CA radiograph shows a

abnormal radiolucent lesion. At times, additional

Different, well-angulated films allow clinicians to

The radiographic examination also provides

FIGURE 12This radiograph suggests the mandibular first

FIGURE 13A clinical photograph demonstrates a reliable

structures. Certain probable defects masquerade as

Importantly, performing repetitive pulp tests, as

VITAL PULP TESTING

When pulpal inflammation is confined to the

intensity of a response to thermal testing can vary

There are four methods that may be employed to

FIGURE 15A clinical photograph demonstrates syringing

liberated by gently pulling the floss. The pencil of

The specific technique for pulp testing is

each response. As with the cold test, the response

On occasion, after conducting a thorough clinical

Dr. Ruddle is founder and director of Advanced

BACTERIA: THE EVIL OF ALL ROOT

Steven Cohen, DDS, Cert.Endo, Gary Glassman, DDS, FRCD(C)

Bacteria: The Evil of All Root

icture this: A small town in

Dr. Steven Cohen is an endodontist on

Dr. Gary Glassman is a fellow and

Joining the chemical warfare front

implant is yet another.

Then there is resistance that

correct answer is: as long as the

ical of ourselves. When we discuss

USE OF OPHTHALMIC DYES IN ROOT CANAL LOCATION

Use of Ophthalmic Dyes

he relationship between uninstrumented root canals

This is of even greater significance in teeth with full coverage

floor anatomy, and teeth with

High visual magnification