John S Olmsted, DDS MS FAGD, FICD, FACD

MORE ENDO TIPS FROM

35 YEARS OF PRACTICE

INTO THE FUTURE101st Thomas P. Hinman Dental Meeting

Thursday, March 21, 2013 12:00PM-3:00 PM

John S Olmsted, DDS MSFAGD, FICD, FACD

Diplomate, American Board of EndodonticsPast President, American Association of Endodontists

TAKE TIME FOR:

DiagnosisAnesthesia, Access, and IsolationInstrumentationBiochemical IrrigationObturationRestorationPost Operative

Obturation

Obturation21.Gutta Percha22.Resilon / RealSeal23.Elements Obturation Unit (EOU)24.Cordless System25.Lateral, Warm Vertical, Carrier, Injection

GUTTA PERCHA STANDARD

Gutta-percha contains approximately:

66% zinc oxide (filler) 20% gutta-percha (matrix)11% heavy metal sulfates (radiopacifier) 3% waxes and/or resins (plasticizer)

RESILON EPIPHANYREAL SEAL

REAL SEAL 1 A new thermoplastic synthetic

polymer-based root filling material

• Based on polymers of polyester• Contains Bioactive glass• Ca(OH)2 • Radiopaque fillers

Elements Obturation Unit

Cordless System

Restoration

Restoration26.Eliminate Man-made, Keep God-given

parts27.Dimple-down / Buildup

28.Post-space / Fiberpost29.Reduce Occlusion30.Emphasize Need For Coronal

Coverage

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Abstract Full Text PDF Images References

Journal of EndodonticsVolume 38, Issue 1 , Pages 11-19, January 2012

Ferrule Effect: A Literature Review

Jelena Juloski, DDS , Ivana Radovic, DDS, MSc, PhD, Cecilia Goracci, DDS, MSc, PhD, Zoran R. Vulicevic, DDS, MSc, PhD,Marco Ferrari, MD, DDS, PhD

published online 15 November 2011.

Abstract IntroductionPreserving intact coronal and radicular tooth structure, especially maintaining cervical tissue to create a ferrule effect, isconsidered to be crucial for the optimal biomechanical behavior of restored teeth. The ferrule effect has been extensivelystudied and still remains controversial from many perspectives. The purpose of this study was to summarize the results ofresearch conducted on different issues related to the ferrule effect and published in peer-reviewed journals listed in PubMed.

MethodsThe search was conducted using the following key words: “ferrule” and “ferrule effect” alone or in combination with “literaturereview,” “fracture resistance,” “fatigue,” “finite element analysis,” and “clinical trials.”

ResultsThe findings from reviewed articles were categorized into three main categories: laboratory studies, computer simulation, andclinical trials. Laboratory studies were further classified into subchapters based on the main aspect investigated in relation tothe ferrule effect.

ConclusionsThe presence of a 1.5- to 2-mm ferrule has a positive effect on fracture resistance of endodontically treated teeth. If the clinicalsituation does not permit a circumferential ferrule, an incomplete ferrule is considered a better option than a complete lack offerrule. Including a ferrule in preparation design could lead to more favorable fracture patters. Providing an adequate ferrulelowers the impact of the post and core system, luting agents, and the final restoration on tooth performance. In teeth with nocoronal structure, in order to provide a ferrule, orthodontic extrusion should be considered rather than surgical crownlengthening. If neither of the alternative methods for providing a ferrule can be performed, available evidence suggests that apoor clinical outcome is very likely.

Key Words: Endodontically treated teeth, ferrule effect, post and core, review

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ConclusionsThe presence of a 1.5- to 2-mm ferrule has a positive effect on fracture resistance of endodontically treated teeth. If the clinical situation does not permit a circumferential ferrule, an incomplete ferrule is considered a better option than a complete lack of ferrule. Including a ferrule in preparation design could lead to more favorable fracture patters. Providing an adequate ferrulelowers the impact of the post and core system, luting agents, and the final restoration on tooth performance. In teeth with no coronal structure, in order to provide a ferrule, orthodontic extrusion should be considered rather than surgical crown lengthening. If neither of the alternative methods for providing a ferrule can be performed, available evidence suggests that apoor clinical outcome is very likely.

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Journal of EndodonticsVolume 38, Issue 12 , Pages 1557-1563, December 2012

Rigid versus Flexible Dentine-like Endodontic Posts—ClinicalTesting of a Biomechanical Concept: Seven-year Results of aRandomized Controlled Clinical Pilot Trial on EndodonticallyTreated Abutment Teeth with Severe Hard Tissue Loss

Guido Sterzenbach, Dr med dent, DDS , Alexandra Franke, DDS, Michael Naumann, Prof, Dr med dent, DDS

Abstract IntroductionThis is the first clinical long-term pilot study that tested the biomimetic concept of using more flexible, dentine-like (low Youngmodulus) glass fiber–reinforced epoxy resin posts (GFREPs) compared with rather rigid, stiff (higher Young modulus) titaniumposts (TPs) in order to improve the survival rate of severely damaged endodontically treated teeth.

MethodsNinety-one subjects in need of postendodontic restorations in teeth with 2 or less remaining cavity walls were randomlyassigned to receive either a tapered TP (n = 46) or a tapered GFREP (n = 45). The posts were adhesively luted using self-adhesive resin cement. The composite core build-ups were prepared ensuring a circumferential 2-mm ferrule. The primaryendpoint was a loss of restoration for any reason. To study group differences, the log-rank test was calculated (P < .05). Hazardplots were constructed.

ResultsAfter 84 months of observation (mean = 71.2 months), 7 restorations failed (ie, 4 GFREPs and 3 TPs). The failure modes wereas follows: GFREP:root fracture (n = 3), core fracture (n = 1) and TP:endodontic failure (n = 3). No statistical difference wasfound between the survival rates (GFREPs = 90.2%, TPs = 93.5%, P = .642). The probability of no failure was comparable forboth post materials (risk ratio; 95% confidence interval, 0.965–0.851/1.095).

ConclusionsWhen using self-adhesive luted prefabricated posts in severely destroyed abutment teeth with 2 or less cavity walls and a 2-mmferrule, postendodontic restorations achieved high long-term survival rates irrespective of the post material used (ie, glass fibervs titanium).

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ConclusionsWhen using self-adhesive luted prefabricated posts in severely destroyed abutment teeth with 2 or less cavity walls and a 2-mm ferrule, postendodontic restorations achieved high long-term survival rates irrespective of the post material used (ie, glass fiber vs titanium).

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Comparison of Fracture Resistance between Cast Posts and FiberPosts: A Meta-analysis of Literature

Lili Zhou, DDS, MD, Qing Wang, DDS, MD

Department of Endodontics, College of Dentistry, Shandong University, Jinan, China

published online 26 October 2012.

Abstract IntroductionThe aim of this study was to compare the fracture resistance of cast posts versus the fracture resistance of fiber posts bymeans of meta-analysis when they were used in the restoration of endodontically treated teeth.

MethodsMEDLINE, Cochrane Controlled Trials Register, China National Knowledge Infrastructure, and China Biology Medicine discwere used in the literature search. Two independent reviewers assessed the titles and abstracts of all articles that were foundaccording to the predefined inclusion criteria. Relevant articles were acquired in full-text form. Data in these studies wereindependently extracted. Standardized mean differences of included studies were combined and analyzed by using meta-analysis.

ResultsThirteen studies met the inclusion criteria. There was considerable heterogeneity among these studies. The standardized meandifference of the combined data was 0.64 (95% confidence interval, 0.08–1.20; P < .001), indicating that the cast post groupdisplayed significantly higher fracture resistance than the fiber post group.

ConclusionsOn the basis of the current best available evidence, we concluded that cast posts had higher fracture resistance than fiberposts.

Key Words: Cast post, endodontically treated teeth, fiber post, fracture resistance, meta-analysis, post and core technique

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ConclusionsOn the basis of the current best available evidence, we concluded that cast posts had higher fracture resistance than fiber posts.

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Comparative Evaluation of Fracture Resistance under Static andFatigue Loading of Endodontically Treated Teeth Restored withCarbon Fiber Posts, Glass Fiber Posts, and an ExperimentalDentin Post System: An In Vitro Study

Khetarpal Ambica, BDS, MDS , Kavitha Mahendran, BDS, MDS, Sangeeta Talwar, BDS, MDS, Mahesh Verma, BDS, MDS,Govindaswamy Padmini, BDS, MDS, Ravishankar Periasamy, BDS, MDS

published online 13 September 2012.

Abstract IntroductionThis investigation sought to compare the fracture resistance under static and fatigue loading of endodontically treated teethrestored with fiber-reinforced composite posts and experimental dentin posts milled from human root dentin by using computer-aided design/computer-aided manufacturing.

MethodsSeventy maxillary central incisors were obturated and divided into 4 groups: control group without any post (n = 10), carbonfiber post group (n = 20), glass fiber post group (n = 20), and dentin post group (n = 20). Control group teeth were prepared to aheight of 5 mm. In all other teeth, post space was prepared; a post was cemented, and a core build-up was provided. Half thesamples from each group were statistically loaded until failure, and the remaining half were subjected to cyclic loading, followedby monostatic load until fracture.

ResultsOne-way analysis of variance and Bonferroni multiple comparisons revealed a significant difference among test groups. Thecontrol group demonstrated highest fracture resistance (935.03 ± 33.53 N), followed by the dentin post group (793.12 ± 33.69N), glass fiber post group (603.44 ± 46.67 N), and carbon fiber post group (497.19 ± 19.27 N) under static loading. Thesevalues reduced to 786.69 ± 29.64 N, 646.34 ± 26.56 N, 470 ± 36.34 N, and 379.71 ± 13.95 N, respectively, after cyclic loading.

ConclusionsResults suggest that human dentin can serve as post material under static and fatigue loading. Although at an early stage inresearch, the use of dentin posts in root-filled teeth looks promising.


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ConclusionsResults suggest that human dentin can serve as post material under static and fatigue loading. Although at an early stage in research, the use of dentin posts in root-filled teeth looks promising.

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Journal of EndodonticsVolume 34, Issue 5 , Pages 519-529, May 2008

A Review of Factors Influencing Treatment Planning Decisions ofSingle-tooth Implants versus Preserving Natural Teeth withNonsurgical Endodontic Therapy

Mian K. Iqbal, BDS, DMD, MS , Syngcuk Kim, DDS, PhD

Department of Endodontics, The Robert Schattner Center, University of Pennsylvania, School of Dental Medicine, Philadelphia,Pennsylvania.

Abstract One of the major issues confronting the contemporary dental clinician is the treatment decision between extracting a tooth withplacement of a dental implant or preserving the natural tooth by root canal treatment. The factors that dictate the correctselection of one procedure over the other for each particular case are not yet established by randomized controlled studies. Theaim of this review is to evaluate key factors allowing the clinician to make clinical decisions on the basis of the best evidenceand in the patient's best interests. General considerations are discussed that will help the reader analyze clinical studiesfocused on this problem. Importantly, the major studies published to date indicate that there is no difference in long-termprognosis between single-tooth implants and restored root canal–treated teeth. Therefore, the decision to treat a toothendodontically or to place a single-tooth implant should be based on other criteria such as prosthetic restorability of the tooth,quality of bone, esthetic demands, cost-benefit ratio, systematic factors, potential for adverse effects, and patient preferences. Itcan be concluded that endodontic treatment of teeth represents a feasible, practical, and economical way to preserve functionin a vast array of cases and that dental implants serve as a good alternative in selected indications in which prognosis is poor.

Key Words: Prognosis of root canal treated teeth, prognosis of single tooth implants, root canal restoration, root canal treatedteeth, single tooth implants, treatment planning

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Welcome, Dr. John Olmsted

AbstractOne of the major issues confronting the contemporary dental clinician is the treatment decision between extracting a tooth with placement of a dental implant or preserving the natural tooth by root canal treatment. The factors that dictate the correct selection of one procedure over the other for each particular case are not yet established by randomized controlled studies. The aim of this review is to evaluate key factors allowing the clinician to make clinical decisions on the basis of the best evidence and in the patient's best interests. General considerations are discussed that will help the reader analyze clinical studies focused on this problem. Importantly, the major studies published to date indicate that there is no difference in long-term prognosis between single-tooth implants and restored root canal–treated teeth. Therefore, the decision to treat a tooth endodontically or to place a single-tooth implant should be based on other criteria such as prosthetic restorability of the tooth, quality of bone, esthetic demands, cost-benefit ratio, systematic factors, potential for adverse effects, and patient preferences. It can be concluded that endodontic treatment of teeth represents a feasible, practical, and economical way to preserve function in a vast array of cases and that dental implants serve as a good alternative in selected indications in which prognosis is poor.

Post OperativeCare

Post Operative Care31.Share Radiographs With Patient

“This is the hardest endo I have done (today)”

32.Non Steroidal Anti Inflammatory (NSAID)

33.Pain Medications34.Antibiotics35.Telephone Call To Patient Next Day

Non Steroidal Anti Inflammatory (NSAID)

Ibuprofen-200, 400, 600, 800800 milligrams per dose or 3200 mg per day (4 maximum doses).

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Journal of EndodonticsVolume 38, Issue 8 , Pages 1035-1039, August 2012

Effect of Bupivacaine on Postoperative Pain for Inferior AlveolarNerve Block Anesthesia after Single-visit Root Canal Treatment inTeeth with Irreversible Pulpitis

Masoud Parirokh, DDS, MSc , Mohammad Hosein Yosefi, DMD, Nouzar Nakhaee, MD, Hamed Manochehrifar, DMD, PaulV. Abbott, MDS, Farshid Reza Forghani, DMD, MS

published online 04 June 2012.

Abstract IntroductionPain control after root canal treatment is of great importance in endodontic practice. The aim of the present study was toinvestigate the effect of a long-acting anesthetic (bupivacaine) on postoperative pain and the use of analgesics after root canaltreatment.

MethodsIn a randomized double-blinded clinical trial, 60 patients (30 per group) having first or second mandibular molars withirreversible pulpitis randomly received either 0.5% bupivacaine with 1:200,000 epinephrine or 2% lidocaine with 1:80,000epinephrine as the anesthetic solutions for inferior alveolar nerve blocks. After single-visit root canal treatment, each patientrecorded their pain score on a visual analogue scale at 6, 12, 24, 36, 48, and 72 hours after treatment. Data were analyzed byMann-Whitney, χ2, Cochrane Q, and t tests as well as Pearson correlation analysis.

ResultsThe results indicate that patients who received bupivacaine had significantly lower pain scores at 6 and 12 hours after rootcanal treatment compared with the patients who received lidocaine (P < .05). The use of analgesics in the bupivacaine patientswas significantly lower than in the lidocaine group (P < .05).

ConclusionsPatients who received bupivacaine as the anesthetic agent for single-visit endodontic treatment of irreversible pulpitis inmandibular molars had significantly less early postoperative pain and used fewer analgesics than those who had lidocaine asthe anesthetic.

Key Words: Bupivacaine, IANB, lidocaine, long acting anesthesia, one visit, postoperative pain, root canal treatment, single


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ConclusionsPatients who received bupivacaine as the anesthetic agent for single-visit endodontic treatment of irreversible pulpitis in mandibular molars had significantly less early postoperative pain and used fewer analgesics than those who had lidocaine as the anesthetic.

SteroidsPrednisone-5mgsDisp:21 tabs XXISig: 6, 5, 4, 3, 2, 1

Prednisone-5mgsDisp:1dose packSig: as directed

Pain Medications

Tylenol Maximum Daily Dosage Extra Strength Tylenol 500mg tablets will go down from 8 per day to 6 per

day, i.e. from 4,000mg per day to 3,000mg per day.

Acetaminophen Pain Medications

• Darvocet®• Endocet®• Fioricet®• Hycotab• Hydrocet®• Hydrocodone Bitartrate• Lortab®• Percocet®

• Phenaphen®• Sedapap®• Tapanol®• Ultracet®• Vicodin®• Zydone®

Some Common Prescription Drugs That Contain Acetaminophen

Pain Medications

• Actifed®• Anacin®• Benadryl®• Cepacol®• Contac®• Coricidin®• Dayquil®• Dimetapp®• Dristan®• Elixir®• Excedrin®• Feverall®• Formula 44®• Goody’s® Powders

• Liquiprin®• Midol®• Nyquil®• Panadol®• Robitussin®• Saint Joseph® Aspirin-Free• Singlet®• Sinutab®• Sudafed®• Theraflu®• Triaminic®• TYLENOL® Brand Products• Vanquish®• Vicks®• Zicam®

Some Common Over-the-Counter Drugs That Contain Acetaminophen

Pain Medications

Pain MedicationsVicodin (acetaminophen/hydrocodone)Lortab (acetaminophen/hydrocodone)Norco (acetaminophen/hydrocodone)Percocet (acetaminophen/oxycodone)OxyContin (oxycodone)Ultram (tramadol)Nucynta (tapentadol)Demerol (meperidine) +(promethazine)Dilaudid (hydromorphone)Opana (oxymorphone)

AntibioticsPenVK-500mgsDisp:25 tabs XXVSig: 2 stat, 1q6h

Amoxicillin-500mgsDisp:25 tabs XXVSig: 2 stat, 1q6h

AntibioticsAugmentin-500mgs(Amoxicillin + clavulanate)Disp:25 tabs XXVSig: 2 stat, 1q6h

Keflex (cephalexin)-500mgsDisp:12 tabs XIISig: 1q12h

Antibiotics

Cleocin (clindamycin)-150mgsDisp:25 tabs XXVSig: 2 stat, 1q6h

Z-Pak (azithromycin)- 250mgsDisp:1 dose packSig: 2 stat, 1 daily next 4 days

AntibioticsCipro (ciprofloxacin)- 250mgsDisp:12 tabs XIISig: 1 q12h

Minocin (tetracycline)- 100mgsDisp:25 tabs XXVSig: 1 q12h

Compassionate Care With Class

Class is never bragging or boasting about your own accomplishments, and never tearing down the achievements of another person.

Class does not depend on money, status, success or ancestry. The wealthy aristocrat may not even know the meaning of the word, yet the poorest man in town radiates it in everything he does.

Compassionate Care With Class

If you have class, everyone will know it and you will have self respect. I you are without class, good luck---because whatever you accomplish will be without meaning.

CLASS DISMISSED

John S Olmsted, DDS MS FAGD, FICD, FACD

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