endodontics
feature
ENDODONTIC
ADVANCEMENTS
How leading technologies help transform
endodontic treatment options
D
Dentistry continues to evolve as a
health science, and numerous aspects of
practice are not the same since we went to
by Jeffrey Krupp, DDS, MS dental school.
Change affects our world. Change has
also applied itself to endodontic therapeu-
tics, allowing for improvements developed
by the mechanism of evidence-based
research. The result has been enhanced
treatment outcomes for our patients.
Advancements of obturation mate-
rials, visibility, metallurgy, file design,
and ultrasonic utilization, as well as
our improved ability to scan—further
visualizing diagnostic services—have all
dramatically improved our armamen-
tarium to render endodontic treatment.
Technological progression in the field of
endodontics can be labeled either incre-
mental or exponential.
Small steps
Incremental advancements, for exam-
ple, include improved NiTi file designs,
which are annually introduced to the
dental market.
Endodontics saw the introduction of
NiTi instruments in the early 1990s. Met-
allurgical advances and modifications,
50 JANUARY 2016 // dentaltown.com
and recommended formatting of these
various NiTi instrument series will
continue to develop. Instrument taper,
flute design, rotation modifications, file
sequencing, and most recently, heat treat-
ments, have all affected the instrument
flexibility, cyclic fatigue, and manufac-
turer file progression recommendations.
Endodontics continues to develop,
blending the widespread integration of
magnification with improved NiTi rotary
instrumentation. As magnification has
become more ubiquitous, an endodontic
dialogue has evolved that promotes a con-
servative endodontic preparation, labeled
by some clinicians as “minimally invasive
endodontics.”1
The advocates for a minimally invasive
preparation have established an inquiry
against a significant volume of studies.
These advocates cite a need for significant
canal preparation, allowing for deeper irri-
gation, which provides for enhanced apical
canal debridement and disinfection.2, 3
Presently, there are no established pro-
tocols for the technique that constitutes a
minimally invasive endodontic procedure.4
However, a number of rotary-file sys-
tems geared toward dentinal conversation
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Technological progression
are on the market today: file systems like the V-Taper (SS White),
Endo-EZE AET (Ultradent), and TRUShape 3D Conforming
Files (DENTSPLY International).

Giant leaps
The introduction of the dental microscope and CBCT are
in the field of
endodontics can be
examples of exponential technologies that have improved the
quality of treatment planning and diagnosis in endodontics.
Exponential technological improvements to enhance visual-
ization have been afforded to endodontics with the incorporation
of the surgical operating microscope. The microscope’s ability to
vastly improve magnification benefits from the added improve- labeled either incremental
ment of site-specific lighting by means of halogen, xenon, and
LED illumination. LED lighting has now become standard.
The clinician’s ability to pair improved magnification with or exponential.
superior lighting allows him or her to address many conventional
endodontic challenges. With more predictability comes the higher
probability to dismantle retreatment cases. qualify this technology as an exponential advancement in the field
Our ability to disassemble retreatment cases, removing posts of endodontics.6
and other obstructions by means of ultrasonic instruments—part- The success of root-canal treatments performed with the Gen-
nered with magnification—has dramatically reduced the need for tleWave System can be attributed to superior cleaning of tissue
more invasive periradicular surgery. debris, bacteria, and biofilm even from complex anatomical areas,
when compared to conventional treatments.7, 8
More improvements The GentleWave System incorporates a patented “Multi-
Another advancement within the field of endodontics is in sonic Ultracleaning” technology with advanced fluid dynamics
obturation choices. and chemistry of the treatment fluids.9 The GentleWave System
Bioceramic obturation materials are gaining acceptance as consists of a console and a sterile, single-patient-use treatment
root-canal filling material. The term “bioceramics” describes a instrument. A stream of treatment fluids is delivered from the tip
biocompatible ceramic material, appropriate for biomedical or of the treatment instrument into the pulp chamber.
dental use.
A new calcium silicate, calcium phosphate product—marketed
as EndoSequence BC sealer and root repair material (Brasseler
USA)—has demonstrated improved handling characteristics com-
pared with earlier-generation materials that had already demon-
strated substantial clinical success. The system involves the use of a
bioceramic sealer, and chemically coated gutta percha points. The
biosilicate sealer has a number of clinically valuable characteristics.
Being hydrophilic, it pulls water from dentinal tubules, establishes
a high antimicrobial pH, and swells slightly upon set.5
The manufacturer states that its sealer “utilizes the moisture
naturally present in the dentinal tubules to initiate its setting
reaction.” Bioceramic sealer forms hydroxyapatite upon setting,
and chemically bonds to both dentin and to the bioceramic gutta
percha points. A possible explanation for the high amount of Ca+2
released by bioceramic cements could be associated with setting
reactions, including hydration reactions of calcium silicates.
Another potentially exciting exponential development in the
overall quality of root-canal treatments comes from Sonendo.
The GentleWave System (Fig. 1) was launched on a selec-
tive-market release. The extensive research and the outcomes of
Fig. 1
thousands of clinical cases completed to date certainly seem to

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 endodontics
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Simultaneously, excess fluid is removed from the pulp
chamber by built-in vented suction, drawn through the treat-
ment instrument, and deposited into a waste canister inside the
console. Upon initiation of flow through the tip of the treatment
instrument, the stream of the treatment fluid interacts with the
stationary fluid inside the pulp chamber, creating a strong shear
Fig. 2A Fig. 2B
Example radiographs before and after GentleWave treatment.
Fig. 3 Fig. 4
force that causes hydrodynamic cavitation in the form of a cav-
itation cloud.
The continuous formation and implosion of thousands of
microbubbles inside the cavitation cloud generates an acoustic
field with a broadband frequency spectrum that travels through
the fluid into the entire root-canal system.
Also, the GentleWave System may
maintain a higher degree of structural
integrity than conventional endodontic
devices, as it requires less root-canal shaping
(Figs. 2A and 2B).
Another recent exponential endodontic
development has been established by the
use of cone-beam computed tomography
(CBCT). This technology has migrated
into the dental diagnostics environment
and become commonplace in the endodon-
tic office.
The clinician can now acquire and eval-
uate a case in three dimensions, revealing a
tremendous amount of diagnostic informa-
tion. CBCT has been specifically designed to
produce undistorted three-dimensional infor-
mation of the maxillofacial skeleton, including
the teeth and their surrounding tissues, using
a substantially lower effective radiation dose
than conventional computed tomography.
CBCT does not replace conventional
dental radiography.10 Yet with indicated
cone-beam imaging, the clinician can offer
a proven indispensable tool in a multidis-
ciplinary approach to patient care in end-
odontics (Figs. 3-6).

Unchanged
Of course, many things in endodon-
Fig. 5 Fig. 6
tics do not—and will not—require any
changes, as they remain foundational to
our profession.
I will mention three cornerstone con-
cepts, although there could undoubtedly
be more. The keystone of these principles
applies to the healing arts in general: First,
do no harm, or primum non nocere.
Applying this principle to endodontic
therapy obligates the clinician to hold off
from definitive treatment until reproduc-
ible signs and symptoms can be duplicated
chairside. We must be as sure as possible,
clinically, that pulpal removal will enhance
the oral condition of the patient. This

52 JANUARY 2016 // dentaltown.com

 endodontics
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concept blends into conservative diagnosis—a treatment concept

that will not change over time.
Another endodontic concept that will not change is patient
comfort. For example, has the area to be treated received adequate
anesthesia? Has the apprehensive patient been adequately treated,
if necessary, with anxiolytic protocols? We want to reinforce
patient comfort for an overall positive treatment outcome.
A third treatment concept that also will not change over time
is the trust our patients place in us to provide professional quality
treatment. The patient places his or her dental treatment in our
hands, which makes a strong pledge and corresponding expecta-
tion of our professionalism.

Conclusion
Dental professionals are blessed with the ability to enhance our
services through innovative improvements in materials, methods,
and treatment protocols. Change will naturally present us with won-
derful opportunities for dental advancement. As professionals, we
are obligated to integrate them into our treatment modalities. At the
same time, there are also significant aspects of our profession that
will never change as we move through our professional careers. ■

References
1. Murdoch-Kinch C A, McLean M E. Minimally invasive dentistry. J Am Dent Assoc 2003; 134:
87–95.
2. Weiger R, Bartha T, Kalwitzki M, Löst C. A clinical method to determine the optimal apical
preparation size. Part I. Oral Surg Oral Med Oral Pathol Oral
3. Shuping G, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-
titanium rotary instrumentation and various medications. J Endod 2000; 26: 751–755.
4. Clark D, Khademi J A. Case studies in modern molar endodontic access and directed dentin conser-
vation. 49. Dent Clin North Am 2010; 54:249–273.
5. Zhang H, et al. Antibacterial activity of endodontic sealers by modified direct contact test against
enterooccus faecalis. JOE. 2009; 35(7): 1051-5
6. Sigurdsson A, Khang TL, Woo SM, Rassoulian SA, McLachlan K, Abbassi F, Garland RW. Six-
month healing success rates after endodontic treatment using the novel GentleWave™ System: the
PURE prospective multi-center clinical study. J Clin Exp Dent. In Press. 2016.
7. Molina B, Glickman GN, Vandrangi P, Khakpour M. Histological evaluation of root canal
debridement of human molars using the GentleWave™ System. J Endod. 2015; 41: 1701-5.
8. Vandrangi P and Basrani B. Multisonic ultracleaning in molars with the GentleWave System. Oral
Health. 2015: 105:72-86.
9. Charara K, Friedman S, Sherman A, Kishen A, Malkhassian G, Khakpour M, Basrani B.
Assessment of apical extrusion during root canal procedure with the novel GentleWave System in a
simulated apical environment. J Endod. In Press. 2016.
10. The SEDENTEXCT project. Radiation Protection: Cone Beam CT for Dental and Maxillofacial
Radiology. Provisional Guidelines (v1.1 May 2009). sedentexct.eu/system/files/sedentexct_proj-
ect_provisional_guidelines.pdf. Accessed on October 26, 2010.

What advancements would you like to see in endodontics?

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Author Bio
Dr. Jeffrey Krupp, a board-certified diplomate of
the American Association of Endodontics, has been
in full-time endodontic practice for more than 33
years in San Jose, California. He earned a DDS de-
gree at UCLA dental school 1979 and received his
postgraduate endodontic certificate and MS at Marquette Univer-
sity 1982. His passionate interest in education has been the energy
behind his teaching program, Success in Endodontics.com. View Dr. Krupp’s
online CE course “Success in Endodontics” on Dentaltown.com.
FREE FACTS, circle 27 on card

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