Wednesday, March 7, 2018

GentleWave by Sonendo: A Second Look

A new research article titled, "Healing of Periapical Lesions After Endodontic Treatment with the GentleWave Procedure: A Prospective Multicenter Clinical Study" by Asgeir Sigurdsson, Randy W. Garland, Khang T. Le, and Shabriar A. Rassoulian, was just published in the March 2018 Journal of Endodontics.

This new study did a great job and addressing some of the design problems with the previous study reviewed in our post titled, GentleWave by Sonendo: A First Look.  While the previous study showed that the new GentleWave procedure could be considered a good alternative to conventional endodontic therapy, I felt that it failed support its claims of superiority over conventional endodontic treatment and specifically the claim to better remove the microbial load of the affected tooth.

The main issue with the study is that it again fails to have any positive or negative controls.  It would have been easy to create a randomized, double-blinded study to compare the new GentleWave procedure with a conventional endodontic treatment.  In stead, it simply evaluates the GentleWave technique and then goes to the literature to compare its success with conventional treatment.

The major improvements in this study are:
  1. Selection/Sampling Improvement:  This study evaluated teeth with periapical lesions.  These are the teeth that have bacterial issues and give us the most challenge in cleaning and obturation.  This change in the study design, makes this study much more relevant and important.
  2. Attrition Improvement:  This study lost only 1 of 45 patients in the study, while the previous study lost 16% to attrition.
  3. Standardization & Calibration of Examiners: training, calibration, independent scoring and consensus scoring of the periapical index (PAI) scores all demonstrate a desire for accuracy.
  4. Citation Bias:  The comparisons made in the discussion to other studies, specifically Orstavik et. al. was more relevant because both studies were evaluating healing of patients with periapical lesions.  Comparing two similar samples (teeth with periapical lesions using the PAI)  makes for a more relevant discussion.  The GentleWave success rate was listed at 97.7% at one year, while Orstavik's study reported 88% success rate at one year.
  5. Sponsorship Bias:  While the study was still "funded in part" by Sonendo, the study design, proper selection/sampling, standardization of examiners all significantly improve the quality of the study design and do a better job at supporting the claims made by the manufacturer.
Overall, I think this new study is much more helpful and relevant.  The next step is a larger, randomized, double-blinded clinical trial comparing GentleWave side by side with conventional treatment on teeth with periapical lesions.


  1. Healing of Periapical Lesions after Endodontic Treatment with the GentleWave Procedure: A Prospective Multicenter Clinical Study Sigurdsson, Asgeir et al. Journal of Endodontics , Volume 44 , Issue 3 , 510 - 517

Friday, March 2, 2018

GentleWave by Sonendo: A First Look

We have had some recent questions about a new technology for cleaning and disinfecting the root canal system that is being heavily marketed in the dental community.  This system, known as the GentleWave System, by Sonendo Inc. (Laguna Hills, CA), consists of a console that is used to deliver the traditional irrigating solutions through a proprietary treatment instrument (TI).  The tooth is accessed, canals are located, patency established and canals shaped to #20 .07 taper, the TI is sealed to the access of the tooth.  The console then systematically delivers the irrigating solutions through the tip of the TI.  Through the TI, irrigating solutions are delivered in a "degassed" state (no air bubbles) using acoustic  and hydrodynamic cavitation.  The solutions are simultaneously removed using built-in vented suction through the same TI.

While Sonendo Inc. has been around for close to 10 years, this company has made a significant investment into the marketing of this product.  The clinical claims made by the company include:
  • the technique provides improved removal of organic matter (pulp tissue and biofilm) a "higher standard of clean"
  • the technique allows for minimal instrumentation of the canals, preserving valuable tooth structure
  • the technique allows for improved cleaning of canals, lateral canals, isthmus
  • 97% success rate of endodontic cases - in initial clincial studies
Like many new technologies and materials that are introduced in dentistry, much of the research supporting the new technology or product comes from the manufacturer or studies that are supported by the manufacturer.  It is well known that studies supported by a manufacturer tend to have bias that favors the funding source known as funding bias.   As clinicians, it is up to us to evaluate the research that is presented to us as we make important decisions.

A recent study titled, "12-Month Healing Rates After Endodontic Therapy Using the Novel GentleWave System: A Prospective Multicenter Clinical Study" by Sigurdsson et. al. published in the Journal of Endodontics, July 2016 is a perfect example of this problem. (click here to see the study)

The study concludes, "...the GentleWave System showed a high level of success after 12-month follow-up".   The abstract states, "The cumulative success of endodontic therapy was 97.3%.  The success rates of necrotic and irreversible pulpits were 92.9% and 98.4% respectively".  The failures in design of this cohort, uncontrolled study, make these numbers less impressive than they sound.

The problem with the study design is:
  • Design Bias:  Bias that occurs when the design of a study selects or encourages a specific outcome.  This is 12 month prospective study with no controls.  How easy would it have been to make this a randomized, double blinded study and compare this new technology to the conventional endodontic approach. Then we might have a better idea if this technology actually improves the outcomes of treatment.  Design bias is also evident in the discussion of this study by its failure to acknowledge the one-sided study design and in the analysis of what the results mean (see below)  
  • Attrition Bias: Systematic error introduced into a study by loss of participants: 75 of the 89 patients in the study returned for the 12 month follow-up.  This is a drop-out rate of 15.7%.  A major problem with almost all of our medical/dental studies is that we make assumptions about that 15%.  Since we don't have information on them, we exclude them from the study results.  So when the study says they have 97.3% success rate - they are assuming that the 15.7% that dropped out were also successes.
  • Selection/Sampling Bias: Bias introduced by the selections of participants: 72 of the 89 patients included in this study were diagnosed with irreversible pulpitis.  Only 14 of 89 patients in the study had a necrotic pulp.  Cases of irreversible pulpitis have the highest success rates in endodontics.  To heavily weight a study with irreversible pulpitis cases creates a significant bias.  A study focused on treating necrotic pulpal tissue would have been much more meaningful - especially if the study aims to prove that the GentleWave procedure will better remove the microbiota from the canal system.
  • Sponsorship Bias: Refers to the overwhelming tendency of a scientific study to support the interests of the study's financial sponsor. While the financial sponsorship is noted in the footnotes of the article, the tendency toward this bias requires a stricter methodology and implementation to reduce bias and a more clear and open discussion regarding analysis of results and clinical interpretation of these results.
The problems that we find in the discussion include:
  • Citation Bias: The success rate of this study (comprised mostly of irreversible pulpitis cases) is then compared to the success rates of other previous studies (comprised of teeth with periapical radiolucencies - which means necrotic cases) as an argument of improved cleaning and efficacy is an example of selection and citation bias together.
  • Internal Validity Bias:  Refers to the author and reviewer's confidence that the study design, implementation and data analysis have minimized or eliminated bias.  There appears to be no effort on the part of the authors to evaluate or report any bias in the study design, implementation or data analysis.
  • External Validity Bias: Refers to the degree to which the study's design allow its findings to be able to be generalized to other groups or populations. The failure in methodology of this prospective study without positive or negative controls, make the comparisons made in the discussion in regards to improved clinicial efficacy unsubstantiated.
    • The discussion regarding single visit vs. multiple visit endodontic treatment is again not a fair comparison when 89% of the cases in the study were irreversible pulpitis.  Those who advocate for multiple visit endodontic therapy are recommending that for necrotic cases and usually treat irreversible pulpitis in single visit as well.
    • The discussion about reduced post-operative pain is again biased by a study heavily weighted with irreversible pulpitis.
So a closer review of this study shows that the study design has major flaws and multiple unidentified and unreported biases.  These biases are then ignored and assumptions are made regarding superior cleaning of the new technology.

Obviously, the GentleWave procedure can be an effective alternative technique for irrigation and cleaning of the canals.  It does not provide evidence that the GentleWave procedure is superior over conventional endodontic therapy.  The series of case reports and in vitro studies available on the Sonendo website are a good beginning to provide evidence to support the claims made by the manufacturer (click here), but there is not evidence of superiority over conventional endodontic treatment at this point.

In order to substantiate the claims being made by the manufacturer, we need randomized, double-blinded, controlled clinical trials focusing on necrotic teeth.  With this kind of data, we would be able to better evaluate the effectiveness of the GentleWave procedure over conventional endodontic therapy.

In our practice at SSE, we are committed to providing the highest levels of endodontic care.  If any technology can demonstrate a significant improvement over conventional approach with serious randomized, controlled studies, rather than cohort  studies, case reports and in vitro studies, we will be interested in incorporating that technology.  We look forward to learning more about the GentleWave procedure in an upcoming office demonstration. We will also be watching for better scientific evidence to be published and will do our best to keep you up to date with our findings.


Elemam RF, Pretty I. Comparison of the Success Rate of Endodontic Treatment and Implant Treatment. ISRN Dentistry. 2011;2011:640509. doi:10.5402/2011/640509.

12-month Healing Rates after Endodontic Therapy Using the Novel GentleWave System: A Prospective Multicenter Clinical Study Sigurdsson, Asgeir et al. Journal of Endodontics , Volume 42 , Issue 7 , 1040 - 1048.

Pannucci CJ, Wilkins EG. Identifying and Avoiding Bias in Research. Plastic and reconstructive surgery. 2010;126(2):619-625. doi:10.1097/PRS.0b013e3181de24bc.

Monday, February 19, 2018

7 Yr Recall on Intentional Replantation

It just so happens that in the last couple weeks I got the chance to do some long term recalls on a couple of intentional replantation cases.  I don't do a lot of these cases, but am surprised how many people are unfamiliar with this treatment option or have never seen one before.  Sometimes it makes me wonder if we should consider this treatment option more often when we have failure with traditional approaches.

This most recent case is a periodontist who came to our practice.  I originally did the root canal in 2005.  It had an odd lateral lucency - which might be suggestive of a root fracture.  We completed root canal without finding a fracture. 

Unfortunately, at the 2 year re-evaluation, the lateral lesion did not resolve. Since I'm working on a periodontist friend of mine, why not try a retreat again?  We tried it and again found no root fracture, or obvious reason for the failure to heal.

Four years later at another re-evaluation, the bone loss on the lateral is even worse. We are still puzzled at why this has not resolved, but not convinced there is a root fracture, so we decided to try intentional replantation.   So, here are some of the best photos I have to document the process.

The tooth is gently extracted. Here it is immediately after extraction.

The root is kept moist and quickly examined for fractures.  None found, so we did retro preparation using and ultrasonic instrument.

An MTA retrofit is placed.

The tooth is replanted into the socket within 10 minutes of extraction.  Firm pressure is placed for an extended period of time. No splinting

A seven year recall finds tooth #31 asymptomatic and fully functional.  While the mesial bone looks irregular, there is no periodontal pocket.  If you look at the initial photo of the extracted tooth, you can see the periodontal ligament, but there appears to be an area where the ligament had been lost.  There was not visible fracture on that area of the root at that time.  My assumption is that the pdl may not have ever reformed in that area - causing the current radiographic appearance. 
It is interesting how a perfectly good root canal and retreatment failed to give the desired results, but a last ditch effort with replantation has been successful up to this point.

Thursday, February 1, 2018

5 Yr Recall on Intentional Replantation

This patient came to SSE for RCT in 2010. It was a necrotic and RCT was completed.  The lesion failed to heal, so retreatment was completed in 2012.  Lesion still failed to heal, so intentional replantation was chosen as a last resort before extracting the tooth #14.
Tooth #14 was carefully extracted and all 3 canals were resected, retrofilled and reimplanted within minutes. 
5 Year recall shows great apical bone healing.  The tooth is functional, normal percussion, normal probing.  Intentional implantation should be considered as an opion in certain situations.

Monday, December 11, 2017

How to Manage a Negative Online Review

Step 1: Relax - A negative review is not the end of the world or the end of your practice. In fact, you can actually turn a negative review into a positive for your practice if you handle it correctly!

Step 2: Respond - After you have taken some time to consider the feedback and do some of your own research, respond to the review on the 3rd party website where it was posted.

Step 3: Thank Them for Their Feedback - First step in your response is a sincere thank-you for them taking the time to provide feedback.

Step 4: Don't Argue - Don't ever argue, make excuses, or blame someone else. Even if they are wrong or their complaints aren't fair, your response to a negative review will say more about your practice than what the negative review says. Other who read the negative review, will also be reading your response. They want to see that you are respectful, understanding and willing to do what's best for the patient.

Step 5: Remember HIPPA - Remember that patients can talk about your practice, but you can't share patient information online. But that doesn't matter because you are not going to argue with the patient but to show the patient and the world you are listening and they are your priority. You may need explain that you will need to discuss their concerns in private, but you can assure them that you will help them resolve their concern.

Step 6: Do The Right Thing - This might be apologize for falling short on customer service, give a refund, offer to re-evaluate a situation or simply express empathy. Only you can decide what the right thing to do is, but remember, this decision will speak volumes about your practice.

Use your response to educate patients about your values. Tell the world what your values/standards are and what you are striving for your practice. If you fell short of your regular standards, own it. People will respect that. Turn the response to a negative review into a promotion for your practice.

Step 7: Ask For A Revision - If you have properly taken care of your patient's concerns, it would be totally appropriate to ask if they would be willing to revise their review. If they don't, can't or won't revise the review, go back to Step 1: Relax.

You have shown the world you are listening to your patients, are responsive to their feedback and are trying to do the right thing. That is how you turn a negative review into a positive for your practice!

PS. There are those who say that if you don't have any negative reviews, then you look like a "fake". Patients who are reading reviews are smart. They can spot a reviewer who is unreasonable just like they can spot a practice who does the right thing for its patients.

Friday, September 29, 2017

How Competent Are You with Endodontics in Your Practice?

The American Association of Endodontists has just released a white paper on the topic of competency of endodontic care.  This paper defines the requisite skills required by all dentists who perform endodontic diagnosis and treatment regardless of whether the clinician is a generalist or specialist.

Topics covered include:

  • Proper pulpal and periapical diagnosis
  • Identifying odontogenic pain from non-odontogenic pain
  • Proper emergency treatment for traumatic dental injuries
  • Role of patient interview in endodontic diagnosis
  • Distinguishing features of irreversible pulpitis
  • The importance of multiple findings in determination of pulpal pathosis
  • Clinician's responsibility for accurate interpretation of radiographs
  • Proper use of 3D imaging
  • Difficult diagnostic cases such as resorption
  • Ability to evaluate case difficulty before treatment is started
  • Responsibility of the clinician to keep up with the latest and best practices in endodontics
  • Proper treatment planning including alternative treatments for patient's review
  • Careful consideration of restorability
  • Proper forecasting of prognosis
  • Proper interpretation of healing of endodontically treated teeth
  • Proper outcome assessment

In modern dentistry, with all it's advancements in technology, instrumentation and materials, we must remember that these are adjuncts to the clinician's skill and expertise. In fact, there are cases where investment in technology without proper skill, training and experience may actually hurt your practice of endodontics.  For example, the false sense of security of having a CBCT image showing the location of the MB#2 canal, without the microscope and skill to locate the canal may put the patient at greater risk of root perforation.  The patient's best interest must always be put first, even before our financial obligations for technology that we have chosen to invest in.

"Since endodontists set the standard of practice for conventional endodontics, if the endodontist’s standard cannot be met, such as the need for microscopy, regenerative procedures, complex traumatic injuries, 3-D imaging for complex anatomy or the need for apical surgery, the generalist should refer the patient to an endodontist. Planned endodontic cases should not be doomed to failure due to a lack of understanding of what is required to produce a certain level of quality treatment. Implants should never become an insurance policy for inadequate endodontic treatment." (AAE White Paper on Endodontic Competency)

The paper makes the important point that "Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant." while at the same time recognizing a shift in the philosophy of restoring endodontically treated teeth.  This shift has begun to recognize the importance of the periodontal tissues associated with the tooth (periodontal ligament, bundle bone, alveolar bone, gingival fibers creating the papilla) that cannot be replaced by a dental implant. These important tissues belong to the tooth.  They come with the tooth and go with the tooth.

At Superstition Springs Endodontics, we are pleased to partner with dentists who perform endodontic treatment and other specialists who are committed to multidisciplinary dentistry.  We are committed to helping and supporting the dentists in our community provide the highest quality of endodontic care available in their practices and the best care for their patients when they choose to refer a patient to SSE.

Wednesday, August 9, 2017

Success with Online Reviews at SSE

Over the last year, we have been using the ReviewWizards system to invite our patient to leave online reviews on third party websites.  We want our patients to leave their reviews on sites that matter to the search engines.  We have found great results in building our online reputation.  With ReviewWizard, our patient are sent a link to the phone that takes them to a customized webpage. inviting them to leave a review.  It then walks them through the process to leave a review at the review site of their choice from a selection of sites that are most important to us.

Here's an example of what we have accomplished using ReviewWizards.

Using the ReviewWizard system, we have increased our number of online reviews to 363!

Using the ReviewWizard system, we have gotten 39 new online reviews in the last 90 days.

In the last 30 days, we were able to get 70 people to visit our customized landing page,  46 to click through and  14 to complete the process of leaving our practice a review on a third party review site like Google, Yelp, HealthGrades, RateMDs etc.
To see where our patients are leaving reviews, click here.
If you have any interest in what your practice's online reputation looks like, sign up for a free reputation report at

Monday, April 24, 2017

Partners in Patient Care: Post and Core Buildup

The endodontists at Superstition Springs Endodontics are skilled in restorative procedures closely associated with endodontic treatment.  At your request, esthetic post and core buildups can be immediately placed following endodontic treatment.


Let the endodontists at Superstition Springs Endodontics be your partners in your patient's care.

Monday, February 20, 2017

Build Your Practice With Online Patient Reviews

In our practice at Superstition Springs Endodontics, we have found that patients of all ages are using online reviews in their selection of dental care providers.  Even many of our patients, referred by their general dentist, will go online, using our website or reading reviews to learn about us before coming to our practice.  We also find patients who self-refer to our practice after reading online reviews.  Patients routinely describe how they use online reviews in selecting their general dentist. This should come as no surprise. A recent survey indicates that 88% of people trust online reviews as much as a personal recommendation. The most effective and reliable online reviews are those left on 3rd party websites like Google, Yelp, Facebook, Healthgrades, RateMDs, etc. etc. These websites are more visible to search engines than your individual practice website.  The key to a successful online review strategy is to get patients talking about your practice online through social media and review websites. An effective online review strategy can be the least expensive and most effective SEO (search engine optimization) strategy you can find.

The key to a simple, effective online review strategy is:
1. Invite patients
2. Simplify the process

Invite: Without an a strategy for inviting patients to leave a review, you can expect to get the same amount of reviews that you are currently getting.  Success with online reviews requires leadership and accountability.  If you are not comfortable inviting patients to leave a review, assign someone in your office to make the invitation.  At SSE, we typically invite patients to leave a review as part of our post-operative instructions.

Simplify: Leaving a review takes time and people are busy.  The easier you can make the process for a patient, the more reviews you will get.  Let them choose a review site with which they are familiar with or already use, such as Google, Yelp, or Facebook.  Some of these sites require an account to leave a review.  Patients are not going to sign up for an account to leave you a review, but if you give them a choice of a place they already use, you have a much better chance of getting that review.  If you can direct them exactly to your profile on the third party review site to leave the review, you reduce the steps/clicks it takes your patient to leave a review.

The reality is that no one cares more about your online reputation than you do.  If you want to improve online reviews, it will require YOUR leadership.  It's a numbers game. You have to make enough invitations and understand that a fraction of them will leave a review.  In our practice, we take great pride in our service and clinical care.  We try to create an experience for every patient that exceeds their expectation making them want to share their experience with others.
In the calendar year of 2016, Superstition Springs Endodontics garnered 123 new online reviews.
 To see a full report of our 2016 results, click here.

Review Wizards is a product to help professionals build their online reputations.  With a platform specifically for dentists, called, it is a low cost, highly effective solution to help your practice build its online reputation by inviting patients to leave reviews on the websites that they like to use and that are most important to you.  With a over a year of successful testing in multiple practices, we are now prepared to share this solution with all of you!

A Review Wizard subscription does this by:
  1. Allowing you or your staff to send your happy patients a review invitation via text or email on their favorite device using the LinkWizard.
  2. Creating a customized and branded webpage for your practice.
  3. Filters unhappy patients and lets them provide direct feedback to your practice.
  4. Gives your patients choices of where they might leave an online review.
  5. Delivers them to the review site with instructions on how to leave a review.
  6. Notifies you of new reviews that have been published online.
  7. Allows you to stream the most current online reviews to your website.  (for example, click here)
Online patient reviews may be the least expensive, most effective marketing tool that you can use to build your online reputation and grow your practice.  We've had great results with this new product/system and invite you to check it out.  Click here.

Friday, January 6, 2017

Targeting Cancer Cells - One by One - The Nowzari Symposium

Everyone knows somebody affected by cancer.  The 2017 Nowzari Symposium will feature a novel approach to treating cancer on a molecular level.  This includes using nano-particle radio treatment, vaccine immunotherapy, isotope imaging and cell therapy.

Speakers will be presenting their groundbreaking findings in a simple, easy to understand language, for clinicians and patients alike.   All are welcome to attend.