tag:blogger.com,1999:blog-60764333778340651122024-03-13T09:27:04.136-07:00The Endo BlogThe Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.comBlogger228125tag:blogger.com,1999:blog-6076433377834065112.post-48826575140448078662023-03-15T18:15:00.002-07:002023-03-15T18:17:07.788-07:00Technique & Long-Term Stability of Bone Grafts & Soft Tissue Grafts<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzJe_Z64l54xmBjIlBIqxUQU_ruLEnPmcjlMFkcUaYC9dIHQLn70S_B814zCthd8CiYAG_o5KOFlTbDf8VAIpk8McDl839--zDe6s73AyGDX-weY0NfJ9uGR_0rgb6oc9DD0pXa7cJufRzpnzJD4x_MjPC-uQ53muu933VeiHAUPmtI1aJwxFsq3g5/s1504/NowzariSeminar.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1504" data-original-width="1170" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzJe_Z64l54xmBjIlBIqxUQU_ruLEnPmcjlMFkcUaYC9dIHQLn70S_B814zCthd8CiYAG_o5KOFlTbDf8VAIpk8McDl839--zDe6s73AyGDX-weY0NfJ9uGR_0rgb6oc9DD0pXa7cJufRzpnzJD4x_MjPC-uQ53muu933VeiHAUPmtI1aJwxFsq3g5/w498-h640/NowzariSeminar.jpg" width="498" /></a></div><br /><p></p><div>If you are doing bone or soft tissue grafting, don't miss this event!</div>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-68573828720134091862022-09-07T17:51:00.000-07:002022-09-07T17:51:01.261-07:00Using CBCT to Diagnose the Depth of a Cracked Tooth<p> One of the many uses of CBCT is to help us determine the depth of a crack - seen on the occlusal surface of a tooth, but uncertain as to how deep it goes down the root. Obviously the deeper the crack goes below the CEJ, the poorer the long term prognosis.</p><p>This patient was mostly asymptomatic until he recently bit into something and has had pain ever since.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpGx6b69vgH-m0s3KUp54OkuslKj4hE5AJo3-V-hPrI2thR1lfcqcgjQCSf3RtNaCpPw-s-X_FfSrbQKDRSth57LAtFid7i0LD-sEqosxtxDlNwGr6AmdLvB0WT4iXobjTFZhBdxINZU5ckga1xAqp-39yCk55oXGdy9bJ4o-i9_43o9NER6xgYOi0/s846/X011025683.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="662" data-original-width="846" height="250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpGx6b69vgH-m0s3KUp54OkuslKj4hE5AJo3-V-hPrI2thR1lfcqcgjQCSf3RtNaCpPw-s-X_FfSrbQKDRSth57LAtFid7i0LD-sEqosxtxDlNwGr6AmdLvB0WT4iXobjTFZhBdxINZU5ckga1xAqp-39yCk55oXGdy9bJ4o-i9_43o9NER6xgYOi0/s320/X011025683.JPG" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;">Periapical film</div><br /><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHpd-SZ91tZuXcD8VT1ow2upapcyjy8G9wEuPErDaKzU3OWdKyO_SK7Ob12-wh3gy5MXBCWxUmpE1OgxNQJhMq43KM47DIpaHLWpaAuvFWdVNioqlqJF24HXz4LItvYnVNImFKPHVm7IS1qqbkQWlcZhxlxyhT3GdydHQ2VOvGxRFZT8jtSKCJGrnk/s6000/X011025683_2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4000" data-original-width="6000" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHpd-SZ91tZuXcD8VT1ow2upapcyjy8G9wEuPErDaKzU3OWdKyO_SK7Ob12-wh3gy5MXBCWxUmpE1OgxNQJhMq43KM47DIpaHLWpaAuvFWdVNioqlqJF24HXz4LItvYnVNImFKPHVm7IS1qqbkQWlcZhxlxyhT3GdydHQ2VOvGxRFZT8jtSKCJGrnk/s320/X011025683_2.JPG" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;">2 Cracks seen on the MMR - with staining</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifxAt88A5EjtC0pbN5quWvoksbfagn7ucXxuBqTFRkkoWMdyTIoBKAYgvQwWJLqWuQbTeL-S6jOE_nzzYZAIA3F-mTzV4UtlSplSpTn6oPP_agl943C68AvrdN6CQDuitnLhmlUpcFTLJlNEVauRTD6Kw_kyk7-RPE4uCJIP5WhUv2OcJ0KmaaGdOl/s6000/X011025683_3.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4000" data-original-width="6000" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifxAt88A5EjtC0pbN5quWvoksbfagn7ucXxuBqTFRkkoWMdyTIoBKAYgvQwWJLqWuQbTeL-S6jOE_nzzYZAIA3F-mTzV4UtlSplSpTn6oPP_agl943C68AvrdN6CQDuitnLhmlUpcFTLJlNEVauRTD6Kw_kyk7-RPE4uCJIP5WhUv2OcJ0KmaaGdOl/s320/X011025683_3.JPG" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhT8-XBgC_BzVpFvDOoHYclYbBnvjtWZe4Pwis4NSlXy3wjkmSMLyc9DxUjHmbxbW_YfTrrd4UkV4X4IIvK9cxZV5ruahIr-39g3XnFM1Z9A39aAJ1_vRfqy2tiD3yPh7XMkuZ5VgcHcM7zA8SMj8ujg5nymXcEtnucN-KsbniWAs727SrWz03t-UxI" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="920" data-original-width="920" height="320" src="https://blogger.googleusercontent.com/img/a/AVvXsEhT8-XBgC_BzVpFvDOoHYclYbBnvjtWZe4Pwis4NSlXy3wjkmSMLyc9DxUjHmbxbW_YfTrrd4UkV4X4IIvK9cxZV5ruahIr-39g3XnFM1Z9A39aAJ1_vRfqy2tiD3yPh7XMkuZ5VgcHcM7zA8SMj8ujg5nymXcEtnucN-KsbniWAs727SrWz03t-UxI=w320-h320" width="320" /></a></div>CBCT shows a narrow, bony defect identifying a crack in the axial (Z) view. The sagittal (Y) view shows the depth of the crack. A new crown would have to go past this depth to cover the crack up. This view helps us make a determination of the restorability of the tooth.</div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;">In this case, the crack would never be completed removed or covered up by the crown making the long term prognosis poor. CBCT allows us to make this evaluation without having to remove the amalgam filling and chase the crack - saving the patient (and us) time and money.<br /><br /></div><br /><p><br /></p>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-3291074472741411082022-03-04T14:03:00.002-08:002022-03-04T14:04:35.752-08:00Innovations in the Dental Insurance World<p> </p><table border="0" cellpadding="0" cellspacing="0" class="galileo-ap-layout-editor" style="background-color: white; border-collapse: collapse; color: black; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="left" bgcolor="FFFFFF" class="article editor-col OneColumnMobile" valign="top" width="100%"><div class="gl-contains-text"><table border="0" cellpadding="0" cellspacing="0" style="border-collapse: collapse; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="left" class="editor-text article-text" style="-webkit-font-smoothing: antialiased; color: #403f42; display: block; font-family: Arial, Verdana, Helvetica, sans-serif; font-size: 12px; line-height: 1.2; overflow-wrap: break-word; padding: 10px 20px;" valign="top"><div class="text-container galileo-ap-content-editor"><div><span style="color: black; font-size: 14px;"><br /></span></div><div><span style="color: black; font-size: 14px;">Medical insurance has been using tiered systems to provide care to patients for some time. A tiered system categorizes physicians by quality and cost efficiency standards. While the patient chooses their provider, the patient's </span><span style="color: black; font-size: 14px;">copay may vary based upon the provider tier that is chosen. Insurance companies can reimburse different tiers on different fee schedules potentially allowing network providers with better outcomes higher reimbursements. An example of medical insurance tiered system:</span></div><div><br /></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black; font-weight: bold;">TIER 1</span></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black;">Providers meet excellent quality and/or cost efficiency standards</span></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black;">Members pay the lowest copayment</span></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black; font-weight: bold;">TIER 2</span></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black;">Providers meet good quality and/or cost efficiency standards</span></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black;">Members pay the mid-level copayment</span></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black; font-weight: bold;">TIER 3</span></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black;">Providers who are outside the insurance network</span></div><div align="center" style="text-align: center;"><span face="Calibri, Helvetica, Arial, sans-serif" style="color: black;">Members pay the highest copayment</span></div><div><br /></div><div><span style="font-size: 14px;">As you know, trends in dentistry typically follow trends in medicine. While the tiered provider system is not yet here for dentistry, the concept of evaluating the quality of dental care has been on the horizon for some time, and will shortly be utilized by major dental insurers. How will this work?</span></div><div><br /></div><div><span style="font-size: 14px;">A leader in this type of data analytics is </span><a href="https://www.pandrdental.com/" rel="noopener noreferrer" style="color: #48a199; font-size: 14px;" target="_blank">P&R Dental Strategies</a><span style="font-size: 14px;">. They have developed a unique, objective, quality measurement program for dentists. Their methodology, called </span><a href="https://www.dentaqualleadersinquality.com/" rel="noopener noreferrer" style="color: #48a199; font-size: 14px;" target="_blank">DentaQual</a><span style="font-size: 14px;">, leverages a nationwide, multi-payer dental claims database (DentaBase) to measure quality by analyzing cross-payer claims and dentist utilization data. Quality is measured based on metrics scored in each of 5 categories.</span></div></div></td></tr></tbody></table></div></td></tr></tbody></table><table border="0" cellpadding="0" cellspacing="0" class="galileo-ap-layout-editor" style="background-color: white; border-collapse: collapse; color: black; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="" class="editor-col OneColumnMobile" valign="top" width="100%"><div class="gl-contains-image"><table border="0" cellpadding="0" cellspacing="0" class="editor-image editor-image editor-image-vspace-on" style="border-collapse: collapse; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="center" style="padding-bottom: 10px; padding-top: 10px;" valign="top"><div class="publish-container"><img alt="" border="0" height="238" hspace="0" src="https://files.constantcontact.com/92ea01b3201/973828f7-4d98-415b-bf40-9c30b04f5dd1.png?rdr=true" style="display: block; height: auto; max-width: 100%;" vspace="0" width="400" /></div></td></tr></tbody></table></div></td></tr></tbody></table><table border="0" cellpadding="0" cellspacing="0" class="galileo-ap-layout-editor" style="background-color: white; border-collapse: collapse; color: black; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="" class="editor-col OneColumnMobile" valign="top" width="100%"><div class="gl-contains-text"><table border="0" cellpadding="0" cellspacing="0" style="border-collapse: collapse; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="left" class="editor-text editor-text" style="-webkit-font-smoothing: antialiased; color: #403f42; display: block; font-family: Arial, Verdana, Helvetica, sans-serif; font-size: 12px; line-height: 1.2; overflow-wrap: break-word; padding: 10px 20px;" valign="top"><div></div><div class="text-container galileo-ap-content-editor"><div><span style="font-size: 14px;">The DentaQual score for a dentist is based upon an individual dentist's "standard deviation from the norm", the norm being the average practice behavior of a dentist's peers in a geographic area. It is not based upon predetermined or subjective benchmarks such as user reviews.</span></div><div><br /></div><div><span style="font-size: 14px;">As the largest dental insurer in Arizona, </span><a href="https://www.deltadentalaz.com/" rel="noopener noreferrer" style="color: #48a199; font-size: 14px;" target="_blank">Delta Dental of AZ</a><span style="font-size: 14px;">, will soon make these quality scores available to patients to help them in selection of their dentist. Other insurers such as United Healthcare and other Delta Dentals have already incorporated this platform and it's probable that other insurers will follow suit.</span></div><div><br /></div><div><span style="font-size: 14px;">In order to better understand the purpose behind these metrics and how insurance companies will be using them, we have invited Mr. Mike Jones, President and CEO of Delta Dental of Arizona to participate in our upcoming seminar. Mr. Jones will provide us with an update of current and future initiatives and explain how Delta Dental will be leveraging these new metrics.</span></div><div><br /></div><div><span style="font-size: 14px;">We have also invited Mr. Michael Urbach, President of New Markets for P&R Dental Strategies to come and explain how DentaQual works and what affect they expect to have on the dental insurance marketplace.</span></div><div><br /></div><div><span style="font-size: 14px;">We look forward to their presentation on Tues, March 22, 2022 at 6:00pm at Superstition Springs Endodontics.</span></div><div><span style="font-size: 14px; text-align: center;"><br /></span></div><div><span style="font-size: 14px; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://files.constantcontact.com/92ea01b3201/3d102b93-f8d9-4ca7-ac34-3a346f65856d.png?rdr=true" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="420" data-original-width="650" height="259" src="https://files.constantcontact.com/92ea01b3201/3d102b93-f8d9-4ca7-ac34-3a346f65856d.png?rdr=true" width="400" /></a></div><br /> </span></div><div><span style="font-size: 14px;"><br /><br /></span></div></div></td></tr></tbody></table></div></td></tr></tbody></table>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-57061992776048206652021-11-01T14:01:00.001-07:002021-11-01T14:01:54.704-07:00Survival in the Dental Office: Brain Based Leadership Concepts to Help your Practice<table border="0" cellpadding="0" cellspacing="0" class="galileo-ap-layout-editor" style="background-color: white; border-collapse: collapse; color: black; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="left" bgcolor="FFFFFF" class="article editor-col OneColumnMobile" valign="top" width="100%"><div class="gl-contains-text"><table border="0" cellpadding="0" cellspacing="0" style="border-collapse: collapse; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="left" class="editor-text article-text" style="-webkit-font-smoothing: antialiased; color: #403f42; display: block; font-family: Arial, Verdana, Helvetica, sans-serif; font-size: 12px; line-height: 1.2; overflow-wrap: break-word; padding: 10px 20px;" valign="top"><div class="text-container galileo-ap-content-editor"><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgENjpRPSj6wKA1Kwpm-AZARakkAH9mpsFbhac7WpNjDXbqFLaKt3JSG3NhMS2fFcK-aoXE0CbSy15jBmz6AgvinGYOhPHCpTXVX4O3vKmhOa35-zIPF1uUZrWjN49EHnH3hEaY_M-X34M/s472/s332.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="472" data-original-width="332" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgENjpRPSj6wKA1Kwpm-AZARakkAH9mpsFbhac7WpNjDXbqFLaKt3JSG3NhMS2fFcK-aoXE0CbSy15jBmz6AgvinGYOhPHCpTXVX4O3vKmhOa35-zIPF1uUZrWjN49EHnH3hEaY_M-X34M/w225-h320/s332.jpg" width="225" /></a></div><span style="color: black; font-size: 14px;"><br />During the 2020 spring shutdown, due to the COVID-19 pandemic, I found myself at home with my family looking for ways to entertain ourselves. We planned daily "quarantainment activities" like playing indoor games, outdoor games,</span><span style="color: black; font-size: 14px;"> cooking competitions,</span><span style="color: black; font-size: 14px;"> bike rides, ping pong tournaments, movies etc. At some point, we began to watch back seasons of the CBS reality show "Survivor". In this show, a group of very different people get stranded on an island, with just the clothes on their backs. They compete individually and in teams but ultimately have to vote each other off the island until there is one remaining survivor. We did some major binge watching, but it was fun. Watching the drama of such different people put in a stressful environment, competing for food & small comforts, making pacts with each other and ultimately doing anything to survive in the game - including the all too famous "blindside" was just too entertaining to look away!</span></div><div><br /></div><div><span style="color: black; font-size: 14px;">At the same time, we all found ourselves in a business survival mode. How do we handle our emergency patients? Do we layoff employees? Can we get a PPP loan? Can we get it forgiven? What happens if someone on staff gets sick? How do we pay for sick time? If a staff member gets sick, do we have to shut down the office? What if my family gets sick, can I come to work? How do I handle the hygienist's concerns? How do we manage our team's anxiety about the whole situation? </span><span style="color: black; font-size: 14px;">How long will this go on? </span><span style="color: black; font-size: 14px;">etc. etc. The threats to our businesses and livelihood were real and we all felt a little "blindsided" by COVID-19.</span></div><div><br /></div><div><span style="color: black; font-size: 14px;">Survival is what the brain is designed to do. The brain identifies threats and keeps us alert and aware of them at all times. Unfortunately, sometimes this state of arousal can create challenges and problems when it comes to communicating, collaborating, solving problems, setting goals, and leading a team in your office. M</span><span style="color: black; font-size: 14px;">odern neuroscience is teaching us many new things about the brain and cutting edge leadership is taking advantage of that new knowledge.</span></div><div><br /></div><div><span style="color: black; font-size: 14px;">Our upcoming Inner Space Seminar, will discuss how brain based leadership focuses on understanding how the brain works and using that information to our advantage. David Rock, of the Neuroleadership Institute, has described five social domains that the brain treats as primary rewards or threats. Since your office is social system, understanding these concepts can change the way you communicate, lead your team and interact with your patients more effectively.</span></div><div><br /></div><div><span style="color: black; font-size: 14px;">Our upcoming Inner Space Seminar will be presented by Jason Hales DDS, MS on Thursday, Nov. 11th, 2021, will review these leadership concepts and help you survive as a leader in your practice.</span></div><div><span style="color: black; font-size: 14px;"><br /></span></div><div><span style="color: black; font-size: 14px;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyMPowaYxViZQnihIsEO95q_OrTQ0S8p3tFw_uX5GPCtDoYT9TgnwE6h-V8ipe-OfC8MbpZtB52Cxeyzr7u3RJECeMX8-4z4G-VnpAoMjmh0mWKfzFqzwV0hqVYzlNKtEDI5Co3XU9E_U/s1624/superendo+survivor.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1010" data-original-width="1624" height="265" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyMPowaYxViZQnihIsEO95q_OrTQ0S8p3tFw_uX5GPCtDoYT9TgnwE6h-V8ipe-OfC8MbpZtB52Cxeyzr7u3RJECeMX8-4z4G-VnpAoMjmh0mWKfzFqzwV0hqVYzlNKtEDI5Co3XU9E_U/w426-h265/superendo+survivor.png" width="426" /></a></div><br /><span style="color: black; font-size: 14px;"><br /></span></div></div></td></tr></tbody></table></div></td></tr></tbody></table><table border="0" cellpadding="0" cellspacing="0" class="galileo-ap-layout-editor" style="background-color: white; border-collapse: collapse; color: black; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="" class=" editor-col OneColumnMobile" valign="top" width="100%"><div class="gl-contains-text"><table border="0" cellpadding="0" cellspacing="0" style="border-collapse: collapse; min-width: 100%; table-layout: fixed; width: 100%px;"><tbody><tr><td align="left" class="editor-text editor-text " style="-webkit-font-smoothing: antialiased; color: #403f42; display: block; font-family: Arial, Verdana, Helvetica, sans-serif; font-size: 12px; line-height: 1.2; overflow-wrap: break-word; padding: 10px 20px;" valign="top"><div></div><div class="text-container galileo-ap-content-editor"><span style="font-size: 14px; font-weight: bold;">To register please contact Annette at </span><a href="mailto:Annette@superendo.com" rel="noopener noreferrer" style="color: #48a199; font-size: 14px; font-weight: bold;" target="_blank">Annette@superendo.com</a><span style="font-size: 14px; font-weight: bold;"> or 480-807-8022. Seating is limited.</span></div></td></tr></tbody></table></div></td></tr></tbody></table>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-84472984333821262702021-04-26T11:23:00.002-07:002021-04-26T11:25:29.258-07:00Dealing with Cracked and Fractured Teeth - An Inner Space Seminar<p> </p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="368" src="https://www.youtube.com/embed/wlwjWLmieVc" width="443" youtube-src-id="wlwjWLmieVc"></iframe></div><br /><p></p><p>At a recent Inner Space Seminar, Dr. Jason J. Hales discussed dealing with cracked and fractured teeth.</p>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-40677704655445200422021-03-08T20:36:00.003-08:002021-03-08T21:58:50.002-08:00Partner for Success - What Does A Real Partnership Look Like?<p><span style="font-family: helvetica;"><span style="color: #717a80;"><span style="white-space: pre-wrap;"></span></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: helvetica;"><span style="color: #717a80;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLltefAUpJGJEuFEaAKkmucQA4vneIwmR7T21kUcI_4yLt3mP8y9vEYMTSvcIhJdacGUPt7NmMqB2cB8v8UURhMMTRLmTrSGTT0rTW8tljMZZKtxgIkZMeTj1k3ONGJDmxJr8yGawLCcg/s860/Value5Icon.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="589" data-original-width="860" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLltefAUpJGJEuFEaAKkmucQA4vneIwmR7T21kUcI_4yLt3mP8y9vEYMTSvcIhJdacGUPt7NmMqB2cB8v8UURhMMTRLmTrSGTT0rTW8tljMZZKtxgIkZMeTj1k3ONGJDmxJr8yGawLCcg/s320/Value5Icon.jpg" width="320" /></a></span></span></div><span style="font-family: helvetica;"><span style="color: #717a80;">At Superstition Springs Endodontics, one of our five core values is "Partner for Success". To us this means, that we are successful when our partners are successful. As we have focused on this value, we have come to more clearly understand who our partners are, and how we can help each other be successful.</span></span><p></p><p><span style="font-family: helvetica;"><span style="color: #717a80;"><span style="white-space: pre-wrap;">At SSE, our partnerships are primarily with our referring dentists, but also include other important providers of supplies, IT services, legal services, accounting services and even </span></span><span style="caret-color: rgb(113, 122, 128); color: #717a80; white-space: pre-wrap;">janitorial services</span><span style="color: #717a80;"><span style="white-space: pre-wrap;">. While insurance companies are often viewed as an adversary, we should look to build partnerships with them, when possible.</span></span></span></p><p><span style="background-color: white; caret-color: rgb(113, 122, 128); color: #717a80; white-space: pre-wrap;"><span style="font-family: helvetica;">A 2009 study by the L.C. Williams & Associates Research Group details a group of dentists who refer less than 10% of their root canals to endodontists. This group of dentists have a very different perspective about working with endodontists. They tend to believe that they perform the same quality of endodontic treatment as specialists at a lower cost. They are less likely to admit that certain difficult cases should have been referred to an endodontist than their peers who refer more than 10% of their endodontic cases. These dentists are also less likely to describe an endodontist as their partner in delivering quality dental care. As you can imagine, these are not the dentists that we are interested in working with.</span></span></p><p><span style="font-family: helvetica;"><span style="color: #717a80;"><span style="background-color: white; white-space: pre-wrap;"></span></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: helvetica;"><span style="color: #717a80;"><span style="background-color: white; white-space: pre-wrap;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2SaX5YBOFOIMACwqu9mnq1fRI8Zj3OyceyaugmxgXRP9rmG4Sn89VMguS_n3KMlpELmXOONR9trMPj6K2sDl7nS7lMhvGnuAQutaD3aZutubEgOMwVOvgT_jBymO0PBsyON3AWiEcwto/s1677/FistBump.jpeg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1119" data-original-width="1677" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2SaX5YBOFOIMACwqu9mnq1fRI8Zj3OyceyaugmxgXRP9rmG4Sn89VMguS_n3KMlpELmXOONR9trMPj6K2sDl7nS7lMhvGnuAQutaD3aZutubEgOMwVOvgT_jBymO0PBsyON3AWiEcwto/s320/FistBump.jpeg" width="320" /></a></span></span></span></div><span style="font-family: helvetica;"><span style="color: #717a80;"><span style="background-color: white; white-space: pre-wrap;"><br />D</span><span style="white-space: pre-wrap;">efining this value of partnership has given us the freedom to realize that while most of our patients come from general dentists, there are times when we are forced to choose which dentists are given access and priority of our time, schedule and expertise. As you can imagine, those dentists with whom we have a partnership will get that priority. W</span></span></span><span style="color: #717a80; font-family: helvetica;"><span style="white-space: pre-wrap;">hile</span></span><span style="background-color: white; font-family: helvetica;"><span style="color: #717a80;"><span style="white-space: pre-wrap;"> working with this previously described group of dentists typically brings frustration, w</span></span></span><span style="color: #717a80; font-family: helvetica; white-space: pre-wrap;">orking in sync with partner dentists, and the relationship with them, is a rewarding and fulfilling part of our work. </span><p></p><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-weight: normal;"><span style="font-family: helvetica;">A partnership is a relationship that benefits both parties. At SSE, this is what partnership looks like to us:</span></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-family: helvetica;"><br /></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-family: helvetica;">Our partners know:</span></div><ol style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; margin: 0px 0px 0px 40px; padding: 0px; white-space: pre-wrap;"><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">We will take care of their patients when in pain.</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">We will stand behind the work we do for their patients.</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">We will treat their patients the same way that they do.</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">We will support their treatment plan.</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">They can contact our doctors directly at anytime with any question or concern.</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">Their patients will return more confident in their dentist and appreciative of their referral to SSE.</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">We will do everything possible to help them be successful.</span></span></li></ol><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-family: helvetica;"><br /></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-family: helvetica;">We know our partners:</span></div><ol style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; margin: 0px 0px 0px 40px; padding: 0px; white-space: pre-wrap;"><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">Respect our team and their efforts to serve their patients</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">Respect our time and are patient and flexible in getting their patients in </span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">They know our treatment is worth the cost. They encourage patients to see the value in coming to our practice regardless of insurance benefits or distance traveled. </span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-family: helvetica;"><span style="font-weight: normal;">See us as a valuable part of </span><span style="font-style: italic; font-weight: normal;">their</span><span style="font-weight: normal;"> dental team - not just an emergency service or someone to call to bail them out when they get in over their head.</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">See value in the work that we do for their patients. They recognize the expertise that comes with endodontic specialization.</span></span></li><li style="line-height: 1.2; margin: 0px; padding: 0px;"><span style="font-weight: normal;"><span style="font-family: helvetica;">Are comfortable calling our doctors directly to help them deal with any especially difficult case or situation.</span></span></li></ol><div><span style="font-family: helvetica;"><span style="color: #717a80;"><span style="white-space: pre-wrap;"><br /></span></span></span></div><div><span style="font-family: helvetica;"><span style="color: #717a80;"><span style="white-space: pre-wrap;">We understand that referral patterns in dentistry can change for many reasons. The previous study found that the longer a dentist was in practice, the more positively they perceived their endodontist colleagues. Younger doctors were more likely to say that economics of treatment and their availability are more important factors when deciding whether to perform or refer to an endodontist. As doctors become more experienced, better acquainted, as professional relationships grow stronger through improved communication and experience together and as teams get to know each other and work together partnership improves. Sometimes doctors are discouraged from referring to endodontists because of their employment status as an associate dentist. Sometimes an owner doctor gets busy enough to choose procedures that are more profitable for them (crown & bridge) or they just get tired of searching for the MB#2 and look to build a partnership with an endodontist.</span></span></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-family: helvetica;"><br /></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-weight: normal;"><span style="font-family: helvetica;">Our mature partners (and by mature I do not mean age) express to us that they feel that relieved sending their patients to SSE because they know the experience their patients will have and how it will move them forward in their treatment plan. While many of these partners may still perform some endodontic treatment, they become experts at diagnosis and case selection. They recognize the cases that will save them time and money by referring rather than treating. If you could ask them, they would explain that they are more successful and profitable by the working partnership they have with SSE.</span></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-weight: normal;"><span style="font-family: helvetica;"><br /></span></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-weight: normal;"><span style="font-family: helvetica;">Because of our value "Partner for Success", our partners are given the highest priority in our schedule. While we try to accommodate everyone who needs to be seen, our partners are given priority over self-referred patients, online referred patients or patients from offices that we don't have an established and working partnership.</span></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-family: helvetica; font-weight: normal;"><br /></span></div><div style="caret-color: rgb(113, 122, 128); color: #717a80; font-weight: bold; white-space: pre-wrap;"><span style="font-family: helvetica; font-weight: normal;">We appreciate working with the best dental practices around and are always excited to make new partners. If you are looking for the kind of partnership described above, please let us know so that we can take the steps to build a stronger relationship with you and your team.</span></div>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-31760992837518686862021-02-08T14:33:00.002-08:002021-02-08T14:33:36.258-08:00How to Manage Your Debt So It Doesn't Manage You<p></p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="407" src="https://www.youtube.com/embed/I9roa6RPlog" width="490" youtube-src-id="I9roa6RPlog"></iframe></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;">At our last Inner Space Seminar, Dr. Danny Masters and attorney Amber Masters discuss financial principles to managing debt so it doesn't manage you.</div><br /> <p></p>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-47086207811368849252020-09-15T23:14:00.116-07:002020-09-16T09:02:13.658-07:00Aerosol Anxiety and COVID-19 Critical Thinking with Dr. Hessam Nowzari<p> </p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="405" src="https://www.youtube.com/embed/Y6fgIgAfkzQ" width="486" youtube-src-id="Y6fgIgAfkzQ"></iframe></div><br /><div class="separator" style="clear: both; text-align: center;">A big thanks to Dr. Hessam Nowzari, and his presentation, "Aerosol Anxiety and COVID-19 Critical Thinking" presented as an Inner Space Seminar. Hosted by Dr. Jason Hales and Superstition Springs Endodontics.</div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><b><br /></b></div><div class="separator" style="clear: both; text-align: center;"><b>HIGHLIGHTS</b></div><div class="separator" style="clear: both; text-align: left;"><ul style="text-align: left;"><li>After 8 or 9 months, those who claim we don't have enough data for proper decision making are misguided or naive.</li><li>Majority of current complications and deaths are based on decisions made upon flawed mathematical models. </li><li>COVID-19 is not a novel virus. COVID-19 shares 90% of its genome with other coronaviruses - which we have been exposed to historically. We already have some amount of cellular immunity to COVID-19 because of our prior exposure to other coronaviruses. COVID-19 is an RNA virus which, by probability, gets weaker as it is replicated.</li><li>The strength of the COVID-19 virus is the speed of contamination - not mortality rate.</li><li>The US has ignored many of our scientific colleagues in Taiwan, Japan, Sweden etc. and the information and warnings they gave us early on and the success that they are currently having.</li><li>We should expect to see increasing case positives and mortality rate as we move into October due to the regular flu season.</li><li>We know that our young people are safe.</li><li>We have to protect our elderly population and people with co-morbidities.</li><li>COVID-19 is very sensitive to soap & water. Wash your hands with soap and don't touch your face or eyes. You don't need alcohol or expensive chemicals that destroy your natural biome.</li><li>Every person has over 100,000 viral elements in their DNA. Viruses are part of who we are.</li></ul></div><b><div style="text-align: center;"><b>WHAT ARE WERE THE HIGHLIGHTS FOR YOU? PLEASE COMMENT.</b></div></b><p></p>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com1tag:blogger.com,1999:blog-6076433377834065112.post-75141043665532617202020-04-03T00:03:00.001-07:002020-04-03T00:03:33.793-07:00Your Brain and the COVID-19 Pandemic<div class="separator" style="clear: both; text-align: center;">
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The COVID-19 pandemic which has spread from China, through Europe and is now increasing in the United States, in addition to the reaction by the World Heath Organization, Centers for Disease Control, state governments, state dental boards and the non-stop media coverage, is causing tremendous anxiety and uncertainty among the dental community. Congress has enacted legislation (HB6201) to expand sick leave and the dramatically expand the Family Medical Leave Act (FMLA) which will now apply to business under 50 employees, causing dentists to scramble to decide how these changes could affect their business. The 2 trillion dollar stimulus package, S3548 Care Act, contains loans for small businesses to keep people employed provides some hope for dentists hoping to keep their teams in tact, but comes with the stress of trying to get approval before the money runs out. This environment has created tremendous anxiety and stress for dentists. Your practice needs leadership now more than ever! As leadership coach, Joel Small says, "Your leadership legacy is being forged right now!"<br />
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Modern neuroscience has come a long way with the devlopment of the fMRI (functional Magnetic Resonance Imaging). This technology allows researchers to see the brain in action by visualizing the neural activity in real time.<br />
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David Rock, of the Neuroleadership Institute, coined the term neuroleadership to describe the application of the findings of modern neuroscience to leadership. This article will help you understand how your brain works and provide some tips to help you to better manage your own anxieties and negative emotions and better communicate, teach, train and mentor your team.<br />
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<b>A Quick Summary:</b><br />
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The brain can be divided into the limbic system and the cortex.<br />
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The limbic brain is considered the primitive part of our brain because it is focused on survival. It is constantly scanning our world for threats and rewards. It the the emotional center of our brain and closely tied to memory. It has the ability to work at tremendous speeds and has inconceivable capacity. The limbic brain is the strongest part of our brain and will typically overpower/override our cortex. This part of your brain is causing you, and your team, to feel great anxiety in the current situation.<br />
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The cortex, and especially the prefrontal cortex (PFC) is the younger, conscious part of our brain. It is the center of conscious thought, reasoning, decision making, memorizing, inhibiting, recalling and moderating social behavior. The PFC is slower, limited in capacity and easily fatigued. While our cortex can easily be overpowered by the limbic brain, modern neuroscience shows that intentional or mindful use of our PFC can change the electrical activity of our brain. By consciously activating this part of your brain, you can inhibit some of the negative emotions and threats you and your team are currently feeling.<br />
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<b><i>Your</i> Brain During the COVID-19 Pandemic:</b><br />
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Right now, in the midst of the COVID-19 pandemic, your limbic brain is highly aroused and likely overpowering you prefrontal cortex, making it harder to make decisions and keeping you focused on the negative emotions and threats you are feeling. These threats include how to keep our teams employed, how to make rent, how to manage debt and cash flow, how to manage patient and employee concerns, how to interpret the laws that have been passed and applying and qualifying for loans with the CARE Act, just to name a few. Add to the fact that many employment lawyers and accountants are recommending layoffs or furlough for that team that you have worked with side by side for years. The 24 hour, non-stop media plays a huge role in activating a threat response in our brains to the current situation. Constant coronavirus headlines, drastic modeling predicting dire consequences make it worse day by day. Everything around you is stimulating the "fight or flight" reaction of the limbic brain. It's no wonder that we are all feeling threatened!<br />
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Overarousal of the limbic system overpowers and reduces the resources to the prefrontal cortex. This inhibits understanding, critical thinking, decision making, memorizing and inhibition, all of which you need to be the leader your practice. When the prefrontal cortex is overpowered, the we tend to do more "automatic" thinking and tend to respond more negatively to situations. We say things that we don't mean and that may trigger threats to the people around us. Because the limbic system is more affected by threats than rewards, you will find that threats to the limbic system come on faster, last longer and are harder to change. It becomes difficult to see the positive and we become more risk averse. We can only see the glass half full.<br />
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Neuroscience has shown that intentional use of the prefrontal cortex can change the electrical activity of the brain. The following techniques can be used to "put the brakes" on the negative emotions/anxieties that your limbic brain is currently focused on. These techniques can be helpful in every aspect of your life and help you as a leader.<br />
<ol>
<li><b>Symbolic Labeling:</b> The act of consciously putting words to the emotions that you are feeling, expressed to yourself or others, actually stimulates the right ventrolateral prefrontal cortex (RVLPFC) which is the center of inhibition for your brain. This will help inhibit the negative emotions/anxiety that you are feeling due the powerful limbic response of your brain.</li>
<li><b>Reappraisal:</b> Reappraisal is another conscious activity of the prefrontal cortex which has been scientifically shown to inhibit the limbic response of the brain. Reappraisal is the conscious activity of looking at your situation from different perspectives. This requires more focus and energy, but has been shown to be more powerful than symbolic labeling at changing your brain's activity. Reappraisal can be done in the following ways:</li>
<ol>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyHtV2XQO2HSCDWBkBt3e488Ksx5YIAfVAB6DY1ZUQS22NYWE-OtwjOqwTqTFm6xPIWlNLLFHoJAmEF8eNqSRZRi8lVF13wbUBjFy8-DtJlHRTiZ8HeKnkJ8LzgpsRH47weKODUUGm_NI/s1600/BrainLockIconWhiteSmall.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="773" data-original-width="655" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyHtV2XQO2HSCDWBkBt3e488Ksx5YIAfVAB6DY1ZUQS22NYWE-OtwjOqwTqTFm6xPIWlNLLFHoJAmEF8eNqSRZRi8lVF13wbUBjFy8-DtJlHRTiZ8HeKnkJ8LzgpsRH47weKODUUGm_NI/s200/BrainLockIconWhiteSmall.png" width="169" /></a>
<li><b>Reinterpreting</b>: Consciously choose to reinterpret your current situation. Look for the positives and find opportunities in your situation. For example, "I have time to re-evaluation our systems" or "I have time to get more CE done" etc.</li>
<li><b>Normalizing</b>: Take a few minutes to focus upon what is normal about your situation. For example, "I am in the same boat as all the other dentists around me. We are all working through this together. etc."</li>
<li><b>Reordering</b>: Consider reordering what your values are in the situation. "My team or family's health is the most important thing right now." "I have to make this tough to decision to protect our practice so our team can have a job in the future."</li>
</ol>
<li><b>Healthy Brain Habits: </b>Re-evaluate these habits in your life and prioritize them for better brain function.</li>
<ol>
<li>Sleep - get enough</li>
<li>Nutrition - find balance</li>
<li>Exercise - make time</li>
<li>Breaks - time correctly</li>
<li>Mindfulness Training - practice</li>
</ol>
</ol>
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Understanding how our brain works will not only help us in times of great anxiety and concern, but will also help us as leaders in our practices. Stay tuned for more brain hacks that will help you as a leader in your practice.</div>
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RESOURCES:</div>
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<br />The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-32306007669724696972020-04-01T13:15:00.002-07:002020-04-01T13:15:58.608-07:00Perspectives on the Pandemic - Interview of Dr. John Ioannidis of Stanford University<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/d6MZy-2fcBw/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/d6MZy-2fcBw?feature=player_embedded" width="320"></iframe></div>
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This is a follow up interview to his recently published <a href="http://www.theendoblog.com/2020/03/dr-john-p-ioannidis-questions-decision.html" target="_blank">article</a>. I think you will find this a fair, balanced, rational and "science-first" approach to data surrounding the COVID-19 pandemic.The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-15442727423411612362020-03-27T14:58:00.004-07:002020-03-27T15:07:07.615-07:00Coronavirus Aid, Relief and Economic Security Act (Care Act) Passes the HouseThe CARE Act has just passed in the House of Representatives. Here are some of the initial provisions of the act, with more details to come:<br />
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The legislation passed by Congress contains several
provisions to provide emergency assistance for Small Businesses affected by the
pandemic. The next step is for the Small Business Administration (SBA) to
issue guidance to banks such as Chase on how and when to provide much needed
loans to our small business clients under the Act. We will update this
information as we learn more.<o:p></o:p></div>
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This is our current understanding of the provisions in the
bill for Small Business owners:<o:p></o:p></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .75in; margin-right: 0in; margin-top: 0in; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: "wingdings"; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->Paycheck
Protection Loan Program expands loan eligibility under the SBA 7a program with
the intention to assist businesses with covering costs related to payroll
(including healthcare and certain related expenses), mortgage interest, rent,
leases, utilities and interest on existing debt.<o:p></o:p></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .75in; margin-right: 0in; margin-top: 0in; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: "wingdings"; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->Borrowers
will need to certify that they’ve been impacted. There will be no
personal guarantees or collateral associated with the loan. Detailed
application requirements are still to be determined.<o:p></o:p></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .75in; margin-right: 0in; margin-top: 0in; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: "wingdings"; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->Loan
amount maximum is 2.5 times average monthly payroll or up to $10 million.<o:p></o:p></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .75in; margin-right: 0in; margin-top: 0in; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: "wingdings"; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->There
will also be a payment deferral and loan forgiveness program. <o:p></o:p></div>
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<br />
Summary provide by our partners at Chase Bank. More Details to come...The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-52658611481421898702020-03-18T19:02:00.002-07:002020-03-18T19:09:40.737-07:00Dr. John P.A. Ioannidis Questions the Decision Making Surrounding the CoVid-19 Pandemic<a href="https://profiles.stanford.edu/john-ioannidis" target="_blank">Dr. John P.A. Ioannidis</a><span id="goog_891988348"></span><span id="goog_891988349"></span><a href="https://www.blogger.com/"></a>, is a Professor of Medicine, Health Research Policy at Stanford University. He is a professor of statistics and one of two directors of the Meta-Research Innovation Center at Stanford (METRICS). In a recent article, he has weighed in on the evidence surrounding the current CoVid-19 pandemic and the drastic measures being taken to "flatten the curve". A must read in these times of panicdemic.<br />
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<a href="https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/">https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/</a></div>
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<div>
John P.A. Ioannidis MD - "<a href="http://www.theendoblog.com/search?q=John+Ioannidis" target="_blank">Why Most Research Findings are False</a>"</div>
The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-47983732141636404982019-08-14T22:41:00.001-07:002019-08-22T23:16:56.845-07:00The Buzz About Endodontic IrrigationThere is lots of discussion about Endodontic irrigation. The introduction of new technologies, such as Gentlewave, and the accompanying marketing associated with this product have increased the attention to the importance of endodontic irrigation. Many of you may remember the cliche you heard in dental school that if you properly clean the canal system, could could fill it with bird feces and it would be successful. While we know that bird feces would reintroduce bacteria into the canals - the funny point of the saying was to stress how important the cleaning of the canals is to the success of endodontic treatment.<br />
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Just like endodontic shaping techniques, there are multiple endodontic irrigation solutions and delivery techniques. Furthermore, there are myriads of combinations and concentrations of each of these irritants. To make this further cloudy, a <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008948.pub2/abstract" target="_blank">Cochrane Systemic Review</a> of endodontic irrigants reports "<span style="font-family: "timesnewromanpsmt"; font-size: 12pt;">Although root canal irrigants such as sodium hypochlorite and chlorhexidine appear to be effective at reducing bacterial cultures when compared to saline, </span><span style="font-family: "timesnewromanpsmt"; font-size: 12pt;">most of the studies included in this review failed to adequately report these clinically important and potentially patient-relevant outcomes. <i>There is currently insufficient reliable evidence showing the superiority of any one individual irrigant.</i> The strength and reliability of the supporting evidence was variable".</span><br />
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For the purpose of the is article, we will consider NaOCl as the gold-standard, most used irrigant in the world and will avoid the discussion about concentration (although I prefer full strength).<br />
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Delivery of the NaOCl irrigation can be done several ways:<br />
<br />
<b>Passive Irrigation</b> - syringe only with instrumentation files pushing the irrigation to the apex<br />
<b>Active Irrigation</b> - sonic or ultrasonic energy used to stir or active the irrigation throughout the canal system<br />
<b>Lasers Activation</b> - use of laser irradiation is typically recommended in addition to traditional NaOCl irrigation protocols<br />
<a href="http://www.theendoblog.com/search/label/GentleWave" target="_blank"><b>GentleWave</b></a> - combination of acoustic and hydrodynamic energy to deliver irrigants through canal system<br />
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In our practice at Superstition Springs Endodontics, we have been using active irrigation for years, starting with ultrasonic and now currently using sonic activation on every case. We have found that with adequate irrigation time, sonic activation and removal of the smear layer (using EDTA), we are finding and filling more and more lateral canals, accessory canals, apical deltas. (The use of radiopaque sealers also increases the visibility) In my opinion, its difficult to say how much of this is attributed to the removal of the smear layer - but I expect that it is a combination of the active irrigation and removal of smear layer.<br />
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Here are a few of the cases demonstrating the benefits of active, sonic irrigation and smear layer removal.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhQPuGFUOikaGZAJb8R0ar_Bq_Kw5UlcrnbNg8FgUprWBCT6ztQZkam6qdbUj0IUC-K2LXzcM1km-u79mc2mouI8cOGdTEMEln3-x4nk-ZAB0CWjO3gzkAbdeRnf6ROWBGygDZXtC7z10/s1600/LateralCanalsCollage.jpg" imageanchor="1"><img border="0" height="217" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhQPuGFUOikaGZAJb8R0ar_Bq_Kw5UlcrnbNg8FgUprWBCT6ztQZkam6qdbUj0IUC-K2LXzcM1km-u79mc2mouI8cOGdTEMEln3-x4nk-ZAB0CWjO3gzkAbdeRnf6ROWBGygDZXtC7z10/s400/LateralCanalsCollage.jpg" width="400" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEim5dsnhbQwxo17Rp8MnYBh5btZPpybRCqv5IecC-R9MVxrFHFqI3YjKjM4Le-CnCmNaGXuukeFjlpuRQ_vHccylvZWLNHZQZY8i3Ylw7f9_QkCo1iuHgNtHdWz_EO692dRkjt-784diKs/s1600/ThrillofFillCollage2.jpg" imageanchor="1"><img border="0" height="363" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEim5dsnhbQwxo17Rp8MnYBh5btZPpybRCqv5IecC-R9MVxrFHFqI3YjKjM4Le-CnCmNaGXuukeFjlpuRQ_vHccylvZWLNHZQZY8i3Ylw7f9_QkCo1iuHgNtHdWz_EO692dRkjt-784diKs/s400/ThrillofFillCollage2.jpg" width="400" /></a><br />
<br />
So as you can see, the proper cleaning, shaping, active irrigation and removal of smear layer of the canals allows for us to open the lateral, accessory and apical deltas that we know exist in the complex canal anatomy.<br />
<br />
Whether this changes the outcomes or success rate of the endodontic procedure is unknown, but it sure looks pretty!<br />
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<br />
Related Articles:<br />
<a href="https://www.ncbi.nlm.nih.gov/pubmed/30264624" target="_blank">Passive ultrasonic irrigation in root canal: systematic review and meta-analysis.</a><br />
<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089055/" target="_blank">Endodontic irrigants: Different methods to improve efficacy and related problems</a><br />
<a href="https://www.ncbi.nlm.nih.gov/pubmed/29372445" target="_blank">Effectiveness of ultrasonically activated irrigation on root canal disinfection: a systematic review of in vitro studies.</a><br />
<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872808/" target="_blank">The Use of Lasers in Disinfection and Cleanliness of Root Canals: a Review</a><br />
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<br />The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-71949147996050148472019-02-26T11:01:00.001-08:002019-02-26T11:01:48.003-08:00"The Root Cause" Netflix Documentary & Psuedoscience: A Recipe for Confusion<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJNeVdLFxlVxW0cZ9ICeJulPG8vJjJmDOVo16_c-l0b_uh11IpsUnrcw4LCOE5Y5_Wr4WCZcBRVjJEPxkxjP0l40QAE3RUkLvmG1oLAqu03MNReMv4tdXNUS1QlWCcBYRk-BQ-7443IiE/s1600/RootCauseFlyer.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: inherit;"><img border="0" data-original-height="1600" data-original-width="1050" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJNeVdLFxlVxW0cZ9ICeJulPG8vJjJmDOVo16_c-l0b_uh11IpsUnrcw4LCOE5Y5_Wr4WCZcBRVjJEPxkxjP0l40QAE3RUkLvmG1oLAqu03MNReMv4tdXNUS1QlWCcBYRk-BQ-7443IiE/s400/RootCauseFlyer.jpg" width="262" /></span></a><span style="font-family: inherit;">A recent trending documentary on Netflix, titled "The Root Cause", has garnered the attention of patients and dentists alike. The documentary tells the dramatic story of a man's search for the solution to his health problems only to discover that a root canal treated tooth was the cause. Multiple "experts" from the fields of biological dentistry and alternative medicine opine on the dangers of root canals, titanium implants and cavitational lesions from improperly done tooth extractions. In the end, people are encouraged to seek out biological dentists to prevent a whole host of health issues from heart disease, cancer, MS and a host of other chronic diseases.</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Some of the outrageous claims made in this documentary include:</span><br />
<ul>
<li><span style="font-family: inherit;">"The vast majority of chronic degenerative diseases begin with problems in the mouth, infections and toxins, and it is only until those are addressed that you are going to get any clear positive response with your disease.</span></li>
<li><span style="font-family: inherit;">"70-90% of all medical problems originate in the mouth"</span></li>
<li><span style="font-family: inherit;">"Data that we have just recently gotten shows now that the #1 cause of heart attack is a root canal treated tooth. Plain and simple. Not correlation, not link, cause and effect"</span></li>
<li><span style="font-family: inherit;">"Conventional dentistry believes that you should save a tooth at all costs and if the patient dies, well that is the price of saving the tooth. They don't really come with the concept that you should take things that are dead out of the body."</span></li>
<li><span style="font-family: inherit;">"All root canals are infected without any exception."</span></li>
<li><span style="font-family: inherit;">Every tooth connects up energetically through a meridian system to certain organs or glands. Root canal treatment disrupts this normal flow of energy and causes problems with the other tissues of the body on those same meridian lines.</span></li>
</ul>
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2C9x-LHHEiz0OUAKKpmS4u7ehe4Iqi2f1HOcl_rmwsP57e1KgwxEfnN5CObcNlqDaPQtoKGuxfnf_2QDy6MSvQNyNWYDaqRYC5jiBcWyNpmb5YaMIf7GjlitWpmxy7romQV35pim5hOo/s1600/Westonaprice2.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="371" data-original-width="268" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2C9x-LHHEiz0OUAKKpmS4u7ehe4Iqi2f1HOcl_rmwsP57e1KgwxEfnN5CObcNlqDaPQtoKGuxfnf_2QDy6MSvQNyNWYDaqRYC5jiBcWyNpmb5YaMIf7GjlitWpmxy7romQV35pim5hOo/s200/Westonaprice2.JPG" width="144" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr. Weston Price 1870-1948</td></tr>
</tbody></table>
<span style="font-family: inherit;">The documentary references the work of Dr. Weston Price in the 1920's and the resulting focal infection theory. While Dr. Price's research was creative at the time, it was primitive and would never stand up to modern scientific standards for research. His research, done in the dawn of what we would call modern microbiology, is still quoted by biological dentists, such as Joseph Mercola, George Meinig and the others in this documentary, as the evidence to support their claims.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div>
<span style="font-family: inherit;">In 2006, Dr. Micheal Barnett wrote, "By the 1930's the validity of the focal infection theory began to be questioned, and investigators found, when they considered the available real outcome data, that there was no clear basis for ascribing the occurrence of much systemic disease to the presence of oral foci of infection. as a result, the focus of dental practice changed such that restorative dental procedures re-emerged as the mainstay of most dental treatment plans."</span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<span style="font-family: inherit;">In 1951, the Journal of the American Dental Association devoted an entire issue to addressing the concept of focal infection and Dr. Price's theory. It was determined that Dr. Price's research lacked many aspects of modern, scientific research, including absence of proper control groups and induction of excessive doses of bacteria. These findings shifted the standard of practice back to endodontic treatment for treatment of teeth with non-vital pulp.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div>
<span style="font-family: inherit;">The American Association of Endodontist has published that "since that time, decades of research contradict the beliefs of the "focal infection" proponents; there is no valid, scientific evidence linking endodontically treated teeth and systemic disease."</span></div>
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<span style="font-family: inherit;">In today's digital world, with the ability to create, publish and distribute digital media, misinformation and myths can live on forever. For example, a 2012 paper by Joseph Mercola, and the recent Netflix documentary, cite the <a href="https://www.snopes.com/fact-check/root-canal-cancer/?fbclid=IwAR1henm3j_EIR8PtQO7MsmordykBMbokRPdhYEb28_F4BuXsftANtD2fC18" target="_blank">recycled claim</a> attributed to Dr. Josef Issels, a German physician, who reported that in his 40 years of treating cancer patients, 97% of his cancer patients had root canals. In today's day and age of fake news, we might also describe these types of claims as "fake science" or pseudoscience. The anecdotal and epidemiological studies quoted in the Netflix documentary are misleading and designed to create fear.</span></div>
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<span style="font-family: inherit;"><b>The Problem With Epidemiological Studies</b></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJyR1nBqj5Oz8f-Lj7ajPYZ73l81dUKs5EmOvPsTphDBZoGs-rKDpDwwnjjT8dDs5B27DMO50JChdT4lcS6vCXbQo1Eua20W7PfXvk4dUwoOMbb3I8H0vlfa7eWAoxMpfMeVTwqioVJUI/s1600/Unknown.jpeg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: inherit;"><img border="0" data-original-height="250" data-original-width="202" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJyR1nBqj5Oz8f-Lj7ajPYZ73l81dUKs5EmOvPsTphDBZoGs-rKDpDwwnjjT8dDs5B27DMO50JChdT4lcS6vCXbQo1Eua20W7PfXvk4dUwoOMbb3I8H0vlfa7eWAoxMpfMeVTwqioVJUI/s1600/Unknown.jpeg" /></span></a></div>
<span style="font-family: inherit;">In a recent discussion with <a href="https://www.beverlyhillsperioimplant.com/" target="_blank">Dr. Hessam Nowzari DDS, PhD</a>, an expert clinician, educator and scientist, he explained the problem with these types of studies. He said, "If you are using epidemiological studies, you can find correlations between anything. You can find that people with cancer that had root canal treatment. But what people don't realize is that you can also find that those people were wearing shoes, but that does not mean that wearing shoes causes cancer! That's the problem with epidemiological studies. <b><i>Epidemiological studies have no right to make any conclusions whatsoever, and they do it all the time</i></b>. Epidemiological studies are routinely used because we are lazy with our research. We don't do long term studies, or prospective studies because we are lazy...there is no accountability and you can say whatever you want." He continued, "That is why we need Bayesian statistics. We cannot have epidemiological studies and we cannot only use this nonsense of p-value. When you start measuring p-value you are measuring so many different outcomes, sooner or later you can find a relationship and then you can justify it with p-value. Take for example this argument...If you go to bed with your shoes, when you wake up you will wake up with a headache. What's the problem here? Is it the shoes? No - the problem is that people who go to bed with their shoes on are usually drunk! The cause of the headache is the alcohol, not the shoes. But if you didn't know about the alcohol, you might argue that the shoes caused the headaches. We have so many of these nonsense types of statements."</span><span style="font-family: inherit;"><b><br /></b></span><br />
<span style="font-family: inherit;"><b>The Tooth is Not Dead!</b></span><br />
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<span style="font-family: inherit;">When discussing the Netflix documentary's claim that a root canal treated tooth is dead and dead tissues should be removed, Dr. Nowzari stated... "First, <b><i>when you do a root canal, the tooth is not dead.</i></b> Even after a root canal, the tooth has bone, ligament, gingival fibers, transeptal fibers, periosteal fibers, innervation, circulation all of which is very much alive. When you go inside the root and do a root canal, it does not affect the system or the rest of the dental organ. The periodontium is still there, intact and very much alive."</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIQFJRLRYfUjU2okfUZNJcn8AfX1xf1gwROxjfnyoNI9987ia_gaPcXdcQoaTzvJRIGqMnVI-7hMw28IVbVfpVlcGVsBUwYP__8gD0qa48fgVB3p6LvDo3mMksfbjR5_o9DJQKDZYTsks/s1600/RCTHealsDentalOrgan.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><span style="font-family: inherit;"><img border="0" data-original-height="753" data-original-width="1600" height="186" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIQFJRLRYfUjU2okfUZNJcn8AfX1xf1gwROxjfnyoNI9987ia_gaPcXdcQoaTzvJRIGqMnVI-7hMw28IVbVfpVlcGVsBUwYP__8gD0qa48fgVB3p6LvDo3mMksfbjR5_o9DJQKDZYTsks/s400/RCTHealsDentalOrgan.jpg" width="400" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: inherit; font-size: small;">The dental organ includes the tooth, periodontal ligament, bundle bone, periosteal fibers, gingival fibers etc. All of these tissues are alive and vital following root canal therapy. These tissues are all considered part of the dental organ because they are derived from the same embryologic tissue. The periodontium belongs to the tooth and remains alive after root canal treatment.</span></td></tr>
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<span style="font-family: inherit;"><b>Stop Hating Bacteria!</b></span><br />
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<span style="font-family: inherit;">The Netflix documentary also makes the assumption that because we cannot completely sterilize the root canal system we should extract the tooth. It argues that if you cannot remove all the bacteria, then you will have a chronic problem. Endodontists agree that there is no way to "sterilize" a root canal. More accurately, we are removing necrotic tissue, disinfecting the canal system and sealing the canal with antimicrobial filling materials. Despite our inability to remove all bacteria from the canal system, we find complete resolution of symptoms, healing of the peridontium and a return to full function for the patient. Dr. Nowzari proposes that we need to take a new approach to looking at the microbiology.</span></div>
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<span style="font-family: inherit;">Dr. Nowzari explains:</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxao2QQL2RHDc_l42bl-O1JDZHKlwKzeIuppnxyx-lGgFKEPzBtCSiBb699dEt_3HJyLKSzrF7gvMJNl4uv1bLbPzxCMBPA3J7TPr47Fvgdcb3mu-2oeMtVodDiEXbQOapGi1fUGrWf1A/s1600/CyanobacteriaRolypothrix.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="440" data-original-width="440" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxao2QQL2RHDc_l42bl-O1JDZHKlwKzeIuppnxyx-lGgFKEPzBtCSiBb699dEt_3HJyLKSzrF7gvMJNl4uv1bLbPzxCMBPA3J7TPr47Fvgdcb3mu-2oeMtVodDiEXbQOapGi1fUGrWf1A/s200/CyanobacteriaRolypothrix.JPG" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Tolypothrix sp. of Cyanobacteria</td></tr>
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<span style="font-family: inherit;">You know for years, we have been trained to think that bacteria are our enemies. But they are not. They are our best friends. Only a very, very small percentage of microorganisms are dangerous. I would say that 99.9% of microorganisms are fantastic!. Microorganisms are responsible for the earth as we know it. They are responsible for the recycling of carbon and the recycling of all atoms. They are in the oceans, like cyanobacterium, responsible for the production of oxygen. Microorganisms are responsible for photosynthesis, production of vitamins, and coagulation. Fortunately, there are so many microorganisms in our eyes and ears and more than a thousand different species on our skin that are protecting us. I’m always surprised that we don’t die a hundred times every day because we are exposed to so many bacteria and viruses. The reason is that most viruses and bacteria are good for us. It’s a very small percentage of them that are harmful.</span></div>
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<span style="font-family: inherit;">Microorganisms are the first life on Earth. They go back to 4 billion years ago and they are still with us. The same cyanobacteria that gave us this gift of oxygen is still with us. They are still inside our mitochondria. Mitochondria has its own DNA because it was a microorganism. Our mitochondria is a result of symbiosis with bacteria. It is fascinating what microorganisms are doing for us!<o:p></o:p></span></div>
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<span style="font-family: inherit;">A fascinating thing to consider is that we have more microbial cells in our body than human cells. This is well known fact in microbiology. Our bodies are made up of about 50 trillion human cells. We have more bacterial cells than human cells. The day that we successfully kill the bacteria is the day we have eliminated life on earth.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmzO2djiGD1yqkA-GE-Cftt85Tp5aHQI6XswLvZe34H3Cvb7NzY-qDyIyGFSiqvnOTJfbKLIyigNzrAo9Fxfnw53iyr3pUI1otGzxAv-zTEpHAYIeolXlNC4uGc8jTSTRGFGkwLw86exY/s1600/DNA.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="691" data-original-width="694" height="316" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmzO2djiGD1yqkA-GE-Cftt85Tp5aHQI6XswLvZe34H3Cvb7NzY-qDyIyGFSiqvnOTJfbKLIyigNzrAo9Fxfnw53iyr3pUI1otGzxAv-zTEpHAYIeolXlNC4uGc8jTSTRGFGkwLw86exY/s320/DNA.jpg" width="320" /></a></div>
<span style="font-family: inherit;">For example we have 100,000 vital elements in our DNA. We call those antique viruses, or domestic viruses. These are viruses that attacked us 2-4 million years ago and we domesticated them. Today they are providing us flexibility. So when we get attacked by these viruses we know them, they are who we are. So first off, we have to recognize that bacteria are our best friends. Microrganisms are the best chance we have. We have to stop hating bacteria and start loving them!"</span></div>
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<span style="font-family: inherit;">Every time you eat, you send billions of microorganisms into your system. Everytime you floss you send billions of microorganisms into your gingiva and your system. You are not dying because they know who we are. People need to realize that we are bacterial ourselves. We are of one entity. It is not humans vs. bacteria. We are bacterial. We share our DNA with them. We are all tied together in this universe and bacteria are an important part of that.<o:p></o:p></span></div>
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<span style="font-family: inherit;">We have to change our understanding and prejudice against microorganisms. Our focus on “anti-bacterial” or “anti-microbial” treatments and products and overuse of antibiotics is killing our best friends. Many of these products that we have developed and are overusing are cycling back into our environment. These are the real environmental threats that we face today. We have to change our educational system. We need to teach our medical students that “anti-bacterial” or “anti-microbial” makes no sense whatsoever. We have to stop it.</span></div>
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<span style="font-family: inherit;">The problem with these charlatans (referring the "doctors" in the Netflix documentary) is they just don’t understand microbiology! They think that microbes are our enemies. Do you really believe that our immune system could protect our nasal cavity from what’s going on outside in our environment? No, it’s all because of the microorganisms. That’s our first line of defense. But in medical school, they teach our first line of defense is macrophages, antibodies, neutrophils. That is not true! Our first line of defense are microorganisms, so we better start loving them again!<o:p></o:p></span></div>
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<span style="font-family: inherit;">When I was the director of periodontics, we did lots of periodontal surgery. We never gave antibiotics to patients after periodontal surgery and nobody ever died. Why? You open the gum, reflected a flap, touched the bone, you put it back and sent them home and nobody ever died. Why? Because of protective bacteria! Now since we are using allografts, alloderms, we give antibiotics. Not to protect the patients, but to protect the product!</span></div>
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<span style="font-family: inherit;">Over the last 30 years, we have entered a period of endarkenment. Who is responsible for this endarkenment? Psuedoscientists. Now we are using epidemiological studies and everybody is a doctor. Psuedoscience is pushing us back into endarkenment. Forget about the enlightenment. People are shocked to hear these kind of things because we have been brainwashed in medical school. Bacteria are bad. Talk to any medical student. Wash or don’t wash your hands five million times a day – nothing is going to happen. Go to the airport – and watch people wiping down the chairs. They don’t realize that contamination is all over the place and the reason nothing happens to us is that microbes are our friends. We need to stop being so sarcastic about microorganisms. We have to get to know them again. We have to understand that Earth would not be what it is today without microorganisms.</span></div>
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<span style="font-family: inherit;"><b>Bacteria and Root Canals</b></span><br />
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<span style="font-family: inherit;">Dr. Nowzari explains: Dentists are trained to think that bacteria are the problem with necrotic teeth. But the problem is the necrotic tissue and the enzymes that are released with necrosis. For example, what is more dangerous, living <i>p. gingivalis</i> or dead <i>p. gingivalis</i> which releases endotoxin? So the problem is necrosis of tissue, and then when the microbes come later, we blame them for the necrosis. We need to tell patients that their tissue is necrotic and a root canal will remove the necrotic tissue. That’s why endodontics works. We can never eliminate microorganisms. A very small percentage of the time do microorganisms cause failure. But what is our failure rate? By far, much less than implants. And up to now, they are still not capable of generating papilla between two implants. If they are so wonderful, so successful, so bright, just give me 2 mm of papilla and I’ll give you the Nobel Prize! A tooth with a root canal does not lose the papilla.</span></div>
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<span style="font-family: inherit;">The root canal has passed the test of time. Gutta percha is still the best. At the apical part of the root canal tooth we have an microbial ecosystem, a microbial community. There is no question that that community is protecting us. Yes, if you look at the inside of the root canal, there are microorganisms. So? So? Why do you think that because there are microorganisms that is a bad thing? That microbial ecosystem between the end of the root canal and the bone is a community and it is protecting us…Having said that, when you have an abscess, it is a planktonic type of problem. It is not an ecosystem or biofilm problem. For whatever reason, the bacterial infection is powerful enough to cause the abscess.</span></div>
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<span style="font-family: inherit;"><b>Bacteria Hasn't Changed, We Have!</b></span><br />
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<span style="font-family: inherit;">We have to stop hating microorganisms. We have to start knowing them again. We have to start appreciating them. We have to start to know them if we want to know ourselves.<o:p></o:p></span></div>
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<span style="font-family: inherit;">If you look at the skulls from a million years ago. They did not have cavities, yet they had the same microorganisms as we have today. Our lifestyle has changed. With that change in lifestyle, we are encouraging the formation of cavities. We change our lifestyle and then we accuse the bacteria of the change, the same bacteria that have been with us for millions of years. We are consuming sugar, 1.2 million people die every year because of sugar, but we don’t attack sugar. We attack bacteria. Why do we accuse the microorganisms of causing the problem when what changed was our lifestyle. The microorganisms that have been with us and have not changed in millions of years. We have changed our lifestyle and then we look for something to blame and that is usually the bacteria.<o:p></o:p></span></div>
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<span style="font-family: inherit;">We must understand that we are all in the same boat. And by all I mean us, dogs, rabbits, birds etc. We are all truly a part of this universe because our DNA is the same. We are all cousins...We have to start to know the other members of our universe. We have to study bacteria. There is an interconnectivity of the members of this universe and we should be really grateful for this. This is really the beauty of life. That is the miracle of life!</span></div>
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<span style="font-family: inherit;"><b>Conclusion</b></span><br />
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<span style="font-family: inherit;">The Root Cause is a non-sensical, non-scientific </span>advertisement<span style="font-family: inherit;"> for holistic dentistry. The 100 year old research used to justify its claims do not stand up to modern, scientific scrutiny. The misinterpreted </span>ep<span style="font-family: inherit;">idemiological s</span>tudies used to support their claims should be considered psuedoscience. The whole premise of the documentary is based on a misunderstanding of microbiology and the role of bacteria in our teeth, bodies and lives. We will never be able to eliminate bacteria from our teeth, mouth, bodies, communities or world. If we did, our lives and world would cease to exist as we know it. Bacteria provide more benefits and protection for us than we give them credit for. Root canal treated teeth are not dead and do not need to be removed. Root canals allow for dead, pupal tissue to be removed providing a cost effective way for patients to retain their natural teeth and the beauty, form and function that only a tooth can provide.</div>
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<b>Learn More!</b><br />
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The past few years have presented an exponential increase in our understanding and knowledge in a variety of scientific and technological endeavors. Scientists and researchers from different backgrounds have been invited to present their unique research at the upcoming <a href="https://www.nowzarisymposium.com/" target="_blank">Nowzari Symposium</a> on Friday, May 10th in Beverly Hills, CA. Dr. Nowzari will present more information about "How our microbes make us who we are".</div>
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<span style="font-family: inherit;"><b>Sources:</b></span></div>
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<span style="font-family: inherit;">Barnett, Michael L. "The Oral-Systemic Disease Connection. An Update for the Practicing Dentist". 2006. JADA vol. 137, p 5S-6S.</span></div>
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<span style="font-family: inherit;">Root Canal Safety: AAE Fact Sheet 2004</span></div>
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<span style="font-family: inherit;">Personal interview with Dr. Hessam Nowzari DDS, PhD on 2/21/2019</span></div>
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Johnson, Marcus. "The Truth About Endodontic Treatment and Your Health. https://www.deardoctor.com/inside-the-magazine/issue-37/root-canal-safety/</div>
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The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-18367916576411060772019-01-17T08:00:00.000-08:002019-01-17T10:19:22.912-08:00HIPPA Compliance and SSE Patient Reports<div class="separator" style="clear: both; text-align: center;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPiX6kUP1facdMwRs4hIwAbokSDKBhKFK8CqnkP8niyAqR9O5ThJGfPdtx92TtEWepq0JcUkVI71WTYX1oYVAINdGp_LuWJpd9ID7tXRcTyRl8_z_4PHYuqD9EZ8-WDI6ZZ38yljbw8ik/s1600/HIPPA.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;"><img border="0" data-original-height="692" data-original-width="692" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPiX6kUP1facdMwRs4hIwAbokSDKBhKFK8CqnkP8niyAqR9O5ThJGfPdtx92TtEWepq0JcUkVI71WTYX1oYVAINdGp_LuWJpd9ID7tXRcTyRl8_z_4PHYuqD9EZ8-WDI6ZZ38yljbw8ik/s200/HIPPA.jpg" width="200" /></span></a><span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">At Superstition Springs Endodontics, we have been discussing the secure, electronic reports that we send back to our referring offices. As you can imagine, when working with different offices with different email services, each computer with different mail settings, security settings on different networks, doctors and team members reading reports on handheld as well as desktop computers and last but not least, human error, there is likely to be some complications along the way. Our recent upgrade to TDO endodontic software was significant technology investment was meant to improve our HIPAA compliance.</span></span><br />
<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "georgia" , "times new roman" , serif;">What is HIPAA? <span style="font-weight: normal;"> Title II of the 1996 Health Insurance Portability and Accountability Act (HIPAA) has broad implications in health care - which includes dentistry. This law created multiple rules & regulations for various purposes. These regulations include a privacy rule, security rule, breach notification rule and an enforcement rule with civil authority to levy monetary penalties for HIPAA violations.</span></span></span><br />
<br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "georgia" , "times new roman" , serif;">The Privacy Rule: <span style="font-weight: normal;">You are likely most familiar with this rule. This rule gives patients certain rights over their personal health information which includes dental records and billing records. This rule gives patients the right to ask for a change in their records, ask health care provider not to disclose their health information to others, or accommodate the patients requests regarding how they communicated with the patient.</span></span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "georgia" , "times new roman" , serif;"><span style="font-weight: normal;"><br /></span></span></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "georgia" , "times new roman" , serif;">The Security Rule:<span style="font-weight: normal;"> This rule puts the burden on the dental practice to have a written risk assessment and develop practice safeguards to protect the confidentiality, integrity and availability of electronic patient information. These safeguards are categorized as 1. Administrative 2. Technical 3. Physical This is a tall order in that these safeguards must make sure that patient data is not corrupted or changed without authorization, and that only authorized people have access to patient data while at the same time making it available for authorized persons to access the information whenever needed. "The HIPAA Security Rule also requires ongoing maintenance of safeguards, periodic risk assessments, workforce training, and documentation."</span></span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "georgia" , "times new roman" , serif;"><span style="font-weight: normal;"><br /></span></span></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Breach Notification Rule:<span style="font-weight: normal;"> The new law enforced the adoption of EHRs for Medicare and Medicaid providers which had a greater impact on our physcians colleagues. The Health Information Technology for Economic a</span><i style="font-weight: normal;">nd Clinical Health (HITECH) Act also created the Breach Notification Rule w</i><span style="font-weight: normal;">hich requires dental practices to provide notification of breaches of unsecured patient information to the patients, the federal government and in some cases the media.</span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-weight: normal;"><br /></span></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Enforcement Rule: <span style="font-weight: normal;"> The enforcement rule has authorized enhanced civil monetary penalties for non-criminal violations of HIPAA rules since February 18, 2009. While there is not a big history of dentists being fined for non-compliance issues, Dr. Joseph Beck was the first dentist to be fined $12,000 for non-compliance with HIPAA rules by the office of the Indiana attorney general. The Health and Human Services Office of Civil Rights (OCR) also has the ability to audit dental practices and issue fines/penalties.</span></span><span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Omnibus Final Rule: On January, 17, 2013 the HHS published the HIPAA Privacy and Security Omnibus Rule which created a compliance deadline of September 23, 2013. The Omnibus Final rule reinforces the HIPAA rules and regulations and:</span></span><br />
<ul>
<li><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">extends the privacy and security rules to the dental practice's business associates and their contractors (any contractor who has access to patient information)</span></li>
</ul>
<ul>
<li><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">establishes new limitations on use of patient data for marketing and fundraising purposes</span></li>
</ul>
<ul>
<li><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">prohibits sale of patient's personal health information without authorization</span></li>
</ul>
<ul>
<li><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">expands patients' rights to request and receive electronic copies of personal health information</span></li>
</ul>
<ul>
<li><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">broadens patients' ability to restrict disclosure of personal health information to health insurance plans</span></li>
</ul>
<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Does HIPAA apply to your practice?<span style="font-weight: normal;"> Yes! HIPAA rules apply to your practice if you are a "covered entity" under the law. You are considered a "covered entity" if you or a third party clearinghouse that you hire transmit electronic claims to a dental plan.</span></span><span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">What doest that mean for my practice? If you are a "covered entity" then you need to take steps to comply with the HIPAA law which includes:</span></span><ul>
<li><span style="color: #404040; font-family: inherit; font-size: x-small;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">Appointing a practice HIPAA privacy official</span></span></li>
</ul>
<ul>
<li><span style="color: #404040; font-family: "arial" , "helvetica" , sans-serif; font-size: x-small; font-weight: normal;">Appointing a practice HIPAA security official</span></li>
</ul>
<ul>
<li><span style="color: #404040; font-family: inherit; font-size: x-small;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">Familiarizing yourself with the law</span></span></li>
</ul>
<ul>
<li><span style="color: #404040; font-family: inherit; font-size: x-small;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">Creating a HIPAA compliance team</span></span></li>
</ul>
<ul>
<li><span style="color: #404040; font-family: inherit; font-size: x-small;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">Performing a risk assessment</span></span></li>
</ul>
<ul>
<li><span style="color: #404040; font-family: "arial" , "helvetica" , sans-serif; font-size: x-small; font-weight: normal;">Deciding on your practice policies and procedures</span></li>
</ul>
<ul>
<li><span style="color: #404040; font-family: "arial" , "helvetica" , sans-serif; font-size: x-small; font-weight: normal;">Training your workforce</span></li>
</ul>
<ul>
<li><span style="color: #404040; font-size: x-small;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">Update business associate agreements to comply with privacy and security rules</span></span></li>
</ul>
<ul>
<li><span style="color: #404040; font-size: x-small;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">Maintain</span></span></li>
</ul>
<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">You can order the ADA HIPAA compliance workbook to help walk you through the process of becoming fully HIPAA compliant at: <a href="https://ebusiness.ada.org/productcatalog/596/HIPAA/J598source=ADAorg&content=HIPAA&medium=button" target="_blank">click here</a></span></span><br /><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-weight: normal;"><br /></span></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">How does SSE secure patient communication work?<span style="font-weight: normal;"> </span><span style="font-weight: normal;">Our current software gives every referring doctor a username and password - allowing them to access all their patients reports, radiographs and relevant clinical data by logging into a secure server. When a consult or treatment has been completed in our office, you will receive an email to view that specific report or log into the server to access any patient report/data. However, every step of security also comes with the cost of added steps and login. Here are some of the trouble spots people have reporting using our secure communication tool:</span></span><br />
<ol>
<li><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;"><i>Clicking on the wrong hyperlink</i>: One hyperlink will take you to your specific patient's report and another hyperlink will take you to the server where you can access all of your referred patient's data.</span></li>
</ol>
<ol>
<li><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;"><i style="font-weight: normal;">Offices with multiple doctors</i><span style="font-weight: normal;">: Each doctor has their own login credentials to access the reports of the patient's they referred. Team members logging in on the doctor's behalf need to login with the correct doctor to access their patient reports. If you have multiple doctors, make sure you are logging in the with doctor's credentials who referred the patient to SSE.</span></span></li>
</ol>
<ol>
<li><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;"><i>Email settings</i>: Your email client (outlook, gmail etc.) may have a setting to string together emails from one source making it harder to find each individual report. Go to your preferences/settings to make changes in your email software application.</span></li>
</ol>
<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;">We are committed to making sure your patient's information is protected and that it is available to you when and where you need it. If you are having any problems accessing your reports, please contact us so we can make sure our electronic communications are working seamlessly.</span></span><br />
<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif; font-weight: normal;"><br /></span></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: inherit;"><i>Sources:</i></span></span><span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://www.ada.org/en/member-center/member-benefits/practice-resources/dental-informatics/electronic-health-records/health-system-reform-resources/hipaa-privacy-security">https://www.ada.org/en/member-center/member-benefits/practice-resources/dental-informatics/electronic-health-records/health-system-reform-resources/hipaa-privacy-security</a></span></span><br />
<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://www.ada.org/en/member-center/member-benefits/practice-resources/dental-informatics/electronic-health-records/health-system-reform-resources/hipaa-privacy-security"><br /></a></span></span><span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://www.hipaajournal.com/dental-offices-hipaa-compliance/">https://www.hipaajournal.com/dental-offices-hipaa-compliance/</a></span></span></h4>
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The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-83892993274694699422018-10-31T16:38:00.001-07:002018-10-31T16:38:40.435-07:00The Good, The Bad & The Ugly - now available for CE Credits on DentalTownIn case you missed this Inner Space Seminar presented at Superstition Springs Endodontics, it is now available on DentalTown.<br />
<br />
1.5 Hrs of CE credit available. <a href="https://www.dentaltown.com/onlinece/details/845/the-good-the-bad-the-ugly-finding-success-with-endodontics-in-your-practice">Click Here</a><br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIrcZrYtwSLd5mN7ipuIAChZGQKSqh_lUbiFd9oy5cj6rvLl2Hy39ZqRe6_ELRlncckaRNNqTJhzjPpFDI4JF7EaRL9AZoahhVm6XTee6V8yn3tQSl4dMXvn2q0jOoJ77ozjpyO8rMKt0/s1600/DentalTownCourse.jpeg" imageanchor="1"><img border="0" height="392" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIrcZrYtwSLd5mN7ipuIAChZGQKSqh_lUbiFd9oy5cj6rvLl2Hy39ZqRe6_ELRlncckaRNNqTJhzjPpFDI4JF7EaRL9AZoahhVm6XTee6V8yn3tQSl4dMXvn2q0jOoJ77ozjpyO8rMKt0/s640/DentalTownCourse.jpeg" width="640" /></a>The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-54164505015063990032018-08-30T13:05:00.000-07:002018-08-30T18:39:13.922-07:00What's the Deal With GentleWave?<!--[if gte mso 9]><xml>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Mention"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<br />
<div class="MsoPlainText">
We have been asked by many dentists regarding our
thoughts on a new irrigating technology called GentleWave by Sonendo Inc.<span style="mso-spacerun: yes;"> </span>After meeting with the GentleWave
representatives, an in-office demonstration, performing the procedure on
extracted teeth, discussing with colleagues using the product and critically
reviewing the clinical research<span style="mso-spacerun: yes;"> </span>on this
technology, we are prepared to answer the question so many of you have asked,
"What's the deal with GentleWave?"<br />
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgYMcWfTH6A1H5QNpaRofxHs1RwVM6Ex5Ix1XQent0kpdg1IRux_11wVcpcKmG_k0byyJgbuFGPKZGlVJG0V6cml66weNtewrik1Y_pw1Y4i7tJAz9heKeDXnCv74jhFeu-dvj4DiJ5mKA/s1600/8a.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1080" data-original-width="1382" height="250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgYMcWfTH6A1H5QNpaRofxHs1RwVM6Ex5Ix1XQent0kpdg1IRux_11wVcpcKmG_k0byyJgbuFGPKZGlVJG0V6cml66weNtewrik1Y_pw1Y4i7tJAz9heKeDXnCv74jhFeu-dvj4DiJ5mKA/s320/8a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">"Thrill of the Fill" accomplished using the EndoActivator</td><td class="tr-caption" style="text-align: center;"><br /></td></tr>
</tbody></table>
<div class="MsoPlainText">
At SSE, we have been early adopters of many new, and
lasting technologies in endodontics such as microscopes and CBCT.<span style="mso-spacerun: yes;"> </span>Our process in adapting a new technology,
like GentleWave, is to carefully evaluate the technology, including the claims
made by the manufacturers and a critical evaluation of whether the published
evidence supports those claims.<br />
<br /></div>
<div class="MsoPlainText">
<span style="mso-spacerun: yes;"> </span>It is also
important to evaluate the financial side of any large investment to make sure
that it is a fiscally sound decision that makes sense for our patients<span style="mso-spacerun: yes;"> </span>and our practice.<span style="mso-spacerun: yes;"> </span>Failure to do so leaves a practice in a
position where a financial commitment to a technology then determines how the
technology is applied to the patient's care.<br />
<br /></div>
<div class="MsoPlainText">
In the #1 bestselling book, Good to Great by Jim Collins,
he makes a point about<span style="mso-spacerun: yes;"> </span>our
"cultural obsession with technology and technological-driven change".
Nowhere can you find a group of professionals more obsessed with technology
than in dentistry!</div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQCS4ymvYxC1CdlqiBg3LuRYxhoLqrsQfnYs8quQ7OWvbK90ORrEBw_GALrT2JrPYt172taUBJ-atXxHX3MHMAfaL9ICVL81Q8X5MaeuCVkWZ0LDRz2DlEotMP1uNVqgo_eASciOcuQGo4/s1600/12a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1080" data-original-width="1382" height="250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQCS4ymvYxC1CdlqiBg3LuRYxhoLqrsQfnYs8quQ7OWvbK90ORrEBw_GALrT2JrPYt172taUBJ-atXxHX3MHMAfaL9ICVL81Q8X5MaeuCVkWZ0LDRz2DlEotMP1uNVqgo_eASciOcuQGo4/s320/12a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">EndoActivator</td><td class="tr-caption" style="text-align: center;"></td></tr>
</tbody></table>
<div class="MsoPlainText">
However, in Collins extensive study of what made good
companies become lasting, great companies, he noted that the great companies
"maintained a balanced perspective on technology, while most companies
become reactionary, lurching and running about like Chicken
Little..."<span style="mso-spacerun: yes;"> </span>Collins finds that
technology alone is never a primary cause of either greatness or decline.<br />
<br /></div>
<div class="MsoPlainText">
If you are following the information that the GentleWave
manufacturer is delivering to offices throughout the greater Phoenix area it is
obvious they are making a sizable marketing investment. With a clever marketing
approach, they have included in the purchase price of the system, a marketing
budget to promote the system and the practice who has invested in it.<span style="mso-spacerun: yes;"> </span>You have likely received several invitations
to CE events promoting the technology. There are several phrases being used by the sales-force to
excite dentists about GentleWave such as "the thrill of the fill",
"this is the new standard of care",<span style="mso-spacerun: yes;">
</span>"anatomy like never before seen" and "becoming part of
the club". There appears<span style="mso-spacerun: yes;"> </span>be an
effort by the manufacturers and early adopters to create an impression that the
evidence is in and this technique is proven to be superior to conventional
irrigation methods.<span style="mso-spacerun: yes;"> </span>If you are not
adopting the technology now, you will be left behind...<br />
<br /></div>
<div class="MsoPlainText">
A short summary of our decision regarding the GentleWave procedure as to why we have decided not invest in
the technology yet because it will cost patients more, increase treatment time,
and decrease our productivity without clinical evidence of improved outcomes was posted on the blog several months ago.
We will continue to watch the technology, its improvement and evaluate<span style="mso-spacerun: yes;"> </span>the evidence published over time.
<br />
<br /></div>
<div class="MsoPlainText">
The following sections provide more detail into our
evaluation regarding the claims made by GentleWave.</div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
<b>What Does the Research Say About GentleWave?</b></div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
The initial clinical study which made claims of 97% success rates, improved cleaning
of canals, isthmuses &<span style="mso-spacerun: yes;"> </span>lateral
canals & improved cleaning had some major design flaws and biases. Design
bias, attrition bias, selection & sampling bias and sponsorship bias were
all evident in this study, including a failure to include proper positive and
negative controls.
</div>
<div class="MsoPlainText">
The second clinical study improved upon many of major design flaws & biases of
the first study, yet again failed to include positive and negative controls.
</div>
<div class="MsoPlainText">
Failure to include controls in the clinical studies is
concerning to us.<span style="mso-spacerun: yes;"> </span>This failure in study
design, is hard to comprehend, unless a direct comparison with conventional
techniques was not desired or conventional techniques were equally effective. <span style="mso-spacerun: yes;"> </span>We have also
asked why there has not yet been a double blind, randomized, controlled study
performed?<br />
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDqTzMyv69aiuIMkiWpNsQA4EV4LljTxW0UvKgfFKrw__1Qh0Oo4shzz-ChpWIljTeujp9DCwlk_YbFqitVoe-C59cbmQYVHnNwqVIRqY8GsfEzqqcPGnDB39SEq2MjXmEzwhNES61HetD/s1600/15a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1250" data-original-width="1600" height="250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDqTzMyv69aiuIMkiWpNsQA4EV4LljTxW0UvKgfFKrw__1Qh0Oo4shzz-ChpWIljTeujp9DCwlk_YbFqitVoe-C59cbmQYVHnNwqVIRqY8GsfEzqqcPGnDB39SEq2MjXmEzwhNES61HetD/s320/15a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">EndoActivator</td></tr>
</tbody></table>
<div class="MsoPlainText">
Why have the universities and residency programs not
published about the Gentlewave technique? After discussing this with several
people involved at that level, the<span style="mso-spacerun: yes;">
</span>reason appears to be that if a university accepts any financial support
from the company, including providing the unit, the company insists on
controlling the publication of any research results.<br />
<br /></div>
So while we can understand the company's desire to
protect its significant investment in the development of it's technology, their scientific research appears designed as a marketing tool to support
manufacturer claims.<span style="mso-spacerun: yes;"> </span>A properly designed
study, (randomized, double blinded study with proper controls) will go a long
way to overcome sponsorship bias that up to now has been evident in the research.<span style="mso-spacerun: yes;"> </span>In fact we have not been able to find one study where the authors are not directly tied to and supported by Sonendo. We will continue to watch<span style="mso-spacerun: yes;"> </span>for this evidence and keep you updated.<br />
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
<b>3 Dimensional Cleaning, Shaping & Filling </b></div>
<div class="MsoPlainText">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRVEg5pjtUkP9_4KVvlq1D1AB_G3yYgW1qsnoVXzU-XKuN0EcnqGbxioY0p03BpcOugRF5FsynSZLjjxCwuFf6mpZhZsDFy3JCLXdXE6GedpNlIfMk7t2AAXGYixNpoQz6-bZ9ASKO91XW/s1600/24a.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1250" data-original-width="1600" height="250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRVEg5pjtUkP9_4KVvlq1D1AB_G3yYgW1qsnoVXzU-XKuN0EcnqGbxioY0p03BpcOugRF5FsynSZLjjxCwuFf6mpZhZsDFy3JCLXdXE6GedpNlIfMk7t2AAXGYixNpoQz6-bZ9ASKO91XW/s320/24a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">EndoActivator</td></tr>
</tbody></table>
<div class="MsoPlainText">
One of the biggest claims made regarding the GentleWave
technique is "improved removal of organic matter" and creating a
"higher standard of clean". Evidence provided for this claim are
usually images of more complex anatomy picked up when the tooth is obturated.
The advocates call this "the thrill of the fill".</div>
<div class="MsoPlainText">
However, the idea of cleaning and filling lateral canals
and isthmuses is not unique to GentleWave.<span style="mso-spacerun: yes;">
</span>In our practice we have used both ultrasonic and sonic activation of
irrigating solutions which has provided 3D cleaning and shaping of complex
canal anatomy.<br />
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQxdD-9hAuZL2tCmzcVRxfN3kSCtpMtny_I1pZiqtzhehoHDl3XfXo0H9mrlm9OC9ih0abPZj_-XKsvuu7L3-EFMkYzYDcy19_fUXGDHD4mmluHGjO8qQB8KPTDNKi8ND5bnlQ4vCf6-Tz/s1600/30a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1080" data-original-width="1382" height="250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQxdD-9hAuZL2tCmzcVRxfN3kSCtpMtny_I1pZiqtzhehoHDl3XfXo0H9mrlm9OC9ih0abPZj_-XKsvuu7L3-EFMkYzYDcy19_fUXGDHD4mmluHGjO8qQB8KPTDNKi8ND5bnlQ4vCf6-Tz/s320/30a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">EndoActivator</td></tr>
</tbody></table>
<div class="MsoPlainText">
I have included several radiographic that demonstrate the "Thrill of the
Fill" routinely seen at SSE using sonic activation of irrigating
solutions. After our hands on demonstration with the GentleWave, I began putting aside radiographs after using sonic activation and found that the fill results were equally impressive.</div>
<br />
In the end, we need to be honest with ourselves. How many
teeth are really returning to our office as failures because we didn't clean
the tooth well enough?<span style="mso-spacerun: yes;"> </span>From our
experience - very few.<span style="mso-spacerun: yes;"> </span>When patients
return to our office with a non-healing root canal procedure, typically it is
because the tooth is fractured, not because it wasn't clean. We would love to
add the Gentlewave technology to our office but first we need to see a tangible
benefit to our patients. That day may come, but for now we would like to see
more evidence than "because the company says it's better", before we
invest in this technology.Anonymoushttp://www.blogger.com/profile/00947754185779793094noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-26962822268844123802018-08-13T11:38:00.005-07:002018-08-13T11:38:57.599-07:00Don't Just Assume A Root Is Fractured When You See Lateral Bone Loss<div class="separator" style="clear: both; text-align: left;">
Sometimes we are quick to assume a tooth is fractured when we see lateral bone loss. But that radiographic finding alone isn't enough to make that determination. If you cannot visualize a fractured, and the tooth is diagnosed as a necrotic pulp, it doesn't matter how big the lucency is, it can and should be given the opportunity to heal. Proper diagnosis to determine vitality is the most important test for the prognosis of this tooth. In this case, with definite necrotic pulps on #26 and #27 and no periodontal defects, endodontic therapy is recommended.</div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4jBG8LnDWggLB0mRa4MwgkohiPAPg6MSmMJodnftpMcBtMal3ugrjzfevjilF7naNUwYKouB3OjrE9fKWmvOq0rNq49Vv5qC8cNq3_L4bqFOpqk03xtXjcCOtKOr0-ocdr0ryOIs11EM/s1600/RTPreOp.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="844" data-original-width="660" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4jBG8LnDWggLB0mRa4MwgkohiPAPg6MSmMJodnftpMcBtMal3ugrjzfevjilF7naNUwYKouB3OjrE9fKWmvOq0rNq49Vv5qC8cNq3_L4bqFOpqk03xtXjcCOtKOr0-ocdr0ryOIs11EM/s320/RTPreOp.JPG" width="250" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Necrotic pulp with sinus tract on the buccal of #26.</td></tr>
</tbody></table>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoaR9Qw8Gj7eA72k0ejlF1RhicjI84mb3DK96NmdLOvqFE_Vostc6ftfDLlY3B2LapL8_tejSiwMHJvQTVJ3EJ7Rgh3iM0NaE4LmrxhAc5qZSNLph2kTSCy0ZvP8lF6jobks9gbIEZ1R8/s1600/RTPreopCBCT.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="688" data-original-width="688" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoaR9Qw8Gj7eA72k0ejlF1RhicjI84mb3DK96NmdLOvqFE_Vostc6ftfDLlY3B2LapL8_tejSiwMHJvQTVJ3EJ7Rgh3iM0NaE4LmrxhAc5qZSNLph2kTSCy0ZvP8lF6jobks9gbIEZ1R8/s320/RTPreopCBCT.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">CBCT shows the apical and lateral bone loss on #26 and #27. The lateral bone loss on #27 is also suggestive of a possible root fracture, but since the tooth is necrotic, radiographic appearance alone is not enough evidence to diagnose this with a root fracture. CBCT also shows a 2 canaled root form on #26.</td></tr>
</tbody></table>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLDDw18zO3H50EyL_T1SHyfvN0fx1WPTsw9wSPqpudaf5v6_1amIl1L_fe69hYLVto3WJhMJ6bHbPecp7zda5DhUGOkSxNN65fYKMXU6CN7QuAHm2IXK4KfJcxCgoPUTQPQDV-u5VrkYs/s1600/RTCaohFirstTime.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="844" data-original-width="660" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLDDw18zO3H50EyL_T1SHyfvN0fx1WPTsw9wSPqpudaf5v6_1amIl1L_fe69hYLVto3WJhMJ6bHbPecp7zda5DhUGOkSxNN65fYKMXU6CN7QuAHm2IXK4KfJcxCgoPUTQPQDV-u5VrkYs/s320/RTCaohFirstTime.JPG" width="250" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">There was concern of a possible root fracture, but none could be see internally with microscope. CaOH medicated dressing was placed after initial debridement and NaOCl irrigation.</td></tr>
</tbody></table>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8dbZJRz0rQVKLfcKtyVe55xBA1b54agoQXNVsqCm5oaM8arN7eyw1KiFgyKkAXEUUsjDjfK44pPAsiE2SI20pZ9yav1NT3ts6S-GD2vdtIzTEELbdVUVZiOTQmwSscS4O90XTwvUNJE4/s1600/RTCaoh2ndTake.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="844" data-original-width="660" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8dbZJRz0rQVKLfcKtyVe55xBA1b54agoQXNVsqCm5oaM8arN7eyw1KiFgyKkAXEUUsjDjfK44pPAsiE2SI20pZ9yav1NT3ts6S-GD2vdtIzTEELbdVUVZiOTQmwSscS4O90XTwvUNJE4/s320/RTCaoh2ndTake.JPG" width="250" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">After 3 months in CaOH, we opened and examined again and could find no fractures. Another application of CaOH medicated dressing was placed.</td></tr>
</tbody></table>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyLkEgAP0UuI_tzgmfnpFqk-emOL9IAVM6Hxgk2kRTGunPmqdlBGrJi7yRK25no34XunHQw9DnYLxf-vGDNABfh7cY0gmkIDf3qL1NKXu_JKVJTLMyPDA-J8HhL6hXg3g7wxGHL0NjvA0/s1600/RTFinal.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="844" data-original-width="660" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyLkEgAP0UuI_tzgmfnpFqk-emOL9IAVM6Hxgk2kRTGunPmqdlBGrJi7yRK25no34XunHQw9DnYLxf-vGDNABfh7cY0gmkIDf3qL1NKXu_JKVJTLMyPDA-J8HhL6hXg3g7wxGHL0NjvA0/s320/RTFinal.JPG" width="250" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">After 6 months of CaOH therapy we saw significant bone healing. The canals were obturated and case completed.</td></tr>
</tbody></table>
Sometimes we are quick to assume a tooth is fractured when we see lateral bone loss. But that alone isn't always enough to make that determination. Even with CBCT available, I tell my patients the only way to be 100% of a vertical root fracture is to see it.<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<br />The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-48457620195789052362018-07-26T08:00:00.000-07:002018-07-26T17:43:50.195-07:00Finding the Right People for Your Practice<br />
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In Jim Collins' bestselling book, Good to Great, he discussed the importance of getting the right people on your team. He describes your team as a bus and if you get the right people on your bus, it doesn't matter where you take your bus, you will be successful. The follow concepts are a summary of Collins's concepts of finding the right poeple from Chapter 3, p. 41-63.</div>
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In “Great” businesses, people are <i>not </i>your most important asset. The <i>right </i>people are. Great businesses make a priority on finding the right people.<o:p></o:p></div>
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CONCEPT: If you have the right people on the bus, the problem of how to motivate and manage people largely goes away. With the right people, you can take the bus anywhere it needs to go. </div>
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CONCEPT: If you have the right people on the bus, they will do everything within their power to build a great company, not because of what they will “get” for it, but because they cannot imagine settling for anything less. The purpose of a compensation system is not to get the right behaviors from the wrong people, but to get the right people on the bus and keep them there.<o:p></o:p></div>
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CONCEPT: In finding the “right” people, greater weight is placed on character attributes than on specific educational background, practical skills, specialized knowledge or work experience.<o:p></o:p></div>
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CONCEPT: Great companies have rigorous – not ruthless – cultures. A rigorous culture means consistently applying exacting standards at all times and at all levels – especially in upper management. The only way to deliver to the people who are achieving is to not burden them with the people who are not achieving. <o:p></o:p></div>
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<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->To let people languish in uncertainty for months/years, stealing precious time in their lives that they could use to move on to something else, when knowing that they are not going to make it – that is ruthless<o:p></o:p></div>
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<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->To deal with it right up front and let people get on with their lives – that is rigorous<o:p></o:p></div>
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CONCEPT: Practical disciplines for being rigorous – not ruthless<o:p></o:p></div>
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<!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->When in doubt, don’t hire – keep looking. The ultimate throttle on growth is not markets, technology, competition or products. It is the ability to get and keep enough of the <i>right </i>people.<o:p></o:p></div>
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<!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->When you know you need to make a people change, ACT. The <i>right </i>people don’t need to be managed. Guided – Yes, Taught – Yes, Lead – Yes, - but not tightly managed.<o:p></o:p></div>
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<!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->Great leaders don’t rush to judgment. They invest substantial effort in making sure they have someone in the right seat before concluding they have the wrong person on the bus. Instead of firing honest and able people who are not performing well, it is important to try to move them once or even two or three times to other positions where they might blossom.<o:p></o:p></div>
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<!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]-->Put your best people on your biggest opportunities, not your biggest problems. Managing problems can only make you good whereas building your opportunities is the only way to become great.<o:p></o:p></div>
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CONCEPT: Right People + Great Company = Great Life. Balance in work and life is possible when you have the right people on the bus. Finding the right people is key in finding that balance and having a great life. If we are not spending the vast majority of our time with people that we love and respect – how will we ever have a great life? Great life is made up of people who love what they do and love who they do it with.<br /><o:p></o:p></div>
The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-57094461939521768572018-04-09T08:00:00.000-07:002018-04-09T08:00:09.030-07:00Single-Visit vs. Multiple-Visit Endodontic Treatment: A Review<div class="separator" style="clear: both; text-align: center;">
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There are differing opinions regarding single-visit vs. multiple-visit endodontics. Some clinicians feel strongly that teeth with apical periodontitis (necrotic or retreatment) need the extra step of CaOH therapy to be successful while others are comfortable with these cases being done in a single visit. What does the research say regarding this? Here's a summary of the more recent research:<br />
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Please note that the systematic reviews, in an effort to summarize the existing research and find the best evidence, exclude review papers, case studies, review studies and studies that are determined to be "low evidence" and focus on randomized clinical trials or quasi-randomized clinical trials. However, like most of our dental research, there is a serious lack of studies that can be considered "high-level" evidence, large enough sample size, good research design and proper identification of study bias. This is a problem found throughout our scientific research and requires the reader to evaluate the quality of research on a study by study basis.<br />
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<a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005296.pub3/abstract;jsessionid=7D0F6DA4FEE4FCD0A4821E8F120C4E0D.f04t03"><b><span style="color: #351c75;">Single versus Multiple Visits for Endodontic Treatment of Permanent Teeth (A Cochrane Review)</span></b></a> by Manfredi et. al. 2016, included in their review, 25 randomized controlled trials, of which only 3 studies were found to be a low risk of bias, 8 unclear bias levels and 14 high bias levels. <i>They found no evidence of a difference between single visit or multiple visit treatment in terms of radiological failure, immediate post operative pain, swelling or flare-up incidence, sinus tract formation or complications</i>. There was moderate evidence that patients undergoing single step treatment were more likely to use painkillers over those undergoing multiple visit treatment.</div>
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<b><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4020891/">A Systematic Review of Nonsurgical Single-Visit Versus Multiple-Visit Endodontic Treatment</a></b> by Wong et. al 2014 which reviewed a total of 47 papers of clinical trials on the subject. Meta-analysis showed that post-operative complications of both groups were similar. Neither group could guarantee the absence of post-operative pain. <i>Neither single-visit or multiple-visit treatment had superior results in terms of healing or success rates.</i><br />
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<b><a href="http://bmjopen.bmj.com/content/bmjopen/7/2/e013115.full.pdf"><span style="color: #351c75;">Single-Visit or Multiple-Visit Root Canal Treatment: Systematic Review, Meta-Analysis and Trial Sequential Analysis</span></a><span id="goog_1809905168"></span><span id="goog_1809905169"></span><a href="https://www.blogger.com/"></a></b> by Schwendicke et. al. 2017 included 29 trials (4341 patients), of which all but 6 showed high risk of bias. Based on 10 trials, risks of complications was not significant. Based on 20 studies, risk of pain was not significant. <i>Based on 8 studies, risk of flare-up was higher in single-visit treatment.</i> <i>Conclusion was insignificant evidence to rule out whether important differences between these strategies exist.</i><br />
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<a href="http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=10958&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=844&isPDF=YES"><b>Outcome of Single- vs. Multiple-Visit Endodontic Therapy of Non-Vital Teeth: A Meta-Analysis</b></a> by Almeida et. al. 2017 is a review of 17 randomized clinical trials of non-vital teeth. <i>They found no difference between single or multiple visit treatment in regard to peri-apical repair or microbiological control. They did find that single-visit treatment results in 21% less post-operative pain.</i><br />
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<b><a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1834-7819.2006.tb00428.x">Single-Visit More Effective Than Multiple-Visit Root Canal Treatment?</a></b> by Hargreaves 2006 is a review that includes 3 randomized controlled trials including 146 cases. In this review, included NSRCT of teeth with necrosis or signs of periapical bone loss - excluding pretreatment and surgical tx. <i>It was concluded that single-visit root canal treatment was slightly more effective than multiple-visit treatment with a 6.3% higher healing rate. </i>However this difference was not statistically significant (P = 0.3809).</div>
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<b><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849111/">S<span style="color: #351c75;">ingle Versus Multi-visit Endodontic Treatment of Teeth with Apical Periodontitis: An In Vivo Study with 1-Year Evaluation</span></a></b> by Gill et. al 2016, found <i>no significant differences in healing between teeth treated in single visit, multi-visit without dressing and multi-visit with CaOH dressing.</i><br />
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<a href="https://bmcoralhealth.biomedcentral.com/articles/10.1186/s12903-015-0148-x"><b><span style="color: #351c75;">Treatment Outcomes of Single-Visit Versus Multiple-Visit Non-Surgical Endodontic Therapy: A Randomized Clinical Trial</span></b></a> by Wong et. al. 2015, was a university study performed by general dentists, on 220 patients followed for at least 18 months. They reported <i>no significant difference in success rate or prevalence of post-operative pain between the single visit or multiple visit treatments.</i><br />
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In my opinion, the evidence does not support that multi-step initial endodontic treatment, even of necrotic teeth, has any significant improvement in outcomes over single step treatment. In my experience, patients usually prefer to have their endodontic treatment in single-step treatment as well. <br />
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BIAS ALERT: In an effort to identify my own biases, I would share that I perform the majority of my endodontic procedures in a single-step. I do use CaOH occasionally on retreatment cases that are not healing as expected or when I run out of time to complete treatment in a single step.</div>
The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-79433402036684684602018-04-02T18:09:00.001-07:002018-04-03T18:13:57.128-07:00GentleWave by Sonendo: A Third Look<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiB1qgG98NmW7LE9WjVGRo7y1R-KN1DHDSJe_P901JycR9sDaOdtnJa9WdpjlSCgSkS_l8Hrcuy8ANwWrs3i4gKWHrk9j4GGQasy2SXDOjEFlOSmORrJOASowe8GBOpTlp2_yEBPEd8w6Y/s1600/MM0151-1_1.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: center;"><img border="0" data-original-height="552" data-original-width="799" height="221" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiB1qgG98NmW7LE9WjVGRo7y1R-KN1DHDSJe_P901JycR9sDaOdtnJa9WdpjlSCgSkS_l8Hrcuy8ANwWrs3i4gKWHrk9j4GGQasy2SXDOjEFlOSmORrJOASowe8GBOpTlp2_yEBPEd8w6Y/s320/MM0151-1_1.jpg" width="320" /></a>We recently had an in-office demo of the GentleWave procedure by Sonendo, Inc. (Laguna Hills, CA). We had a great team from Sonendo who came to our office and gave a us a presentation and demonstration, including the opportunity to perform the procedure on an extracted tooth. We spent almost 3 hours together learning about GentleWave.<br />
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The presentation was very informative and clearly explained the unique approach of the GentleWave system. This included a history of its development with some amazing visual imaging of the technology and how the multi-sonic energy and fluid dynamics are used to clean the canal system. We also had Dr. Mehrzad Khakpour, a GentleWave co-founder, on a conference call to answer any questions.</div>
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There is no doubt that the GentleWave system by Sonendo is a novel and unique approach to the endodontic challenge of cleaning root canal systems. There are a several things I find very interesting about the GentleWave approach which I really like.</div>
<ol>
<li>The multi-sonic energy and fluid dynamic approach to enhance irrigation and cleaning is very interesting.</li>
<li>The minimalization of canal shaping with files continues to move us in a
conservative direction to preserve maximum tooth structure. </li>
<li>The concept of a negative pressure and evacuation of the irrigants and debris through the treatment instrument is a great idea.</li>
<li>The de-gassed irrigants ability to penetrate the complexities of the canal system.</li>
<li>The removal of smear layer using multi-sonic and fluid dynamics.</li>
<li>For those who do 2-step treatment, this may be a way for them to feel more comfortable with single step treatment - which patients prefer.</li>
<li>Sonendo insists that they are focused on continuing the clinical research.</li>
<li>Sonendo does have a volume discount for treatment instruments, which gives the endodontist a slight economic advantage over a general practicioner.</li>
<li>The technology is really cool. Who doesn't like new technology?</li>
</ol>
Here are some of the questions or concerns that I have about the GentleWave procedure:<br />
<ol>
<li>We have current ways to create sonic or ultrasonic activation in the canal system. These work very well and are much faster and less expensive the GentleWave.</li>
<li>With the GentleWave procedure, you still have to locate all the canals, including calcified canals, get patency and open them up to a minimal size. This is the most difficult and time consuming part of the endodontic procedure. GentleWave does not solve those problems. No time saved there.</li>
<li>Cost of the treatment instrument, materials to create the platform, additional volume of irrigants and sealers double or triple the material overhead costs of the treatment.</li>
<li>Using the GentleWave procedure will add time to the procedure. It has been estimated by one clinician currently using it that it takes 30% more time per case (20 min for this practitioner). This would decrease the number of patients that could be treated each day.</li>
<li>The claims being made regarding improved success rates and decreased post-op sensitivity are anecdotal.</li>
<li>Hidden costs of ownership make this technology much more expensive than it appears. A business model that requires up to 73% of the cost of the initial investment in disposable, single use treatment instruments per year (in order to get the discounted rate) ends up being a much bigger investment.</li>
<li>Will insurance companies really allow contracted clinicians to charge additional "non-covered" fees to the root canal procedure?</li>
</ol>
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Being among the earliest adopters of microscopes and CBCT in Arizona, we have been through the process of evaluating new technologies and their impact on the clinical practice of endodontics. When it comes to incorporating a new technology into practice, it should be able to:</div>
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<ol>
<li>Make you better - improve outcomes</li>
<li>Make you faster - more efficient</li>
<li>Make you more profitable</li>
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The GentleWave procedure will not make you faster or more profitable and there is not enough evidence to determine if it would make you better by improving outcomes significantly for patients.</div>
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This technology is fascinating. However, for such a large expense, it would be foolish to incorporate any technology into a practice that can so profoundly affect the overhead and productivity of the practice without doing an adequate cost benefit analysis, measuring the opportunity cost and evaluating the return on investment.<br />
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The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-99394308567006062018-03-07T20:28:00.003-08:002018-03-07T20:29:02.333-08:00GentleWave by Sonendo: A Second Look<div class="separator" style="clear: both; text-align: center;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8FrZEbKqXb5DHBCVkl9jOXZnq4JJYuqkpefAXZRwk59_xDYkr9uDUzuuLihC3imBoC57E7k2mk-OSfsh1UiXpRP-B5VorjPx42xe9ac5j26t62iJUMLcP869hNuUBOxF7VBKLAGloEG4/s1600/tech_sonendo_fig1.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="468" data-original-width="300" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8FrZEbKqXb5DHBCVkl9jOXZnq4JJYuqkpefAXZRwk59_xDYkr9uDUzuuLihC3imBoC57E7k2mk-OSfsh1UiXpRP-B5VorjPx42xe9ac5j26t62iJUMLcP869hNuUBOxF7VBKLAGloEG4/s320/tech_sonendo_fig1.jpg" width="204" /></a>A new research article titled, "<a href="http://www.jendodon.com/article/S0099-2399(17)31273-6/pdf">Healing of Periapical Lesions After Endodontic Treatment with the GentleWave Procedure: A Prospective Multicenter Clinical Study</a>" by Asgeir Sigurdsson, Randy W. Garland, Khang T. Le, and Shabriar A. Rassoulian, was just published in the March 2018 <i>Journal of Endodontics</i>.<br />
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This new study did a great job and addressing some of the design problems with the previous study reviewed in our post titled, <a href="http://www.theendoblog.com/2018/03/gentlewave-by-sonendo-first-look.html">GentleWave by Sonendo: A First Look</a>. 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.<br />
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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.<br />
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The major improvements in this study are:<br />
<ol>
<li>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.</li>
<li>Attrition Improvement: This study lost only 1 of 45 patients in the study, while the previous study lost 16% to attrition.</li>
<li>Standardization & Calibration of Examiners: training, calibration, independent scoring and consensus scoring of the periapical index (PAI) scores all demonstrate a desire for accuracy.</li>
<li>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.</li>
<li>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.</li>
</ol>
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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.</div>
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Source:<br />
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Healing of Periapical Lesions after Endodontic Treatment with the GentleWave Procedure: A Prospective Multicenter Clinical Study <span style="font-family: "helvetica neue" , "helvetica" , "arial" , sans-serif; font-size: 12px;">Sigurdsson, Asgeir et al. Journal of Endodontics , Volume 44 , Issue 3 , 510 - 517</span></h4>
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<br />The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-15743993129942801222018-03-02T16:05:00.002-08:002018-03-02T16:21:54.976-08:00GentleWave by Sonendo: A First Look<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxfxSo0mP9bdKDBdg8kFyww_nkUCna23Z6zhpqpEoxvNMH2XjfRu5dsWQInectWVrXzez9HA6B0H-21laFWOfY75kUoM2ggtAQgaOdsvoOol9WCqQ-A8l5tvrLAmngF8fZ2yIJk7eyyzs/s1600/Unknown.jpeg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxfxSo0mP9bdKDBdg8kFyww_nkUCna23Z6zhpqpEoxvNMH2XjfRu5dsWQInectWVrXzez9HA6B0H-21laFWOfY75kUoM2ggtAQgaOdsvoOol9WCqQ-A8l5tvrLAmngF8fZ2yIJk7eyyzs/s400/Unknown.jpeg" /></a><br />
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. <br />
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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:</div>
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<ul>
<li>the technique provides improved removal of organic matter (pulp tissue and biofilm) a "higher standard of clean"</li>
<li>the technique allows for minimal instrumentation of the canals, preserving valuable tooth structure</li>
<li>the technique allows for improved cleaning of canals, lateral canals, isthmus</li>
<li>97% success rate of endodontic cases - in initial clincial studies</li>
</ul>
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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.<br />
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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. (<a href="http://www.jendodon.com/article/S0099-2399(16)30196-0/fulltext">click here</a> to see the study)</div>
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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.<br />
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The problem with the study design is:</div>
<div>
<ul>
<li><b>Design Bias: Bias that occurs when the design of a study selects or encourages a specific outcome.</b> 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) </li>
<li><b>Attrition Bias: Systematic error introduced into a study by loss of participants:</b> 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.</li>
<li><b>Selection/Sampling Bias: Bias introduced by the selections of participants:</b> 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.</li>
<li><b>Sponsorship Bias: Refers to the overwhelming tendency of a scientific study to support the interests of the study's financial sponsor.</b> 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.</li>
</ul>
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The problems that we find in the discussion include:</div>
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<div>
<ul>
<li><b>Citation Bias:</b> 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.</li>
<li><b>Internal Validity Bias: Refers to the author and reviewer's confidence that the study design, implementation and data analysis have minimized or eliminated bias. </b> 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.</li>
<li><b>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. </b>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.</li>
<ul>
<li>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.</li>
<li>The discussion about reduced post-operative pain is again biased by a study heavily weighted with irreversible pulpitis.</li>
</ul>
</ul>
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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.</div>
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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 i<i>n vitro</i> studies available on the Sonendo website are a good beginning to provide evidence to support the claims made by the manufacturer (<a href="http://sonendo.com/research-clinical">click here</a>), but there is not evidence of superiority over conventional endodontic treatment at this point.</div>
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In order to substantiate the claims being made by the manufacturer, we need randomized, double-blinded, controlled clinical trials focusing on <i>necrotic</i> teeth. With this kind of data, we would be able to better evaluate the effectiveness of the GentleWave procedure over conventional endodontic therapy.<br />
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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 <i>in vitro</i> 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.<br />
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<span style="color: #333333; font-family: "georgia" , serif; font-size: 14px;">SOURCES:</span><br />
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<span style="font-family: inherit;"><span style="background-color: white; color: #303030; font-size: 13px;">Elemam RF, Pretty I. Comparison of the Success Rate of Endodontic Treatment and Implant Treatment. </span><i style="color: #303030; font-size: 13px;">ISRN Dentistry</i><span style="background-color: white; color: #303030; font-size: 13px;">. 2011;2011:640509. doi:10.5402/2011/640509.</span></span><br />
<span style="background-color: white; color: #303030; font-family: inherit; font-size: 13px;"><br /></span></div>
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<span style="font-family: inherit;"><span style="color: #333333; font-size: 14px;">12-month Healing Rates after Endodontic Therapy Using the Novel GentleWave System: A Prospective Multicenter Clinical Study </span><span style="color: #333333; font-size: 12px;">Sigurdsson, Asgeir et al. </span><span style="color: #333333; font-size: 12px;">Journal of Endodontics , Volume 42 , Issue 7 , 1040 - 1048.</span></span><br />
<span style="font-family: inherit;"><span style="color: #333333; font-size: 12px;"><br /></span>
<span style="color: #333333; font-size: 12px;"><span style="background-color: white; color: #303030; font-size: 13px;">Pannucci CJ, Wilkins EG. Identifying and Avoiding Bias in Research. </span><i style="color: #303030; font-size: 13px;">Plastic and reconstructive surgery</i><span style="background-color: white; color: #303030; font-size: 13px;">. 2010;126(2):619-625. doi:10.1097/PRS.0b013e3181de24bc.</span></span></span></div>
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The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-177562788285684992018-02-19T08:30:00.000-08:002018-02-19T08:30:22.409-08:007 Yr Recall on Intentional ReplantationIt 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.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTudDlpW9Mmy1hm5yKKOsUxy24KlxkIhmtOOu0ri4t3J5O6u1qR7kmP3ewaxoMjLz-9BQ9fmaH3wj42iOXTE6zC_PqRNssn7CJWB2S3La0jM0SJ07fj5px-O2Ibt9daOXVvvpbgLvS7mQ/s1600/Pre.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="640" data-original-width="800" height="160" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTudDlpW9Mmy1hm5yKKOsUxy24KlxkIhmtOOu0ri4t3J5O6u1qR7kmP3ewaxoMjLz-9BQ9fmaH3wj42iOXTE6zC_PqRNssn7CJWB2S3La0jM0SJ07fj5px-O2Ibt9daOXVvvpbgLvS7mQ/s200/Pre.jpg" width="200" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8X7ebaMmIjc1LkMf54n_gPpO2m4K1PzU7cT1OKTSmFMVfmTok4vQWdP2k_1JBi7JwcLrjTtm48Rfs3dV89iJ5wh8rEI84Bf7ksLcVwvOO16VEQCXZg9LCLMlKS773V4nK95SG-P1yqXg/s1600/PostOp.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="640" data-original-width="800" height="160" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8X7ebaMmIjc1LkMf54n_gPpO2m4K1PzU7cT1OKTSmFMVfmTok4vQWdP2k_1JBi7JwcLrjTtm48Rfs3dV89iJ5wh8rEI84Bf7ksLcVwvOO16VEQCXZg9LCLMlKS773V4nK95SG-P1yqXg/s200/PostOp.jpg" width="200" /></a>T</div>
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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. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiv5-tjiRY_lIHzxaYnR97nInIDPdsxKD4HfKd-9j1RxYfVQ-sBsHAT18q-7RE7WneOm0OLh9cRS1_t_DUdbfWD6I5qvGGhRXtFg5balA-EdIc-sMxiMAHhm3xUwt7VerhT0AH8CvDJn8E/s1600/RetxPre.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="640" data-original-width="800" height="160" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiv5-tjiRY_lIHzxaYnR97nInIDPdsxKD4HfKd-9j1RxYfVQ-sBsHAT18q-7RE7WneOm0OLh9cRS1_t_DUdbfWD6I5qvGGhRXtFg5balA-EdIc-sMxiMAHhm3xUwt7VerhT0AH8CvDJn8E/s200/RetxPre.jpg" width="200" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFAdxjXyD7762XfR6btWHCPxAc_uGOmBN1Zw-ZYiLc162LO9hIDf-R8TaJuQRiymrf54iLUZ5zeQKTIrse8HTI6Km8RcGNyFCRJduTzNlmE_k6l5q1mBaMoZqvND2eCLtxV8LpAZwWArw/s1600/RetxPostOp.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="640" data-original-width="800" height="160" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFAdxjXyD7762XfR6btWHCPxAc_uGOmBN1Zw-ZYiLc162LO9hIDf-R8TaJuQRiymrf54iLUZ5zeQKTIrse8HTI6Km8RcGNyFCRJduTzNlmE_k6l5q1mBaMoZqvND2eCLtxV8LpAZwWArw/s200/RetxPostOp.jpg" width="200" /></a></div>
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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.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZXuHDkGxlLIcN9sVqaBnHjBdBM4G18ppSN3zzYcl-xpvYrlpOOXMz35N8QErZVuMSx8bI0KNNRTcGkE9V0FhTQeCQQBO3yqvsD6z4za3EvPdDeH1ZfYZiqqOSZMSaDK9432q0cisINqA/s1600/ReplantPreOp.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="640" data-original-width="800" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZXuHDkGxlLIcN9sVqaBnHjBdBM4G18ppSN3zzYcl-xpvYrlpOOXMz35N8QErZVuMSx8bI0KNNRTcGkE9V0FhTQeCQQBO3yqvsD6z4za3EvPdDeH1ZfYZiqqOSZMSaDK9432q0cisINqA/s320/ReplantPreOp.jpg" width="320" /></a></div>
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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.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8EbarTMYDu7K_RhBuklz4-fQZsEq2LjQfcmDiDnDt_uG2kzeRhBH3M95tzhGv3qizyNGDtSFKPApbiprAq0g2PaZwS2uiNjVPOxNXDBIh2WGQqsT5Y-XMzmnHeH0WR7apEnOjmVwkTZs/s1600/Extraction.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8EbarTMYDu7K_RhBuklz4-fQZsEq2LjQfcmDiDnDt_uG2kzeRhBH3M95tzhGv3qizyNGDtSFKPApbiprAq0g2PaZwS2uiNjVPOxNXDBIh2WGQqsT5Y-XMzmnHeH0WR7apEnOjmVwkTZs/s320/Extraction.jpg" width="320" /></a></div>
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The tooth is gently extracted. Here it is immediately after extraction.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-V4925FZMMg5rYYfKZ5MOhqbIeRSQzJWwowFZZRREtraiIwCm4eW2G3x9NqnO3YzFYXQrlL8uSX_ZXpWxoiuA9OXYzNVMMfVCevZUed5T9_PDzND5vGoVd1558RvfLPCdQjWGj2m1ODI/s1600/ReplantPrep.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-V4925FZMMg5rYYfKZ5MOhqbIeRSQzJWwowFZZRREtraiIwCm4eW2G3x9NqnO3YzFYXQrlL8uSX_ZXpWxoiuA9OXYzNVMMfVCevZUed5T9_PDzND5vGoVd1558RvfLPCdQjWGj2m1ODI/s320/ReplantPrep.jpg" width="320" /></a></div>
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The root is kept moist and quickly examined for fractures. None found, so we did retro preparation using and ultrasonic instrument.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtBpHQtLbYIclFsiojJwal_abazE2F-tI22VgJ9isBPam8L0TJVyQLN42K9snNnknyloEAYktp9lnCS2QupmsE6f3LsVa93YYeaOS90kmS69f21BDB0Ag8ri2WVEPJ_MPU5zpuFruV7A0/s1600/ReplantRetrofill.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtBpHQtLbYIclFsiojJwal_abazE2F-tI22VgJ9isBPam8L0TJVyQLN42K9snNnknyloEAYktp9lnCS2QupmsE6f3LsVa93YYeaOS90kmS69f21BDB0Ag8ri2WVEPJ_MPU5zpuFruV7A0/s320/ReplantRetrofill.jpg" width="320" /></a></div>
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An MTA retrofit is placed.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsAu9H9-Gn-Q_my_7bb08eHCUV-IuGusOg-Do5Q-UPOJ9GrXrfiAhb8v0wXyUlkS0FgfcusPA-wmkkpTtTEjjTL31KaztPAA3zze0JH-lCtKjZas87mGFCCbHuJp-Gn4WixzqMR_36urc/s1600/ReplantPostOp.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="640" data-original-width="800" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsAu9H9-Gn-Q_my_7bb08eHCUV-IuGusOg-Do5Q-UPOJ9GrXrfiAhb8v0wXyUlkS0FgfcusPA-wmkkpTtTEjjTL31KaztPAA3zze0JH-lCtKjZas87mGFCCbHuJp-Gn4WixzqMR_36urc/s320/ReplantPostOp.jpg" width="320" /></a></div>
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The tooth is replanted into the socket within 10 minutes of extraction. Firm pressure is placed for an extended period of time. No splinting</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjboHen198ds_g3Qbx4scwcrI61pBkQ9YW-0-5liEWCEfAJXEkStXZQWH6qdl0sR-3G-2fRpZWBJPvt9AKN38MWEh6VsT_-PuEfXv1ydsvghtgbxt7bKvYROhBelYMluIHt1tkyaEVuk5A/s1600/7YrRecall.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="660" data-original-width="844" height="250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjboHen198ds_g3Qbx4scwcrI61pBkQ9YW-0-5liEWCEfAJXEkStXZQWH6qdl0sR-3G-2fRpZWBJPvt9AKN38MWEh6VsT_-PuEfXv1ydsvghtgbxt7bKvYROhBelYMluIHt1tkyaEVuk5A/s320/7YrRecall.JPG" width="320" /></a></div>
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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. </div>
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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.</div>
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The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0tag:blogger.com,1999:blog-6076433377834065112.post-9062427872254107092018-02-01T20:28:00.000-08:002018-02-01T20:28:11.570-08:005 Yr Recall on Intentional Replantation<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhRaselOg4TomzwcL5hBlUkd8Oed0ue8PnaQWb7KDiaotYhtlmFID4LzdJrWJHPMwvYQ5XB9pV0laCjMLxOHtB8xcwM09f5kPfayT3nouIa6oyEWExsahf5MkeU4eQkrPguCB7sDtL_Lq4/s1600/X0110262314.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhRaselOg4TomzwcL5hBlUkd8Oed0ue8PnaQWb7KDiaotYhtlmFID4LzdJrWJHPMwvYQ5XB9pV0laCjMLxOHtB8xcwM09f5kPfayT3nouIa6oyEWExsahf5MkeU4eQkrPguCB7sDtL_Lq4/s400/X0110262314.JPG" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">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.</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrClKhDtvjfuoUcW662R2XsCX11Jldz26T7rs5DEAtGZJhocoMZXjqV_-djzC4YQ4rCg_6FglbbvQtbL8u6hVv5Gjsgk9AztDuj4U_z28C_mbED9gRzFmwZyvv7FCFzHidiTKsQBIpHkc/s1600/X0110262315.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="312" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrClKhDtvjfuoUcW662R2XsCX11Jldz26T7rs5DEAtGZJhocoMZXjqV_-djzC4YQ4rCg_6FglbbvQtbL8u6hVv5Gjsgk9AztDuj4U_z28C_mbED9gRzFmwZyvv7FCFzHidiTKsQBIpHkc/s400/X0110262315.JPG" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Tooth #14 was carefully extracted and all 3 canals were resected, retrofilled and reimplanted within minutes. </td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBbyiRpATCfACPqAVROex5vz9xZCIEA5jJxl6_osWlZA-6UTKetFxqCVBBcBARLlrlfhhyl7R513aiGNQZYq5_R7mWRyu4F-lG99mIHKFuoDUXZL4KMbD8t4rAGsWFe3iq2O0XpDVuVdo/s1600/X0110262319.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="312" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBbyiRpATCfACPqAVROex5vz9xZCIEA5jJxl6_osWlZA-6UTKetFxqCVBBcBARLlrlfhhyl7R513aiGNQZYq5_R7mWRyu4F-lG99mIHKFuoDUXZL4KMbD8t4rAGsWFe3iq2O0XpDVuVdo/s400/X0110262319.JPG" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">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.</td></tr>
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<br />The Endo Bloghttp://www.blogger.com/profile/11190879753218706390noreply@blogger.com0