An Endodontist’s Mission to Guatemala

815 Ayrault Road, Fairport, NY 14450 | 585.381.2200 ~ 69 South Main Street, Canandaigua, NY 14424 | 585.381.2200

An Endodontist’s Mission to Guatemala

This year my family and I used our winter break to join a small group of dentists on a mission to Guatemala. We had come to Guatemala with the Spear, Open Wide Foundation to work in the foundation’s Peronia Clinic.

According to the foundation, Guatemala suffers from a level of inequality and widespread poverty that is extreme even within Latin America.  Families struggle to provide basic needs for their families. Many homes are made of scavenged materials with dirt floors, no toilets or running water. Access to quality health care and housing is also scarce.

As the only endodontist to ever participate in the program, I was curious as to what I would find. What I did find over the next several days would be both challenging and wonderfully rewarding.

The first morning we left our hotel in Antigua with the other dentists and their families. The journey was long and took us over mountainous and windy roads. After almost an hour of travel the pavement gave way to a dirt road that brought us to the top of a hill and the small three building dental clinic.

As we approached the clinic we were first greeted by a guard with a small hand held shot gun for security.

The Open Wide Foundation Clinic

In the first building there was a room full of patients. As we entered they all turned and stared to see who had come to help them.

Walking by the middle building we were greeted by a chicken who was also curious to see who had arrived.
The dental clinic contained five new ADEC chairs donated by Patterson Dental. There was a director, an administrator and a resident dentist. A group of four dental students had come to help from the dental school in Guatamala City.

Although supplies were limited, we learned to make do with what we had. The endodontic equipment was in a small basket and not often used. There were some Protaper files and hand K files. The hand piece motor was working but would stall or get stuck in the root canal space. It required a special experienced touch to keep it working.

The apex locator was a nice surprise but it required some repair.  A pair of loops with head light sufficed to replace the endodontic microscope I use in my office. There were no rubber dams on the first day, so we improvised and stretched gloves over the rubber dam frame. Fortunately the next day the rubber dams arrived.

The x-ray system consisted of a Nomad unit. It was connected to a single computer that was also used to run patient software. Since the Nomad was often unavailable, we relied on the apex locator instead of working and intermediate radiographs. The only way to obturate the canal system was to use lateral condensation removing the excess by heating the end of an old instrument with a cigarette lighter. This is a technique I used in dental school over twenty six years ago proving it pays to always know the basics.

My son Christopher helping assist

Since no endodontist had come before me, multi rooted endodontics was not done. People would be referred to the dental school but often they could not go and extraction became their only option. Even though it was a bit of a stretch to do calcified molars with the limited set up, as the days went by we became efficient at improvising endodontic treatment. We were able to treat many people, saving their teeth to improve function and health.

Although the facility was well run and properly supplied due to generous donations from the foundation and volunteers, specialized dental procedures such as advanced endodontic treatment was limited. What was not limited was the kindness and care of the resident doctor, administrator, auxiliary staff and visiting dental students.

As we ended our time at the clinic, we all reflected on the warmth and gratitude we felt from the people we had met.

Using your education and training to help improve the oral health of those who otherwise would have few alternatives is a wonderful experience. It was a privilege we will cherish forever.

I’m here with a young patient.

My daughter Valerie handing out the toys we had brought from home.

Clinic waiting room seemed to be always full

View of the clinic. Modern facility provided by the Open Wide Foundation

The dental students, the clinic administrator and Dr. Lepore and Dr. Garcia-Lepore

An Endodontists Journey from Gutta Percha to Titanium

An Endodontists Journey from Gutta Percha to Titanium

815 Ayrault Road, Fairport, NY 14450 | 585.381.2200 ~ 69 South Main Street, Canandaigua, NY 14424 | 585.381.2200

An Endodontists Journey from Gutta Percha to Titanium

You may have heard the expressions, “if you have a hammer everything looks like a nail,” or “if you have a screwdriver everything looks like a screw.” As an Endodontist I believe that with proper case selection the success of a root canal and root canal retreatment is just as high as dental implants. Having said that however, an endodontist having experience in both implants and root canal treatment can give the patient choices with less bias to save or remove their natural teeth. In cases where a root canal could not be completed due to fracture or non-restorability, the patient is left with an “incomplete endo” (code #3332) and the same bad tooth. Deciding if a tooth is fractured and transitioning to extraction with graft or immediate implant can save the patient substantial time and money and is often favored by the referring doctor. Although endodontists can extract, graft and place dental implants, most still do not because of the significant investment required in continuing education and advanced technology. At Advanced Endodontic Solutions, we continue to make those investments to serve our referring doctors and their patients.

Continuing education

I began my implant training by taking hands-on courses on cadavers in the anatomy lab at the University of Maryland. Later I traveled with a group of local general dentists to study at the Misch International Implant Institute. There under the watchful eyes of Carl Misch and Randy Resnik, the founders of the institute and authors of best-selling book, “Contemporary Implant Dentistry”, I gained valuable experience placing implants and performing sinus surgery on live patients I have had the privilege of going through the Misch Institute course series multiple times. In addition I have attended several live training programs at Temple University Periodontal Department and completed several mini residencies in Mexico and the Dominican Republic with Dr. Mohamed Shirarwy, the Director of Oral surgery and Anatomical science at the Dental College of Georgia. I have also participated in surgical anatomy dissections on cadaver specimens with Dr. Sharawy teaching surgical anatomy and bone biology.

Dr. Lepore graduates and receives Implant Surgery Certificate from Carl Misch and Randy Resnik as well as an Implant Prosthetic Achievement Certificate.

Dr. Lepore with mentor and surgeon Dr. M Sharawy

Dr Lepore has studied with Drs. Misch, Resnik and Sharawy, three experts who literally wrote the book on implant procedures.

Advanced technology

Cone Beam Computed Technology

It has become the standard of care in implant dentistry and in endodontics to employ CBCT technology for more accurate diagnosis and treatment. Although the principles of ALARA (as low as reasonably achievable) should always be adhered to, the value of CBCT scanning greatly outweighs the risks. CBCT cone beam technology has very low exposure compared to other similar medical radiography. Limited field of view (FOV) and medium FOV can be selected on modern cone beam machines to tailor your care to the specific needs of the patient. CBCT does not yet replace 2D digital radiographs for routine care. The Joint Position statement of the AAE and AAOMR provides recommendations for the use of Cone Beam computed Tomography in  Endodontics. CBCT scanning systems integrate CAD CAM technology, optical scanners and digital printing for fabrication of surgical guides.

The MB2 or ML canal is visualized with the 3D rendering of the CBCT scan.

The MB2 or ML canal is visualized with the 3D rendering of the CBCT scan.

The MB2 or ML canal visualized with high power through the Zeis endodontic microscope

Endodontic Surgical Operating Microscope

Although the endodontic microscope is a huge advantage in the treatment of the root canal system with illumination and magnification, it can be used for grafting and implant surgery as well. Extracting teeth and curetting the surgical site is aided with the operating microscope as well as micro suturing techniques. Digital photography and video monitoring can be achieved through the surgical microscope.

IV sedation

Surgery often requires sedation. At Advanced Endodontic Solutions we are licensed in IV sedation and oral sedation. We have completed the DOCS sequence of courses, attend didactic courses at ADSA every year with SIM man emergency scenarios, trained at Montifiore Oral Surgery Department in IV sedation and trained with dental anesthesiologists in advanced IV sedation and airway management. We have also been trained in Advanced Cardiac Life Support and basic life support training.

Advanced endodontic procedure with IV sedation.

SIMM Mann emergency training at ADSA in Las Vegas

Endodontists as referring doctors

Endodontists do not replace periodontists or oral surgeons. We refer many cases to oral surgery, periodontists and implantologists for a team approach to dentistry. If asked not to place the implant we are happy to provide expertise and support to referring doctors.

Conclusions

Endodontists who place dental implants will find it is not just one area of study. The endodontist should have a strong understanding of many areas such as: CBCT, sinus anatomy, surgical anatomy, implant prosthetics, guided surgery, intra oral scanners, basic hard and soft tissue grafting, atraumatic extraction with graft, piezo surgery, guided tissue regeneration, block grafting, ridge expansion, bone biology, dental emergencies and sedation. He/she should receive regular implant journals and attend implant seminars. The endodontist must have relationships with oral surgeons, periodontists, implantologists, oral radiologists and ENT physicians. At advanced endodontic solutions we take pride in meeting these criterion for the past ten years of implant surgery practice. Hopefully, this newsletter has provided an understanding of the continuing journey and study of dental implant surgery.

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