Well-being, postoperative pain and outcome after clinical application of a novel root canal irrigation fluid-RISA-in teeth with apical periodontitis: A first-in-human study.

AIM: The aim of the study was to assess the tolerance to the new root canal irrigation fluid RISA after root canal treatment (RCT) by evaluating the subject's postoperative well-being, postoperative pain (PP) and treatment outcome. METHODOLOGY: A single-arm prospective study with 16 subjects (17 teeth) diagnosed with asymptomatic apical periodontitis. Endodontic treatment in one session performed using RISA for root canal irrigation. Well-being was assessed on the same day and after 24 h by telephone. For pain intensity, a visual analogue scale was used at 0-5 days. Clinical and radiographic evaluations were performed at ≥12 months. Well-being, occurrence of PP and outcome were qualitatively reported. Friedman test for paired samples and Spearman correlation coefficient were used. Significance was set at p < .05. RESULTS: At the same day and after 24 h, 14/16 subjects felt 'good'. 9/16 presented intra- or extra-oral swelling. The frequency of PP ≥36 (weak) was 82.4%. On the same day, 1 and 2 days postoperatively, there was more pain compared with preoperative pain p < .05. At Day 3, PP equalled preoperative pain (p > .05). 62.5% of subjects needed analgesics Day 0-2. The recall rate was 94.1%, and resolution of apical periodontitis was observed in 87.5%. CONCLUSIONS: The well-being of subjects was good, and the overall PP intensity was low. However, postoperative intra- and extra-oral swelling occurred often. At the recall visit, the effectiveness of the RCT with RISA appeared high (87.5%). The encouraging outcome results plus the fact that RISA has a broader action range than NaOCl in vitro, justify further work on the RISA solution. To reduce postoperative swelling, it is advised to further investigate the optimal way of application of RISA in the laboratory before clinical application is recommended.

Comparison of Fracture Resistance between Single-cone and Warm Vertical Compaction Technique Using Bio-C Sealer® in Mandibular Incisors: An In Vitro Study.

AIM: The aim of the study was to compare the fracture resistance of the single-cone technique with the warm vertical compaction technique (WVCT) in mandibular incisors using Bio-C sealer®, by applying a compressive force using a universal testing machine (UTM) (Instron 5943; Instron, Norwood, Massachusetts, USA). MATERIALS AND METHODS: Twenty-two mandibular incisors were selected and divided into two groups after applying the same shaping protocol. To assess the influence of the wave vertical compaction technique on the fracture resistance, the first group was obturated by a single-cone obturation technique (SCOT) (n = 12), and the second group was obturated with a WVCT (n = 10). Bio-C sealer® (Angelus, Hague Netherlands) was used in the two obturation techniques. Wax-coated roots were put in an acrylic mold and loaded to compressive strength fracture in a mechanical material testing machine (UTM) (Instron 5943; Instron, Norwood, Massachusetts, USA), with Bluehill 3 software (version 3.15.1343) recording the maximum load at fracture. Fracture loads were compared statistically, and data were examined with the Mann-Whitney U test with a level of significance set at p ≤0.05. RESULTS: No statistically significant difference was registered between the SCOT (264.97 ± 83.975 N) and WVCT (313.35 ± 89.149 N) concerning the endodontically treated mandibular incisors' fracture resistance (p = 0.159). CONCLUSION: Warm vertical compaction technique (WVCT) did not affect the fracture resistance of endodontically treated mandibular incisors when compared to SCOT canal preparation. CLINICAL SIGNIFICANCE: General practitioners and endodontists face challenges during root canal treatment such as cracks and root fractures. This article aims to guide experts in choosing between the single-cone and the continuous WVCT aiming for higher long-term quality of root canal filling.

Effect of XP-endo Shaper versus conventional rotary files on postoperative pain and bacterial reduction in oval canals with necrotic pulps: a randomized clinical study.

AIM: To assess postoperative pain and bacterial reduction following the use of XP-endo Shaper versus conventional rotary files in preparation of oval canals with necrotic pulps. METHODOLOGY: This superiority, parallel, randomized, double blinded clinical trial was conducted in the clinic of the Endodontic Department, Faculty of Dentistry, Cairo University, Egypt. Sixty single-canalled mandibular premolars with necrotic pulps were randomly assigned into two equal groups. Canals were instrumented using XP-endo Shaper files in the intervention group and iRaCe rotary files in the control group. Bacterial samples were taken before and after canal instrumentation. Incidence and severity of postoperative pain was assessed using a modified VAS after 6, 12, 24 h and daily for 5 days. A culture method was used to assess the number of bacterial colony forming units. Incidence of analgesic intake as well as flare-ups was recorded. Data were analysed using chi-square, Fisher Exact, Mann-Whitney, Independent t-test, and Spearman's correlation for pain and bacterial counts. RESULTS: The XP-endo Shaper compared with the iRaCe group was associated with a significantly lower incidence of postoperative pain at 6, 12, and 24 h (P = 0.039, 0.047, and 0.026, respectively), and severity of postoperative pain at 6 h (mean difference: 1.33, 95% CI: 0.307-2.352, P = 0.02), 12 h (mean difference: 1.1, 95% CI: 0.26-1.936, P = 0.007), 24 h (mean difference: 0.94, 95% CI: 0.178-1.701, P = 0.008) and 48 h (mean difference: 0.97, 95% CI: 0.192-1.747, P = 0.038). There was a significant decrease in bacterial count following canal instrumentation in both groups (P < 0.001) with no significant difference between them (mean difference: 0.83 × 105 , 95% CI: 0.336 × 105 -1.996 × 105 , P = 0.56). A weak correlation existed between postoperative pain severity and bacterial counts (P = 0.54). There was no significant difference in analgesic intake between the two groups (P = 0.085). Flare-ups occurred in 3.3% of teeth in the iRaCe group, while no flare-ups occurred in the XP-endo Shaper group. CONCLUSIONS: XP-endo Shaper was associated with a significantly lower frequency of postoperative pain for up to 24 h, and lower severity of postoperative pain for up to 48 h compared with iRaCe files. Both systems were equally effective in bacterial reduction from oval root canals with necrotic pulps.

TREATMENT OF CHRONIC APICAL PERIODONTITIS: IN A SINGLE OR MULTIPLE VISITS? (REVIEW).

The article describes the effectiveness of the treatment of chronic apical periodontitis in one visit compared to multiple visits. A systematic review of the literature was conducted analyzing articles published on PubMed, Google scholar, ResearchGate and ScienceDirect between 2011 and 2021, treatment effectiveness was the selected outcome variable. A total of 21 articles were selected, 9 of which were selected for detailed review. Chief question in this article was: which treatment approach is more effective? Cleaning, Shaping, disinfecting and obturating in one visit? Or multiple (two) visit protocol? Chronic Apical Periodontitis is treatable in one visit, if done properly. Chronic Apical Periodontitis is treatable in one visit, if done properly, with proper shaping, disinfection, and proper hermetic obturation of the root canal. Bioceramic sealers showed the highest success rate out of all sealers used, the usage of 3-5.25% sodium hydrochloride and 17% ethylenediaminetetraacetic acid showed favorable results, although photodynamic therapy and ultrasonic activated irrigation showed outstanding results.

Surgical endodontics for management of progressive actinomycosis.

Actinomycosis is caused by gram-positive, branching, filamentous, anaerobic bacteria of the genus Actinomyces. This case report describes treatment of a 35-year-old woman who had a progressive apical lesion after nonsurgical endodontic retreatment of her maxillary left lateral incisor. The area had localized soft tissue swelling, and the tooth was sensitive to percussion. Radiographic evaluation showed a large apical lesion with a clear margin. After treatment options, including extraction, were discussed, the patient chose to preserve the tooth through endodontic surgery. Root-end resection, canal preparation, and filling with calcium-enriched mixture cement were performed. Histopathologic examination of surgical specimens revealed a radicular cyst associated with actinomycosis. At an 18-month follow-up, the patient was symptom free and bone healing was almost completed. Periradicular actinomycosis is one of the most common reasons for the failure of nonsurgical endodontic treatment and retreatment. If a tooth is nonresponsive to nonsurgical endodontic treatments, apical actinomycotic infection should be suspected and a surgical approach should be planned to obtain a successful outcome.

Potential of Operative Torque in Evaluating NiTi Instruments.

The role of nickel-titanium (NiTi) in the production of endodontic instruments increased in the last few decades; therefore, the way of evaluation of its performance increased as well. Nowadays, there are several ways to evaluate NiTi instruments, divided into static and dynamic tests. The static ones are cyclic fatigue tests, torsional resistance tests, flexibility, and cutting efficiency tests. These methodologies have been deeply used to evaluate some of the metallurgical properties of the instruments on the market. Up-to-date, we know very well the behavior of NiTi under static conditions, but these knowledges are too fragmented to be relevant for understanding and evaluating the complexities of intracanal instrumentation. Starting from the purpose to introduce the variable of movement in the testing procedure, some dynamic tests have been proposed, such as dynamic cyclic fatigue test.1,2 Although these kinds of studies were capable of evaluating more precisely the behavior of rotary instruments inside the root canal, they could not take into account, at this moment, the complexities of stresses that instruments undergo during the shaping procedure.3-5 Therefore, some of these tests are not accepted anymore by the scientific community and on the contrary they do not help the general practitioner to orientate in the large amount of rotary instruments present on the market.6 This tends to withdraw the general dentistry from the scientific literature, wearing a groove between the practice and the science.7 Starting from these ideas, in the last couple of years some authors started to think the proper way to real-time evaluation of the performance of NiTi rotary instruments inside the root canal. To do so, a countable and repeatable measurement of instrument's developed stresses was needed. Setzer and Böhme8 first used the torque generated by Revo-S, Vortex, and ProFile to evaluate their performance during instrumentation. The so-called "operative torque" is the summation of torque generated in each point of the instrument during its simultaneous movement around its own axis and up and down inside the canal. The recorded values are influenced by both torsional and flexural stresses, becoming this way a reliable method to analyze, evaluate, and compare the performance of NiTi instruments inside the root canal.9 This methodology is applicable for not only in vitro but also in vivo measurement, as demonstrated by Gambarini et al.10 The main drawback of this kind of evaluation is the not well-determined correlation between the torsional and the flexural stresses; therefore, it is still unpredictable how each influence the other. In conclusion, the potential of real-time torque measurement is wide and still unexplored, but further studies are needed to better understand how torque is developed inside the root canal.

Outcomes of necrotic immature open-apex central incisors treated by MTA apexification using poly(ε-caprolactone) fiber mesh as an apical barrier.

BACKGROUND/PURPOSE: Although unset mineral trioxide aggregate (MTA) has some cytotoxicity, MTA is still a biocompatible material suitable for doing apexification. This study assessed the outcomes for 8 necrotic immature open-apex permanent maxillary central incisors treated by MTA apexification using poly(ε-caprolactone) fiber mesh (PCL-FM) as an apical barrier (so-called PCL-FM/MTA apexification) to prevent extrusion of MTA materials into the periapical tissues of open-apex teeth. METHODS: Eight necrotic immature open-apex permanent maxillary central incisors with the open apices measuring 2.5 mm-3.5 mm in diameter in 8 patients (6 boys and 2 girls; age range, 8-10 years) were first cleaned using ultrasonic activated irrigation with 2.5% sodium hypochlorite solution and then treated by PCL-FM/MTA apexification procedure. RESULTS: All the 8 permanent maxillary central incisors showed successful outcomes after PCL-FM/MTA apexification procedure. The mean duration for apical hard tissue barrier formation of the 8 incisors was 6.8 ± 0.5 weeks (range 6-7 weeks). The mean increased root length was 1.8 ± 0.7 mm (range 1-3 mm) at 7 weeks and 3.1 ± 0.6 mm (range 2-4 mm) at 3 months. The mean increased dentinal wall thickness at the most apical portion of the root was 1.3 ± 0.5 mm (range 1-2 mm) at 7 weeks and 2.4 ± 0.6 mm (range 1.5-3 mm) at 3 months. None of the teeth treated by PCL-FM/MTA apexification showed tooth discoloration after a follow-up period of 3 months. CONCLUSION: PCL-FM/MTA apexification is an excellent technique for treatment of necrotic immature open-apex permanent maxillary central incisors.

Enamel matrix derivative (Emdogain) in treatment of replanted teeth - a systematic review.

OBJECTIVE: The main purpose of the present systematic review was to evaluate the efficacy of enamel matrix derivative Emdogain in healing of replanted teeth in humans. MATERIALS AND METHODS: This review conducted in adherence to PRISMA standards and was registered in PROSPERO with registration number CRD42017062736. We graded the methodological quality of the studies by means of Cochrane's tool of risk of bias in non-randomized studies - of interventions (ROBINS-I). RESULTS: In total, 65 studies were identified for screening, and five studies were eligible. The uneventful healing of replanted teeth was varied from 20% to 75%. Two controlled trials found Emdogain treatment significantly reduced resorption of replanted teeth and improved the healing of periodontal ligament compared with controls. Two studies showed high recurrent resorption in Emdogain treated teeth. CONCLUSIONS: To conclude, the number of publications that met all inclusion criteria were limited and did not allow for drawing evidence for Emdogain being effective in supporting healing of replanted teeth.

Lasers in Apicoectomy: A Brief Review.

Since the invention of laser, various applications for lasers in endodontics have been proposed, such as disinfection of the root canal system, canal shaping, pulp diagnosis, and apico-ectomy. One of the major applications of laser in endodontics is apicoectomy. The aim of this article is to review the benefits and drawbacks of laser applications in apicoectomy, including effect on apical seal, effect on dentin permeability, effect on postsurgery pain, effect on crack formation, effect on root-end morphology, effect on treatment outcome, and connective tissue response to laser-treated dentin.

Evaluation of various filling techniques in distal canals of mandibular molars instrumented with different single-file nickel-titanium systems.

BACKGROUND AND AIMS: The aim of this study was to evaluate the quality of various filling techniques in distal canals of mandibular molars instrumented with different single-file nickel-titanium (NiTi) systems. MATERIALS AND METHODS: A total of 150 distal roots of mandibular molar teeth were randomly assigned into three main groups and instrumented by using Reciproc (VDW, Munich, Germany), WaveOne (Dentsply Tulsa, Tulsa, OK, USA), or One Shape (MicroMega, Besancon, France) NiTi file systems. The roots were then treated using one of five filling techniques: (1) Matched-single-cone, (2) cold lateral compaction with matched gutta-percha (GP) cone, (3) Thermafil filling, (4) System B/Obtura II, and (5) lateral compaction with standardized GP cones. The roots were then sectioned at three levels (coronal, middle, and apical). Photographs were acquired under a stereomicroscope, and the percentage of GP-filled areas (PGFAs), percentage of sealer-filled areas (PSFAs), and voids were measured using the ImageJ software. Comparisons between groups were applied using Student's t-test or one-way ANOVA for normally distributed data. The Mann-Whitney U-test or Kruskal-Wallis test was used when variables were not normally distributed. RESULTS: Canals filled with the System B/Obtura showed the highest PGFA and lowest PSFA, whereas those filled with matched-single-cone showed the highest PSFA and lowest PGFA (P < 0.05). The cold lateral compaction with matched GP cone group, lateral compaction group, and Thermafil filling group showed no statistically significant differences in PSFA and PGFA (P > 0.05). CONCLUSIONS: System B/Obtura technique appears to be the best technique to properly fill root canals, whereas the matched-single-cone technique in oval-shaped distal canals of mandibular molars was inadequate.

Endodontic treatment.

The Finnish guideline on endodontics emphasizes good quality of endodontic treatment and coronal seal of the restoration. For prevention of endodontic treatment need caries control is essential. For deep carious lesions stepwise excavation or partial caries removal are recommended. Partial pulpotomy can be used if bleeding can be controlled. The decision for root canal treatment is based on prognosis, occlusion and general health of the patient. The use of kofferdam is essential in aseptic working. Chemomechanical preparation with NaOCI and root canal filling within 0-2 mm from the apex improve prognosis. Healing should be controlled annually up to four years.

Pain following foraminal enlargement in mandibular molars with necrosis and apical periodontitis: A randomized controlled trial.

AIM: This randomized controlled trial was conducted to evaluate the effect of foraminal enlargement during chemomechanical root canal preparation on postoperative pain. METHODOLOGY: Seventy mandibular first molars with asymptomatic pulp necrosis and chronic apical periodontitis were randomized into two groups - foraminal enlargement (FE) and conventional nonforaminal enlargement (NFE). Canals were prepared according to the respective protocols, and the teeth were restored temporarily. Postoperatively, the patients were prescribed ibuprofen 400 mg, to be taken if required. Pain experience and analgesic intake were recorded for 7 days following chemomechanical preparation. The data were analysed using Mann-Whitney U-test and chi-square tests. RESULTS: Pain experience was higher with foraminal enlargement than when using a conventional technique. A significant difference was observed in postoperative pain during the first 4 days and the sixth day (P < 0.05), with greater pain in the FE as compared to the NFE group. There was no significant difference in prevalence of analgesic intake and number of doses between the experimental groups (P > 0.05). CONCLUSION: Enlargement of the apical foramen during root canal treatment increased the incidence and intensity of postoperative pain.

Modern Endodontic Planning Part 1: Assessing Complexity and Predicting Success.

Following a diagnosis of irreversible pulpal disease, periapical disease or failed endodontic therapy, the options for the tooth are extraction or root canal treatment. There is increasing evidence that certain factors may allow the clinician to predict the likely outcome of root canal therapy (RCT) and thus better inform the patient of the possible success rates. Should the patient choose root canal treatment, the clinician must also be able to gauge the potential difficulties that may be encountered and consequently determine whether it is within their competency. CPD/CLINICAL RELEVANCE: Assessing outcomes and complexity of care is an essential part of informed consent. Knowing when to refer is an essential component of best clinical practice.

Study of the anesthetic efficacy of inferior alveolar nerve block using articaine in irreversible pulpitis.

AIM: The purpose of this study was to determine the anesthetic efficacy of inferior alveolar nerve block (IANB) using 4% articaine and 2% lidocaine supplemented with buccal infiltration. MATERIALS AND METHODS: Forty five patients, diagnosed with irreversible pulpitis of a mandibular posterior tooth were included in the study. The first group of 15 patients received 2% lidocaine with 1:200000 epinephrine, the second group 2% lidocaine with 1: 80,000 epinephrine and the third group of 15 subjects received 4% articaine with 1:100000 epinephrine. During the access cavity preparation those patients who complained of pain received an additional buccal infiltration. The percentage of subjects who got profound anesthesia and failure to achieve anesthesia were calculated and tabulated using a visual analog scale. RESULTS: The results revealed that 87% of subjects who received 4% Articaine with 1:100,000 epinephrine got satisfactory anesthesia with inferior alveolar nerve block alone. Only 2 (13%) subjects received an additional buccal infiltration and none of the patients failed to obtain complete anesthesia with articaine. In comparison only 40% of subjects got complete anesthesia with 2% lidocaine with 1:200000 and 60% with 2% lidocaine with 1:80,000. CONCLUSION: It can be concluded that 4% articaine can be used effectively for obtaining profound anesthesia for endodontic procedures in patients with irreversible pulpitis.

A technique to salvage endodontically compromised maxillary anterior tooth.

A complication of endodontic treatment is over-preparation of the tooth structure in an attempt to access calcified pulp chambers and root canals. This could result in thin root walls that might compromise the long-term prognosis of the tooth. There are various treatment options when such a complication occurs, among them, extraction of the compromised tooth and its replacement with a dental implant. This clinical report describes a nonsurgical, multidisciplinary treatment alternative where a maxillary anterior tooth with a thinned root wall was successfully saved by repairing the damaged root to its original thickness using a composite resin material and subsequently restoring with a cast post and core and a crown.

Outcome of root canal retreatment filled with gutta-percha techniques: A systematic review and meta-analysis.

OBJECTIVE: The present systematic review and meta-analysis aimed to evaluate the success rate of root canal retreatment filled with gutta-percha and the variables related to retreatment success. DATA: The PRISMA guidelines were followed for the present review. The study protocol was registered in the International Prospective Database of Systematic Reviews (PROSPERO CRD42021283134). Risk assessment was performed using the Newcastle-Ottawa scale. Funnel plots were used to detect publication bias and asymmetry was assessed using Egger's tests. SOURCES: PubMed, Scopus, ScienceDirect, Cochrane, and additional sources were searched. STUDY SELECTION: Studies published until 10 December 2022. Clinical studies evaluating the success of root canal retreatment filled with gutta-percha with at least a 1-year follow-up were selected. RESULTS: Ten studies and one unpublished study fulfilled the inclusion criteria for quantitative analysis. The success rate of non-surgical root canal retreatment was 71% (95% CI: 66%-76%) with strict criteria and 87% (79% - 93%) with loose criteria for 1-3 years of follow-up, and 77% (66% - 86%) with strict criteria for a 4-5 years of follow-up. Endodontically retreated teeth with periapical lesions had a lower success rate under strict criteria. The tooth type, dental arch, initial periapical index (PAI) score, and the number of visits also affected the treatment success rate under strict criteria. For the loose criteria, teeth with larger periapical lesions and higher initial PAI scores had a lower success rate. CONCLUSIONS: According to the present systematic review and meta-analysis, non-surgical root canal retreatment results in favourable outcomes. The presence of a periapical radiolucency, periapical lesions >5mm, a higher initial PAI score, multiple-visit retreatments, and mandibular and molar teeth resulted in a lower success rate. CLINICAL SIGNIFICANCE: Non-surgical root canal retreatment filled with gutta-percha techniques is a relatively predictable procedure with a high success rate. Several variables can affect retreatment success, mainly the presence and size of a periapical lesion and the type of tooth.

Efficacy of Er,Cr:YSGG laser with endodontical radial firing tips on the outcome of endodontic treatment: blind randomized controlled clinical trial with six-month evaluation.

Clinical reports stating the efficacy of novel root canal disinfection protocols are an important focus in endodontic research. This blind randomized clinical trial assessed the clinical efficacy of the erbium, chromium:yttrium-scandium-gallium-garnet (Er,Cr:YSGG) laser radial firing tips (RFT) versus the concomitant use of 3 % sodium hypochlorite and interim calcium hydroxide paste in necrotic teeth with chronic apical periodontitis. We hypothesized to find similar or improved bone healing in the laser-assisted endodontic treatment. Thirty-six anterior and premolar teeth were randomly assigned. In group 1, teeth were prepared with 3 % sodium hypochlorite for irrigation and calcium hydroxide as inter-appointment dressing; in group 2, teeth were prepared with saline solution and irradiated with Er,Cr:YSGG laser using RFT2 (140 µs, 37.5 mJ, 20 Hz) and RFT3 (140 µs, 62.5 mJ, 20 Hz) in the first and second appointment, respectively, four times each, moving at 2 mm s(-1) from apical to coronal. The primary outcome measure was changed in apical bone density at 6 months, using the periapical index (PAI) for blind radiographic evaluation. Twenty-nine patients were examined and subjected to statistical analysis, 12 in group 1 and 17 in group 2. There was one treatment failure in group 1. Both groups gave similar outcomes exhibiting statistically significant decreases in PAI scores.

Clinical efficacy of various root canal obturating methods in primary teeth: a comparative study.

AIM: The purpose of this in vivo study was to evaluate and compare the efficacy of different obturating methods used in primary teeth, when obturated using a combination of zinc oxide and iodoform paste (Endoflas F.S.). MATERIALS AND METHODS: A group of 29 patients aged 3-9 years and a total of 64 teeth were selected. These 64 teeth (32 anterior teeth=32 canals, and 32 posterior teeth=80 canals) were randomly divided into 4 groups. Teeth were obturated with Lentulo spiral, pressure syringe, bi-directional spiral and Pastinject. Post-operative evaluation was done for: quality of canal obturation, (underfilled, optimally filled, overfilled) and presence of voids. RESULTS: Pastinject exhibited the highest number of optimally filled canals, while the highest number of underfilled canals were observed with bi-directional spiral, and the highest number of overfilled canals were observed with pressure syringe. A minimum number of voids was present in canals filled with the Pastinject technique and pressure syringe. CONCLUSION: These results suggest that Pastinject was the most effective technique for obturation of primary teeth.

Nonsurgical management of large periapical lesion in mature and immature teeth using different calcium hydroxide formulations: case series.

This case series evaluates the effectiveness of different calcium hydroxide formulations with various vehicles in management of large periapical lesion in mature and immature teeth. This will help clinicians to make informed judgments about which formulations of calcium hydroxide should be used for specific endodontic procedures.