Vital pulp therapy-Factors influencing decision-making for permanent mature teeth with irreversible pulpitis: A systematic review.

BACKGROUND: There is an increased tendency towards adopting minimally invasive interventions in dentistry, supported by advancement in materials and techniques. However, the decision-making process in choosing conservative or invasive treatments is influenced by several factors, particularly in permanent teeth with irreversible pulpitis. OBJECTIVES: The objective of the study was to systematically review the literature regarding factors that influence decision-making for vital pulp therapy (VPT) as definitive treatment option in permanent mature teeth diagnosed with irreversible pulpitis. METHODS: Two independent reviewers searched five electronic databases (PubMed, Embase, Web of Science, Scopus and Cochrane Library). Grey literature was searched through Google Scholar and contact with experts. Defined search keys were applied, and all peer-reviewed literature published with no language nor publication date limits were included. The All studies investigating the factors influencing treatment decision-making in mature permanent teeth with irreversible pulpitis were included. The quality of included studies was assessed by two independent reviewers using the Joanna Briggs Institute quality assessment tool. RESULTS: Six articles were included in the review. All included studies used questionnaires to characterize clinician preferences and attitudes in choosing treatment options for mature permanent teeth with irreversible pulpitis. The available evidence suggests that dentist-related factors have a significant influence on the chosen treatment in teeth with irreversible pulpitis, with speciality training and years of experience influencing the choice of VPT over other treatment options. COVID-19 reportedly swayed the dentists' decision to favour VPT. Only one article studied the influence of patient-related factors, such as age and presence of spontaneous pain on decision-making. Of note, a history of cardiovascular disease moved dentists towards prescribing VPT. DISCUSSION: Collectively, the included studies demonstrated an overriding influence of dentist-related factors on choosing among treatment options for painful teeth diagnosed with irreversible pulpitis. Patient-related factors were acknowledged but there are also potential factors such as socio-economic constraints that were not included in the component studies. CONCLUSION: In teeth with irreversible pulpitis clinicians educational background influence the decision towards a specific treatment option. Further data, preferably derived from clinical records, is necessary in future investigations to explore the effect of other important factors related to both dentists and patients. REGISTRATION: PROSPERO database (CRD42022339653).

Evaluating the stress of root canal treatment in patients and dentists compared to other dental treatments: A systematic review and meta-analysis.

This systematic review aimed to investigate whether root canal treatment caused greater stress than other dental treatments for patients and dentists. All peer-reviewed literature published in English between January 1990 and January 2023 was included. This included randomized/non-randomized control trials, cohort studies, case-control studies, and cross-sectional studies. An electronic search used PubMed, Scopus, Medline, Cochrane Collaboration, and Embase. Hand searching supplemented the screening pool. Studies examining physiological or psychological stress measures within patients or providers of dental treatment (dentists, dental specialists, and dental students) were eligible. The study must have reported on the stress outcome for root canal treatment and at least one other dental procedure. After screening 3639 eligible records, there were 23 studies included, varying from very-low to low certainty of evidence. This review found that root canal treatment was more psychologically stressful for patients than routine restorative or cleaning procedures. However, the stress of root canal treatment relative to other dental procedures, especially extractions, was inconclusive for both dental patients and providers. Since patients regard root canal treatment as more stress-evoking than other routine dental procedures, providers should endeavour to minimise their own bias toward root canal treatment when providing adequate information for an informed treatment choice.

Design of an interactive system for access cavity assessment: A novel feedback tool for preclinical endodontics.

INTRODUCTION: A software program was developed to provide visual, guided feedback to students for access cavity preparations in preclinical learning. The specific aim of the study was to investigate students' overall experiences with the new learning method and compare their experiences with traditional teaching. MATERIALS AND METHODS: A workflow based on freely available software was designed to interactively register three-dimensional models of molars with access cavities, and to metrically compare these to instructor-prepared standard cavities. Third-year students practicing molar endodontics access cavity preparation in the preclinical course were then surveyed. A total of 44/79 students completed self-administered questionnaires prior and after the use of the feedback software to gauge their learning experience. RESULTS: The results of the post-training questionnaire illustrated that all surveyed students agreed/strongly agreed that the software assisted their learning in access cavity preparation. In addition, 86 and 89%, respectively, of students agreed that the use of the software improved their skills of access cavity preparation and felt more confident about their access cavity preparation skills after using the software package, 3D Dental Align. DISCUSSION: The presented software solution permitted setting and comparing access cavity preparations by students against a standard access prepared by an instructor. The process of data acquisition and registration was fast and straightforward. Student feedback was very positive and suggested the integration of this type of experiential learning into the preclinical curriculum. CONCLUSION: This feasibility study demonstrated the utility of the new technology to assist dental students' access cavity preparation learning.

Dental trauma simulation training using four splinting models: A cross sectional study.

BACKGROUND/AIM: Opportunities for dental students to obtain clinical experience in the management of traumatic dental injuries are scarce, and most dentists encounter difficulties with their first trauma patients after graduation. The aim of this study was to question students on the ease of handling of four types of flexible splints, with two common methods of bonding to the tooth. MATERIAL AND METHODS: A total of 161 fourth year dental students completed a simulated treatment of an avulsed tooth using orthodontic wire, Twistflex wire, nylon fishing line, and Powermesh as splints. The bonding materials were composite resin (Spectra ST LV) or glass ionomer cement (GC Fuji LC Ortho). The students then answered 16 questions on a 5-point Likert scale, or with an open answer field. RESULTS: Most students agreed (48.8%) or strongly agreed (31.3%) that the simulated trauma exercise assisted their learning. There was strong agreement (68.8%) and agreement (28.7%) that the simulation added value to their dental training compared to didactic training only. Similarly, 52.3% of participants strongly agreed and 40% agreed that they felt engaged in the learning activity. Only 53.8% of the participants agreed and 7.5% strongly agreed that the simulation felt realistic. Most students (56.2%) found a Powermesh/composite splint was the easiest to place, and nylon fishing line/GC Fuji LC Ortho splints was the least difficult to remove (35%). CONCLUSION: Wire-free splints with composite bonding were judged as the easiest to place by students, while glass ionomer cement was the easiest to remove.

Comparison of calcium hydroxide extrusion with syringe versus spiral filler delivery: A pilot study.

This study aimed to evaluate Ca(OH)2 extrusion in relation to delivery technique, apical size and depth of placement. Plastic blocks had j-shaped canals shaped to apical sizes #35 and #45 (n = 32 each). Amounts of calcium hydroxide extrusion was determined relative to apical taper, depth of insertion and whether syringe or spiral filler at 500 rpm was used. Blocks were immersed in pH-sensitive gel and observed for colour change. Extent of extrusion was expressed in mm2 . Extrusion occurred in 48/64 of the samples. At 3 mm from the canal terminus, the device affected the frequency of extrusion, with syringe placement causing extrusion significantly (P < 0.01) more frequently, irrespective of apical size. Extrusion was significantly greater at 2 mm short of the canal terminus (median 27.44 mm2 ) compared to 3 mm (median 19.69 mm2 ). Under in-vitro conditions, a spiral filler at 500 rpm, 3 mm short of the apex, minimised extrusion of Ca(OH)2 from root canals.

The double-edged sword of calcium hydroxide in endodontics: Precautions and preventive strategies for extrusion injuries into neurovascular anatomy.

BACKGROUND: Nowhere in the consideration of dental care involving endodontics does a patient become more vulnerable to potentially life-changing injuries than during a root canal procedure on the mandibular dentition that may invade and injure the neurovascular anatomy. CASE DESCRIPTION: The authors present a series of 5 cases wherein using calcium hydroxide as a disinfection strategy in endodontics caused serious neurologic injury to the treated patients. The mechanism in all cases was the inappropriate use of needle applications resulting in significant overfill into the inferior alveolar nerve space. Although calcium hydroxide has been recognized and used as a meaningful disinfectant in endodontic therapy for many years, the dangers and risks associated with a needle delivery technique are discussed and analyzed with recommendations based on current research to minimize risk. CONCLUSIONS AND PRACTICAL IMPLICATIONS: A literature search revealed that the 5 cases are not solitary cases; indeed, consequences of calcium hydroxide overfills have been described before. Therefore, a clinician initiating root canal therapy on a mandibular posterior tooth should always be mindful of the vital neurovascular anatomy, which commonly approximates the ends of these roots. Preoperative cone-beam computed tomographic imaging and the thoughtful delivery of medicaments in treatment can help the clinician manage close proximity to neural anatomy and avoid potential injuries.

Rotary Versus Reciprocation Root Canal Preparation: Initial Clinical Quality Assessment in a Novice Clinician Cohort.

INTRODUCTION: Reports comparing clinical outcomes using nickel-titanium (NiTi) reciprocating instruments with other instrumentation modalities are scarce. This study examined initial shaping outcomes after an instrumentation change of root canal instrumentation technique in a doctor of dental surgery educational program. Student characteristics, faculty/student ratio, facility, and overall endodontic treatment guidelines remained unchanged. METHODS: A total of 200 nonsurgical initial molar root canal treatments completed by third-year dental students were evaluated. The cases were examined regarding the number of treatment appointments, access cavity preparation, canal taper, canal transportation, perforations, missed canals, presence of ledges, fractured instruments, obturation length, obturation quality, and sealer extrusion. Two independent evaluators determined the number of appointments per case; 4 independent and blinded evaluators analyzed radiographs at 4 treatment stages: preoperative situation, working length, cone fit, and obturation. RESULTS: The following factors were significantly different between the 2 cohorts: the number of appointments, preparation length, taper, and occurrence of ledges. The WaveOne (Dentsply Sirona, York, PA) cohort had a significantly reduced treatment time compared with hand/GT rotary instrumentation (Dentsply Tulsa Dental, Tulsa, OK) (average of 3.3 vs 4.3 appointments). Appropriate length control and adequate taper were significantly more frequent in the WaveOne group. The frequency of ledges was significantly larger in the hybrid group. Other variables, such as access cavity preparation, canal transportation, perforations, missed canals, fractured instruments, obturation quality, and sealer extrusion, were statistically similar between the 2 groups. CONCLUSIONS: NiTi reciprocation instrumentation was superior to hybrid hand/NiTi rotary instrumentation in reducing both patient appointments and the incidence of ledging and in improving obturation length and taper in a dental student clinic setting.

Comparison of 2 canal preparation techniques in the induction of microcracks: a pilot study with cadaver mandibles.

INTRODUCTION: The purpose of this pilot study in a cadaver model was to compare 2 different shaping techniques regarding the induction of dentinal microcracks. METHODS: Three lower incisors from each of 6 adult human cadaver skulls were randomly distributed into 3 groups: the control group (CG, no instrumentation), the GT group (GT Profile hand files; Dentsply Tulsa Dental, Tulsa, OK), and the WO group (WaveOne; Dentsply Tulsa Dental). In the GT group, manual shaping in a crown-down sequence with GT Profile hand files was performed. In the WO group, Primary WaveOne files were used to the working length. Teeth were separated from the mandibles by careful removal of soft tissue and bone under magnification. Roots were sectioned horizontally at 3, 6, and 9 mm from the apex using a low-speed saw. Color photographs at 2 magnifications (25× and 40×) were obtained. Three blinded examiners registered the presence of microcracks (yes/no), extension (incomplete/complete), direction (buccolingual/mesiodistal), and location. Data were analyzed with chi-square tests at P < .05. RESULTS: Microcracks were found in 50% (CG and GT) and 66% (WO) of teeth at 3 mm, 16.6% (CG) and 33.3% (GT and WO) at 6 mm, and 16.6% in all 3 groups at 9 mm from the apex. There were no significant differences in the incidence of microcracks between all groups at 3 (P = .8), 6 (P = .8), or 9 mm (P = 1). All microcracks were incomplete, started at the pulpal wall, and had a buccolingual direction. CONCLUSIONS: Within the limitations of this pilot study, a relationship between the shaping techniques (GT hand and WaveOne) and the incidence of microcracks could not be shown compared with uninstrumented controls.

The effect of three rotational speed settings on torque and apical force with vortex rotary instruments in vitro.

INTRODUCTION: Both the number of rotations in curved canals and torque are related to fracture resistance of nickel-titanium rotaries via the respective mechanisms of brittle and flexural failure. Increased rotational speed (rotations per minute [RPM]) may lead to higher cutting ability and could overcompensate for increased fatigue. The impact of three RPM settings on peak torque (Nmm) and apically directed force (N) during root canal preparation were investigated in vitro. METHODS: S-shaped canals in plastic blocks (n = 12/group) were instrumented with Vortex rotaries (Dentsply Tulsa Dental, Tulsa, OK) sizes #15 to 30 with a .04 taper. Rotaries were used in a manufacturer-recommended sequence: #30, 25, and 20 in a crown-down approach progressively deeper into the canal, #15 to the working length, and apical enlargement with sizes 20 and 25 to WL. A total of 216 preparation procedures were performed using a custom testing platform. RPM was set at 200, 400, or 600; automated axial feed mirrored clinical handling, resulting in two in-and-out movements, each to preset insertion depths. Torque and apical force were continuously recorded and peak values statistically contrasted using analysis of variances. RESULTS: No file fractures were observed in any of the three experimental groups. Peak torques and forces varied by instrument size and were highest at 200 RPM for all sizes; torque and force were reduced by 32% and 48%, respectively, at 400 RPM (P < .001). Increasing RPM to 600 did not result in further reductions. The number of discernible peaks for torque (threshold: 0.3 Nmm) and force (threshold: 0.2 N) significantly decreased from 200 RPM to 400 RPM and did not decrease further with 600 RPM. CONCLUSIONS: Under the present experimental conditions, rotational speed had a significant impact on preparation with Vortex rotaries, with instruments at 400 RPM generating less torque and force compared with 200 RPM.

Homogeneity of root canal fillings performed by undergraduate students with warm vertical and cold lateral techniques.

OBJECTIVES: The aim of this study was to determine radiographic and microscopic appearances of root canal fillings performed by undergraduate students using vertical and lateral compaction techniques. STUDY DESIGN: Thirty dental students were instructed how to fill curved simulated canals with gutta-percha and sealer using lateral and vertical compaction. Digital radiographs were taken in buccolingual and mesio-distal projections; radiographs were evaluated for homogeneity and root canal wall contact. Plastic blocks with simulated canals were sectioned and cross sections were assessed under a light microscope for voids. Probabilities were expressed as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Radiographs showed that the chances of obtaining a homogeneous root canal filling by using a vertical compaction technique were 3 times higher in the coronal canal third (OR 3.2; CI: 1.9, 5.3), the same in the middle third, and 2 times higher in the apical third (CI: 1.1, 2.4) than when using lateral compaction. Microscopic evaluation of the same canals revealed that the chances of obtaining a homogeneous root canal filling by vertical compaction were 3 times higher in the coronal canal third (CI: 1.6, 5.8), almost 3 times higher in the middle canal third (CI: 1.6, 4.7), and about 10 times higher in the apical canal third (OR 9.8; CI: 2.2, 43.4) than by lateral compaction. The chances of transporting filling material beyond the apex were almost 5 times higher (OR 4.6; CI: 2.8, 7.6) when using vertical rather than lateral compaction. CONCLUSION: Inexperienced students obtained more homogeneous root canal fillings with the vertical compaction method; however, the probability of overextruding filling material with this method was high.

Soft tissue management in endodontic surgery.

Modern endodontic surgery involves both root-end preparation and proper sealing of all apical portals of exit. Both components are requirements for mechanical and biological success, but the management of soft tissues becomes increasingly important for an esthetically successful treatment. A healthy appearance of soft tissues plays an important role in the esthetic outcome of periradicular surgery. This is true considering maintenance of attachment levels and regarding the amount of possible recession after surgical procedures. Complete, recession-free and predictable healing of gingival tissue is one important goal of endodontic surgical treatment. A critical review of currently used techniques based on clinical and scientific data reveals great potential for improvements. Possible reasons for scar formation and recession specifically in healthy periodontal conditions requiring surgical endodontic intervention are highlighted. Based on anatomical considerations various incision types are evaluated and recommendations made. Clear understanding of wound closure and tissue-healing patterns call for the use of atraumatic procedures, nonirritating suture materials and adequate suturing techniques. This article gives an overview and guidance for integrating current and new successful flap designs and wound closure methods. The methods described have the intention of maintaining the attachment level and avoiding postoperative recession after surgical endodontic therapy.