Comparison of endodontic diagnosis and treatment planning decisions using cone-beam volumetric tomography versus periapical radiography.

INTRODUCTION: Accurate and confident treatment planning is an essential part of endodontic practice. Periapical radiographs have been used to aid in the diagnosis of pathology and to help establish an appropriate treatment strategy. Recently, a new imaging modality, cone-beam volumetric tomographic (CBVT) imaging, has been shown to be a useful tool in a number of endodontic applications. The aim of this study was to compare the relative value of preoperative periapical radiographs and CBVT scanning in the decision-making process in endodontic treatment planning. METHODS: Thirty endodontic cases completed in a private endodontic practice were randomly selected to be included in this study. Each case was required to have a preoperative digital periapical radiograph and a CBVT scan. Three board-certified endodontists reviewed the 30 preoperative periapical radiographs. Two weeks later, the CBVT volumes were reviewed in random order by the same evaluators. The evaluators were asked to select a preliminary diagnosis and treatment plan based solely on their interpretation of the periapical and CBVT images. Diagnosis and treatment planning choices were then compared to determine if there was a change from the periapical radiograph to the CBVT scan. RESULTS: A difference in treatment plan between the 2 imaging modalities was recorded in 19 of 30 cases (63.3%, P = .001), 17 of 30 cases (56.6%, P = .012), and 20 of 30 cases (66.7%, P = .008) for examiners 1, 2, and 3, respectively. CONCLUSIONS: Under the conditions of this study, preoperative CBVT imaging provides additional information when compared with preoperative periapical radiographs, which may lead to treatment plan modifications in approximately 62% of the cases.

Applicant selection procedures in endodontic specialty programs in the United States: program director's perspective.

INTRODUCTION: The purpose of this study was to determine the criteria evaluated by directors of endodontic specialty programs in the United States when selecting their residents and their satisfaction with the current process. Besides this, the study also aimed to determine the expected effect of the change in National Board Dental Examination (NBDE) score reporting to pass/fail on applicant evaluation. METHODS: A 38-question web-based survey was distributed to the 54 endodontic specialty program directors (of 55 programs) in the United States. Questions regarded general program information, information obtained from applications, the interview process, the decision process, a retrospective view of the selection process, and director demographics. RESULTS: Twenty-six (48.1%) responses were returned and analyzed. The most important application factors were interview ratings, dental school class rank, and general practice residency or advanced education in general dentistry experience. The most preferred sources for letters of recommendation were endodontic pre- and postdoctoral program directors and other academic endodontists. Desirable applicant characteristics included enthusiasm, listening skills, and verbal skills. Program directors indicated concern regarding the initial screening of applicants after the NBDE scoring change but not as much concern relating to final selection. Respondents generally supported a uniform acceptance date but did not support participation in the Postdoctoral Dental Matching Program (the Match). CONCLUSIONS: Some important criteria when selecting prospective residents were identified. Program directors did not appear overwhelmingly concerned with the changes in NBDE score reporting. In addition, the establishment of a uniform acceptance date may resolve the biggest problem most respondents have with the current selection process.

The effects of beverages on plaque acidogenicity after a sugary challenge.

BACKGROUND: Caries prevention traditionally has emphasized the restriction of cariogenic foods and beverages, but it has placed less emphasis on how the choice, combination and sequence of consumed foods and beverages may help reduce plaque acidogenicity. The authors conducted a study to examine whether whole milk, 100 percent apple juice or tap water affect dental plaque acidity in people after a sugary challenge. METHODS: Twenty adults participated in a randomized controlled crossover study. Participants consumed four combinations of foods: 20 grams of dry sugary Froot Loops (FL) (Kellogg's, Battle Creek, Mich.) cereal, 20 g of FL followed by 50 milliliters of milk (FL/milk), 20 g of FL followed by 50 mL of juice (FL/juice) and 20 g of FL followed by 50 mL of water (FL/water). The authors used a touch microelectrode to take plaque pH readings at the interproximal space just below the contact area between the maxillary premolars on both left and right sides at two and five minutes after FL consumption and at two to 30 minutes after milk, juice or water consumption. RESULTS: Consumption of FL plaque pH (standard deviation [SD]) was 5.83 (0.68) at 30 minutes, whereas plaque pH (SD) in the FL/milk group was 6.48 (0.30), which was significantly higher than that for FL/juice (5.83 [0.49]) or FL/water (6.02 [0.41]) (P < .005) at 35 minutes. CONCLUSION: Drinking milk after a sugary cereal challenge significantly reduced plaque pH drop due to the sugary challenge. PRACTICAL IMPLICATIONS: When discussing the cariogenicity of foods and beverages with patients, dentists and other health care professionals should emphasize that the order of ingesting sugary and nonsugary foods is important and may affect their oral health.

Different representations of vertical root fractures detected by cone-beam volumetric tomography: a case series report.

INTRODUCTION: Vertical root fractures (VRFs) pose a clinical dilemma and a challenge to clinicians. Definitive diagnosis is often complicated by the lack of consistent signs and symptoms and the low sensitivity of conventional radiographs in the detection of VRFs. New radiographic imaging systems have recently become available for use in dentistry. Among these new imaging technologies is cone-beam volumetric tomography (CBVT). CBVT technology allows the precise visualization and evaluation of teeth with VRFs. The use of CBVT has great potential as a diagnostic tool to assist in the detection of VRFs. METHODS: Seven cases are presented to demonstrate the use of CBVT in detection of VRFs in endodontically treated teeth. RESULTS: Five specific findings on CBVT exam were consistent with confirmed VRFs. CONCLUSIONS: As demonstrated in this case series, CBVT can provide valuable additional diagnostic information in the detection of VRFs and may help prevent unnecessary treatment.

Efficacy of berberine, an antimicrobial plant alkaloid, as an endodontic irrigant against a mixed-culture biofilm in an in vitro tooth model.

INTRODUCTION: Berberine, a plant alkaloid isolated from many medicinal plants, has shown antimicrobial activity against selected oral pathogens. The purpose of this investigation was to evaluate the antimicrobial efficacy of berberine solution against selected endodontic pathogens using a multispecies biofilm tooth model. METHODS: The bacterial species used in the multispecies biofilm tooth model were Fusobacterium nucleatum, Enterococcus faecalis, and Prevotella intermedia. Extracted human anterior teeth were collected and standardized to a length of 14.0 mm. Teeth were cultured in Schaedler broth with the 3 test bacteria strains for 21 days and then randomly assigned to 6 treatment groups (ie, sterile saline, 5.25% NaOCl, 2% chlorhexidine [CHX], 1% CHX, 2 mg/mL berberine, and 1 mg/mL berberine plus 1% CHX). The teeth were instrumented to size 35/.06 and irrigated with 6 mL irrigant for 2 minutes. Surviving bacteria were sampled before and after instrumentation. Data were analyzed using analysis of variance (P < .05) followed by the Scheffé test. RESULTS: The minimal inhibitory concentration of berberine against F. nucleatum, P. intermedia, and E. faecalis was 31.25 µg/mL, 3.8 µg/mL, and 500 µg/mL, respectively. Instrumentation and irrigation resulted in 99% bacterial reduction in all groups. All tested solutions resulted in a statistically significant reduction in bacteria when compared with the saline control. When used alone, berberine (2 mg/mL) was less effective than the other test irrigants. However, when combined with 1% CHX, berberine (2 mg/mL) was comparable in bactericidal activity with 5.25% NaOCl, 2% CHX, and 1% CHX (Table 2). CONCLUSIONS: Berberine was more effective than saline as an endodontic irrigant against selected endodontic pathogens in vitro and, when combined with CHX, was comparable with NaOCl in its bactericidal efficacy.

Separation anxiety: Gates-Glidden drills can be hazardous to your health.

INTRODUCTION: Gates-Glidden drills are commonly used during endodontic therapy to aid in the development of straight-line access and coronal enlargement of the root canal. The drills come in various sizes and are typically used in a low-speed air-driven or electric handpiece. As a safety feature to aid in retrieval if separation of the drill occurs during use, Gates-Glidden drills are designed to separate near the hub of the drill to allow for easier retrieval. METHODS: This case report presents a potentially serious complication associated with the use of Gates-Glidden drills. RESULTS: A contaminated drill became embedded in the arm of an endodontic resident and required surgical removal. CONCLUSIONS: Proper office safety precautions can help prevent accidents that may result in serious injury.

Biomimetic approach to perforation repair using dental pulp stem cells and dentin matrix protein 1.

INTRODUCTION: Dentin regeneration could be an ideal treatment option to restore tissue function. This study was conducted to evaluate the ability of dental pulp stem cells (DPSCs) and dentin matrix protein 1 (DMP1) impregnated within a collagen scaffold to regenerate dentin. METHODS: Simulated perforations were created in 18 dentin wafers made from freshly extracted human molars. Six groups were established. They were (1) empty wafers, (2) mineral trioxide aggregate, (3) collagen scaffold, (4) scaffold with DMP1, (5) scaffold with DPSCs, and (6) scaffold with DPSCs and DMP1. One sample was placed subcutaneously in each mouse with three mice in each group. After 12 weeks, the samples were subjected to radiographic, histological, and immunohistochemical evaluations. RESULTS: DPSCs impregnated within a collagen scaffold differentiated into odontoblast-like cells forming a highly cellular, vascular, and mineralized matrix in the presence of DMP1. CONCLUSIONS: A triad consisting of DPSCs, DMP1, and a collagen scaffold promotes dentin regeneration in a simulated perforation repair model.

The prevalence of persistent pain after nonsurgical root canal treatment.

OBJECTIVE: To investigate the prevalence of persistent pain of neuropathic origin after nonsurgical root canal treatment and to determine its characteristics, location, and severity utilizing a self-reported validated postal survey. METHOD AND MATERIALS: A modified version of the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) survey was mailed to 2,338 adult subjects who received a single-tooth nonsurgical root canal treatment at the University of Illinois at Chicago College of Dentistry Postgraduate Endodontics Clinic over a 4-year period. Two-hundred and fifty (10.7%) completed surveys were returned. Descriptive analysis, Pearson correlation to determine correlations between the S-LANSS scores and variables of interest, and t tests for group comparisons of the S-LANSS score were performed. Statistical significance was determined at P<.05. RESULTS: The prevalence of persistent pain of neuropathic origin among respondents after receiving single-tooth nonsurgical root canal treatment was 7% with the average pain reported as 7.2 on a visual analogue scale (where 0 is no pain and 10 is pain as severe as it could be). Neuropathic pain was more common in middle-aged (mean 50.6 years of age) individuals with no sex predilection and occurred more frequently in the mandibular arch without any differences attributable to the number of canals treated. Also, the majority of subjects most frequently endorsed their pain experiences as abnormal sensitivity to touch and pain when the area is pressed or rubbed. CONCLUSION: Dental providers need to recognize and understand the differences between nociceptive and neuropathic pain. Understanding these concepts will assist in preventing inappropriate, irreversible, and unnecessary interventions.

Orofacial injuries due to trauma following motor vehicle collisions: part 1. Traumatic dental injuries.

Dental providers must determine the presence of orofacial injury, and diagnose and treat dental and orofacial outcomes of trauma caused by motor vehicle collisions. Determination of causation and relation to the trauma is indicated. Dental trauma includes concussion, subluxation and dislocation of teeth, and fracture of teeth and maxillofacial bone, in addition to soft tissue injury that may cause ecchymosis, hematoma and laceration or abrasion. This article focuses on orofacial injury and dental complaints following motor vehicle collisions, while part 2 focuses on temporomandibular symptoms.

Biologic markers for odontogenic periradicular periodontitis.

INTRODUCTION: The diagnosis and assessment of apical periodontitis by traditional periapical radiographs can be challenging and might yield false-negative results. The aim of this study was to determine whether interleukin-1beta (IL-1beta) and dentin sialoprotein (DSP) in gingival crevicular fluid (GCF) can be used as biological markers for apical periodontitis. METHODS: Forty healthy patients with teeth diagnosed with apical periodontitis of pulpal origin were included in the study. GCF samples were obtained from the diseased tooth and from a healthy contralateral control tooth. Total protein concentration in each sample was determined by using the Bio-Rad protein assay. Enzyme-linked immunosorbent assay was used to analyze the concentration of IL-1beta and DSP in the samples. RESULTS: Protein content of the GCF was statistically significantly higher in the disease group compared with the control group. The levels of IL-1beta and DSP were not statistically different between disease and control groups. CONCLUSIONS: Although this study was unable to demonstrate a significantly higher level of IL-1beta or DSP in the GCF of teeth with apical periodontitis, the observed presence of a significantly higher level of total protein in the GCF of diseased teeth suggests the possible role of total protein level as a marker for periapical disease.

Identify and determine the metrics, hierarchy, and predictive value of all the parameters and/or methods used during endodontic diagnosis.

A Consensus Conference on Terminology was convened by the American Association of Endodontists in Chicago on Oct 3, 2008 to review solicited papers on focused questions. This paper addressed the question: Identify and determine the metrics, hierarchy, and predictive value of all the parameters and/or methods used during endodontic diagnosis. The best available clinical evidence was used to determine the sensitivity, specificity, and predictive value of pulpal and periapical testing methods and imaging technologies. Diagnosis of dental pulp diseases suffers from operator's inability to test/image that tissue directly due to its location within dentin. In general, current pulp tests are more valid in determining teeth that are free of disease, but less effective in identifying teeth with pulp disease. Radiographic imaging is probably the most commonly used diagnostic tool to determine the status of root-supporting tissue, although interpretation of structural changes in the periradicular tissues is still considered unreliable.

Endodontic access.

Access preparation may be the single most important mechanical phase of root canal therapy. This article reviews the essential components of good access design and research intended to help guide treatment planning and clinical treatment, with an emphasis on using available information to develop a three-dimensional mental image of the tooth prior to endodontic access, allowing for safe and efficient endodontic therapy. Guidelines for developing an ideal access form, locating small and calcified canals, and avoiding iatrogenic mishaps are presented. Specific tools for efficient access preparation are identified and explained; in addition, case selection and indications for possible referral to a specialist are discussed.

Differences in clinical decision making: a comparison between specialists and general dentists.

OBJECTIVE: The aim of this study was to compare clinical decision making choices of general dentists, prosthodontists, endodontists, oral surgeons,and periodontists when presented with endodontics-related patient scenarios. STUDY DESIGN: A survey instrument with 5 patient scenarios was mailed to 1,250 randomly selected dentists, 250 in each group noted above. The participants were asked to choose from different treatment options and to assess the difficulty of making their choice. The answers were analyzed to identify differences in clinical decision making between groups. RESULTS: A total of 293 surveys were returned, for an overall response rate of 23.4%. Significant differences in treatment planning decisions between the 5 groups were found. Practitioners expressed more difficulty and more variation in making treatment recommendations in cases involving previously endodontically treated teeth than initial treatment scenarios. CONCLUSIONS: Dental specialty status has a significant influence on a clinician's recommendation to perform root canal therapy or extract a tooth.

In vivo generation of dental pulp-like tissue by using dental pulp stem cells, a collagen scaffold, and dentin matrix protein 1 after subcutaneous transplantation in mice.

The presence of a perforation is known to significantly compromise the outcome of endodontic treatment. One potential use of regenerative endodontic therapy might be the repair of root canal perforations. In addition to nutrients and systemic in situ interactions, the 3 main components believed to be essential for tissue regeneration are stem cells, scaffold, and growth factors. This study investigated the role of each component of the tissue engineering triad in the organization and differentiation of dental pulp stem cells (DPSCs) in a simulated furcal perforation site by using a mouse model. Collagen served as the scaffold, and dentin matrix protein 1 (DMP1) was the growth factor. Materials were placed in simulated perforation sites in dentin slices. Mineral trioxide aggregate was the control repair material. At 6 weeks, the animals were killed, and the perforation sites were evaluated by light microscopy and histologic staining. Organization of newly derived pulp tissue was seen in the group containing the triad of DPSCs, a collagen scaffold, and DMP1. The other 4 groups did not demonstrate any apparent tissue organization. Under the conditions of the present study, it might be concluded that the triad of DPSCs, a collagen scaffold, and DMP1 can induce an organized matrix formation similar to that of pulpal tissue, which might lead to hard tissue formation.

Outcome of one-visit and two-visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation.

The choice of one-visit versus two-visit root canal therapy for necrotic teeth with apical periodontitis is a source of current debate. The primary objective of this randomized controlled clinical trial was to compare radiographic evidence of periapical healing after root canal therapy completed in one visit or two visits with an interim calcium hydroxide/chlorhexidine paste dressing. Ninety-seven patients met the inclusion criteria and consented to participate in this study. Patients were randomly assigned to either the one-visit or two-visit group, and root canal therapy was performed with a standardized protocol. Patients in the two-visit group received an intracanal dressing of calcium hydroxide/chlorhexidine paste. Sixty-three patients, 33 in the one-visit group and 30 in the two-visit group, were evaluated at 12 months. The primary outcome measure was change in apical bone density by using the periapical index (PAI). Secondary outcome measures were proportion of teeth healed or improved in each group. Both groups exhibited equally favorable periapical healing at 12 months, with no statistically significant differences between groups.

Strategic partnerships between academic dental institutions and communities: addressing disparities in oral health care.

BACKGROUND: A landmark report from the U.S. surgeon general identified disparities in oral health care as an urgent and high-priority problem. A parallel development in the dental education community is the growing consensus that significant curriculum reform is long overdue. METHODS: The authors performed a literature review and conducted a series of structured interviews with key institutional and community stakeholders from seven geographical regions of the United States. They investigated a wide range of partnerships between community-based dental clinics and academic dental institutions. RESULTS: On the basis of their interviews and literature review, the authors identified common themes and made recommendations to the dental community to improve access to care while enhancing the dental curriculum. CONCLUSIONS: Reducing disparities in access to oral health care and the need for reform of the dental curriculum may be addressed, in part, by a common solution: strategic partnerships between academic dental institutions and communities. Practice Implications. Organized dentistry and individual practitioners, along with other major stakeholders, can play a significant role in supporting reform of the dental curriculum and improving access to care.

Use of an Electronic Patient Record system to evaluate restorative treatment following root canal therapy.

Electronic Patient Record (EPR) systems are rapidly gaining acceptance as an important tool for managing patient information. The purpose of this project was to evaluate the use of an EPR system for assessment of quality of care in an academic dental institution. The primary outcome of interest was the timeliness and completeness of restorative care following completion of nonsurgical root canal therapy. An initial query of the EPR database was performed using the following inclusion criteria: root canal treatment performed in the postgraduate endodontics clinic between September 2002 and June 2004, patient age > or =18 years old, and posterior tooth (premolars and molars). A total of 925 patients with 1,014 endodontically treated teeth met the inclusion criteria. A random sample of 30 percent of the treated teeth (302 teeth on 281 patients) was selected for detailed review. This sample of 302 teeth was then screened to determine if any restorative treatment had been performed between September 2002 and November 2005. Forty-eight percent (n=146) of the 302 teeth did not receive any form of permanent restoration over the time period studied. Twenty-five percent (n=75) of the teeth received a buildup only, and 27 percent (n=82) received the recommended treatment, a full occlusal coverage restoration. This study documents the use of an EPR system to objectively and efficiently assess one aspect of quality of care in a dental school environment.

Antimicrobial effect of triclosan and triclosan with Gantrez on five common endodontic pathogens.

Microbial control of the root canal system is one of the key objectives of root canal therapy. Triclosan is a widely accepted broad spectrum antimicrobial agent proven to be effective against many gram-positive and gram-negative bacteria. Triclosan acts by blocking bacterial fatty acid biosynthesis. The addition of Gantrez copolymer has been shown to enhance the antimicrobial activity of triclosan. The purpose of this study was to determine the minimum inhibitory and bactericidal concentrations of triclosan and triclosan with Gantrez against Prevotella intermedia, Fusobacterium nucleatum, Actinomyces naeslundii, Porphyromonas gingivalis, and Enterococcus faecalis. The minimum inhibitory concentration (MIC) of both test solutions was determined for each of the 5 microorganisms by using microtiter serial dilutions. Samples were streaked on 5% sheep blood agar plates and placed in an anaerobic incubator to determine the minimum bactericidal concentration (MBC). The MBC of triclosan ranged from 12-94 microg/mL. The MBC of triclosan with Gantrez ranged from <0.3-10.4 microg/mL. The addition of Gantrez enhanced the bactericidal activity of triclosan. Both triclosan and triclosan with Gantrez demonstrated bactericidal activity against the 5 specific endodontic pathogens.

A scanning electron microscopy evaluation of microfractures, deformation and separation in EndoSequence and Profile nickel-titanium rotary files using an extracted molar tooth model.

The development of microfractures in the EndoSequence nickel-titanium rotary (NTR) file (Brassler USA, Savannah, GA) and Profile NTR file was evaluated by using scanning electron microscopy (SEM). Seventy-three maxillary buccal roots and 53 mandibular mesial roots with an average canal curvature of 37 degrees were randomly assigned to one of three groups and prepared with 21-mm .06 taper NTR files as follows: (1) EndoSequence at 300 rpm, (2) EndoSequence at 600 rpm, and (3) ProFile at 300 rpm. File sizes .45 to .20 were used in a crown-down technique to a master apical file (MAF) size of .35/.06. The MAF instruments were evaluated by SEM before use, after completion of 7 canals, and after completion of 14 canals. All EndoSequence instruments developed microfractures by the seven-canal evaluation. The ProFile instruments showed no microfractures at the 7- or 14-canal evaluations. EndoSequence files separated at a higher rate than ProFile instruments. Under the conditions of this study, unique file design and electropolishing did not inhibit the development of microfractures in EndoSequence NTR.