What ultimately matters in root canal treatment success and tooth preservation: A 25-year cohort study.

AIM: There are currently no prospective studies evaluating the long-term outcomes of non-surgical root canal treatments beyond 5 years, both in terms of treatment success and tooth preservation, and identifying factors predictive of treatment outcome. The aim of the present work was therefore to fill this gap by assessing these outcomes over time and identifying predictive variables based on systematic data collection over a 25-year period. METHODOLOGY: Data concerning the treatments (N = 2500) were systematically collected since 1990. Information was recorded among clinical, technical, radiographic and patient-related characteristics, i.e., approximately 150 variables for each treatment. The data were analysed regarding both treatment success and tooth preservation by multivariable Cox proportional hazards model, and survival curves were generated. The statistical significance level was set at 0.0125. RESULTS: In total, 56.4% of the treatments could be followed over time (0-25 years, mean = 6.5 years, median = 5 years). Survival probability decreased almost linearly for treatment success, with about 85% after 5 years and 60% after 20 years, and for tooth preservation, with about 90% at 5 years and 50% at 20 years. The variables significantly associated with treatment failure were: pre-operative pain (Hazard Ratio-HR = 1.56 [95% CI 1.23-1.97]), persistent pain (HR = 2.63 [95% CI 1.44-4.80]), good operator rating of treatment prognosis (HR = 0.46 [95% CI 0.36-0.58]), size of periapical bone radiolucency (HR = 1.88 [95% CI 1.67-2.11]), and tooth type (p = .0006). For tooth extraction, they were: combined endodontic-periodontal lesion (HR = 3.37 [95% CI 1.88-6.05]), pre-existing complication before treatment (HR = 1.67 [95% CI 1.26-2.21]), good operator rating of treatment prognosis (HR = 0.45 [95% CI 0.33-0.60]), clinical failure of root canal treatment (HR = 2.78 [95% CI 1.98-3.89]) and tooth type (p = .0012). CONCLUSION: Root canal treatment success and tooth preservation on the arch are not static outcomes, but evolve with time. Among a substantial set of potential predictors, only a small proportion was significantly predictive of treatment success and tooth preservation, most of them being disease and patient characteristics, and not technical aspects, except pre-existing complications. These observations challenge the importance frequently given to byzantine considerations related to the numerous technical details of endodontic procedures, as opposed to general concepts of good clinical practice.

Pulp therapy for primary and immature permanent teeth: an overview.

Pulp therapy for pediatric patients aims to alleviate pulpal infection, relieve associated symptoms, and, ultimately, preserve the tooth. Primary teeth adequately retain space for their successors and have been described as "the best space maintainers." Therefore, the decision to extract a primary tooth should take into consideration occlusal growth and development as well as the potential outcome of pulp therapy. Maintaining pulpal vitality in young permanent teeth is essential for continued root formation; if vitality is lost, the root will cease growth and remain at an unfavorable length. A systematic approach to diagnosis and treatment planning is imperative, and a good history of signs and symptoms and a detailed evaluation of radiographs are prerequisites to accurate diagnosis. The purpose of this review is to aid dental professionals in correctly establishing a pulpal diagnosis and selecting the appropriate method of pulp therapy to achieve a successful outcome. The article discusses contemporary views on indications and pulp medicaments and presents step-by-step descriptions of pulp treatments for both primary and immature permanent teeth.

Crown Reduction and Vital Pulp Therapy in a Dog With Malocclusion.

Crown reduction and vital pulp therapy is an accepted treatment for abnormal occlusion resulting in palatal trauma caused by malpositioned mandibular canine teeth in dogs and cats. This article describes use of mineral trioxide aggregate for vital pulp therapy after crown reduction. A list of materials and commonly used equipment is provided.

[Endodontic treatment efficacy enhancement by means of instrumental physiotherapy]. / Povyshenie éffektivnosti éndodonticheskogo lecheniia s pomoshch'iu apparaturnykh metodov.

The article describes in detail and examines the prospects of such methods as electroodontodiagnosis, diathermocoagulation and apex-phoresis. It proves the necessity of development and standardization of devices for the mentioned treatment modalities that will improve the effectiveness an quality of caries complications treatment.

The impact of autologous platelet concentrates on endodontic healing: a systematic review.

The current literature was reviewed to determine the impact of autologous platelet concentrates (APCs) on endodontic healing. All types of clinical study designs concerning any kind of endodontic treatment involving the application of APCs were included. Two independent reviewers searched three databases (PubMed, Embase, and Cochrane Library) for studies, complemented by hand search, until 16/1/2016. From the 423 identified records, 48 articles met the inclusion criteria. Selected randomized controlled clinical trials (RCTs) underwent Cochrane Collaboration's risk-of-bias assessment and data extraction. Only two RCTs showed low risk of bias. There was considerable heterogeneity between the RCTs with regard to the type of therapy, type of APCs, assessment method, and study quality, and therefore the data could not be analyzed quantitatively. The included case reports/series and non-randomized comparative studies underwent qualitative analysis with the revised Methodological Index for Non-Randomized Studies (MINORS) and data extraction. The two comparative non-randomized studies scored qualitatively high, though the MINORS-scores of the case series and reports were dispersed. APCs were involved in five endodontic treatment modalities, namely apexification, regenerative endodontic procedures, pulpotomy, apical surgery, and treatment of endo-perio/perio-endo lesions. APCs seem to accelerate postoperative bone healing, augment the patients' postoperative quality of life, aid further root development, and support maintenance/regaining of pulp vitality. No adverse events were reported. APCs in endodontic treatments seem to contribute to the healing of soft and hard tissues, though there is a lack of long-term high quality clinical trials and standardized treatment protocols.

WITHDRAWN: Pulp management for caries in adults: maintaining pulp vitality.

BACKGROUND: There is a range of treatment options for the management of the pulp in extensively decayed teeth. These include direct and indirect pulp capping, pulpotomy or pulpectomy. If the tooth is symptomatic or if there are periapical bone changes, then endodontic treatment is required. However, if the tooth is asymptomatic but the caries is extensive, there is no consensus as to the best method of management. In addition, there has been a recent move towards using alternative materials and methods such as the direct or indirect placement of bonding agents and mineral trioxide aggregate.Most studies have investigated the management of asymptomatic carious teeth with or without an exposed dental pulp using various capping materials (e.g. calcium hydroxide, Ledermix, Triodent, Biorex, etc.). However, there is no long term data regarding the outcome of management of asymptomatic, carious teeth according to different regimens. OBJECTIVES: This study aims to assess the effectiveness of techniques used to treat asymptomatic carious teeth and maintain pulp vitality. SEARCH METHODS: Electronic searches of the following databases were undertaken: The Cochrane Oral Health Group's Trials Register (March 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to week 4, February 2006), EMBASE (1974 to 13 March 2006), National Research Register (March 2006), Science Citation Index - SCISEARCH (1981 to March 2006). Detailed search strategies were developed for each database. Handsearching and screening of reference lists were undertaken. There was no restriction with regard to language of publication. SELECTION CRITERIA: Studies included were randomised controlled trials (RCTs). Asymptomatic vital permanent teeth with extensive caries were included. Studies were those which compared techniques to maintain pulp vitality. Outcome measures included clinical success and adverse events. DATA COLLECTION AND ANALYSIS: Data were independently extracted by three review authors. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Collaboration's statistical guidelines were followed. MAIN RESULTS: Only four RCTs were identified. Interventions examined included: Ledermix, glycerrhetinic acid/antibiotic mix, zinc oxide eugenol, calcium hydroxide, Cavitec, Life, Dycal, potassium nitrate, dimethyl isosorbide, and polycarboxylate cement. Only one study showed a statistically significant finding; potassium nitrate/dimethyl isosorbide/polycarboxylate cement resulted in fewer clinical symptoms than potassium nitrate/polycarboxylate cement or polycarboxylate cement alone when used as a capping material for carious pulps. AUTHORS' CONCLUSIONS: It was disappointing that there were so few studies which could be considered as being suitable for inclusion in this review. The findings from this review do not suggest that there should be any significant change from accepted conventional practice procedures when the pulp of the carious tooth is considered. Further well designed RCTs are needed to investigate the potential of contemporary materials which may be suitable when used in the management of carious teeth. It is recognised that it is difficult to establish the 'ideal' clinical study when ethical approval for new materials must be sought and strict attention to case selection, study protocol and interpretation of data is considered. It is also not easy to recruit sufficient numbers of patients meeting the necessary criteria.

[The importance of pulp therapy in deciduous teeth]. / Importance des traitements pulpaires en denture de lait.

Preserving primary teeth is crucial for maintaining the maxillary growth, aesthetics, mastication, and speech and for preventing from abnormal habits. Given the peculiar anatomy of the primary tooth, caries grow faster and more frequently to the pulp. In pediatric dentistry, new methods and enhanced material have been recently released on the market and broadened the field of treatments. In this paper, we review the pulp diseases affecting children and focus on the current root canal therapies that favour the physiological primary tooth loss.

Conserver les dents de lait est essentiel pour assurer la croissance des maxillaires, l'esthétique, la mastication et la phonation ainsi que pour prévenir l'apparition de dysfonctions. Vu les particularités anatomiques des dents de lait, la carie progresse toujours plus rapidement et plus fréquemment jusqu'à la pulpe. L'avènement de nouvelles techniques et de nouveaux matériaux en dentisterie pédiatrique a élargi nos possibilités thérapeutiques. De même, l'interdiction d'utilisation de certains produits a conduit le pédodontiste à devoir trouver des alternatives de traitement. Le but de cet article est de faire le point sur les pathologies pulpaires chez l'enfant et sur les thérapeutiques endocanalaires actuelles.

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.

Dental pulp therapy for primary teeth in children undergoing cancer therapy.

BACKGROUND: Childhood cancer treatment negatively affects the immune system, increasing the risk for bacteremia and septicemia. As the oral cavity is a major entry portal for pathogens into the bloodstream dental care in such children tends to be radical, favouring tooth extraction over less drastic treatments such as pulpotomy, the amputation of infected dental pulp. The present study aimed to compare pulpotomy treatment success rate in children with cancer receiving immunosuppressive therapy with that of healthy children, and investigate if unsuccessful pulpotomy treatment in oncologic patients may lead to systemic complications. PROCEDURE: Twenty-six medical records of children from a paediatric oncology referral centre who had dental pulpotomy treatment (in 41 teeth) while receiving active cancer care during the years 2006-2012 were compared with records of 41 randomly selected healthy children who had undergone pulpotomy treatment (41 teeth) in the same institute during these years. Clinical and radiographic data were collected during treatments and at the end of the follow-up period (six months post dental treatment). RESULTS: No statisticaly significant difference was found between pulpotomy success rate amongst the two groups. Treatments success rates in the study and control groups were 82.9% (± 5.9) and 90.2% (± 4.7), respectively. No patient in the study group suffered from sepsis from a dental origin during follow-up period. CONCLUSIONS: Pulpotomy in paediatric cancer patients did not increase the risk for bacteremia or systemic complications from oral origin. We therefore recommend the re-evaluation of the current protocol for treating paediatric oncology patients.

Treatment of periodontal-endodontic lesions--a systematic review.

BACKGROUND: The treatment of periodontal-endodontic lesions is challenging due to the involvement of both periodontal and endodontic tissues. OBJECTIVE: To evaluate the treatment options and outcomes of periodontal-endodontic lesions. MATERIAL AND METHODS: A systematic literature search was performed for articles published by 12 May 2013 using electronic databases and hand search. Two reviewers conducted the study selection, data collection and validity assessment. The PRISMA criteria were applied. From 1087 titles identified by the search strategy, five studies and 18 case reports were included. RESULTS: Clinical studies and case reports were published from the years 1981 to 2012. A pronounced heterogeneity exists among studies regarding applied treatment protocols and quality of reporting. In all clinical studies, comprising 111 teeth, a non-surgical root canal treatment (RCT) was performed as initial treatment step. Non-surgical and/or a surgical periodontal therapy was applied in some studies without re-evaluation of the endodontic healing. Probing pocket depth reductions were reported in all included studies, comprising the data from 80 teeth at follow-up. CONCLUSIONS: A sequential treatment with root canal treatment as a first treatment step appears to be reasonable. An adequate time for tissue healing is suggested prior to re-evaluation.

Radix Entomolaris - a rare case series.

INTRODUCTION: The success of root canal treatment is determined by satisfying the basic principles of complete removal of the endodontic pathology through chemo-mechanical cleansing of the root canals followed by shaping and then by obturation to provide the ideal hermetic seal. To achieve such success a thorough knowledge of the root canal anatomy is a basic requirement. Several anatomic variations of the mandibular molars have been reported among which is the reportedly rare Radix Entomolaris(RE), a mandibular molar with an additional root located lingually. AIMS AND OBJECTIVES: To present five cases of RE diagnosed pre-operatively using radiographs and subsequently successfully endodontically treated. We also aim to highlight the considerations for the diagnosis and management of RE in general dental practice. CONCLUSION: Even though RE is rarely encountered in general dental practice, the possibility that it may occur warrants the need to have sufficient knowledge regarding diagnosis and the appropriate modifications in endodontic management of these teeth. Preparedness coupled with a carefully modified clinical approach aids in successful management of RE and ensures that these cases could be handled with ease.

Expert consensus on endodontic therapy for patients with systemic conditions.

The overall health condition of patients significantly affects the diagnosis, treatment, and prognosis of endodontic diseases. A systemic consideration of the patient's overall health along with oral conditions holds the utmost importance in determining the necessity and feasibility of endodontic therapy, as well as selecting appropriate therapeutic approaches. This expert consensus is a collaborative effort by specialists from endodontics and clinical physicians across the nation based on the current clinical evidence, aiming to provide general guidance on clinical procedures, improve patient safety and enhance clinical outcomes of endodontic therapy in patients with compromised overall health.

Recent Advances in Functional Hydrogels for Treating Dental Hard Tissue and Endodontic Diseases.

Oral health is the basis of human health, and almost everyone has been affected by oral diseases. Among them, endodontic disease is one of the most common oral diseases. Limited by the characteristics of oral biomaterials, clinical methods for endodontic disease treatment still face large challenges in terms of reliability and stability. The hydrogel is a kind of good biomaterial with an adjustable 3D network structure, excellent mechanical properties, and biocompatibility and is widely used in the basic and clinical research of endodontic disease. This Review discusses the recent advances in functional hydrogels for dental hard tissue and endodontic disease treatment. The emphasis is on the working principles and therapeutic effects of treating different diseases with functional hydrogels. Finally, the challenges and opportunities of hydrogels in oral clinical applications are discussed and proposed. Some viewpoints about the possible development direction of functional hydrogels for oral health in the future are also put forward. Through systematic analysis and conclusion of the recent advances in functional hydrogels for dental hard tissue and endodontic disease treatment, this Review may provide significant guidance and inspiration for oral disease and health in the future.

The efficacy of 3 root canal sealers combined with warm gutta-percha vertical compression technique in the treatment of dental pulp disease.

To investigate the efficacy of 3 root canal sealants such as AH Plus, GuttaFlow and iRoot SP combined with warm gutta-percha vertical compression technique in the treatment of dental pulp disease. This was a single-center retrospective study. 180 patients with dental pulp disease were divided into AH Plus group (n = 60), GuttaFlow group (n = 60) and iRoot SP group (n = 60) according to the different treatment methods. Patients in different groups were treated with corresponding root canal sealant combined with warm gutta-percha vertical compression technique. The quality of root canal filling, filling time, filling area ratio, the incidence of pain after operation, serum interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) and efficacy at 6 months after operation were compared among the 3 groups, respectively. The filling time in the GuttaFlow group and the iRoot SP group was significantly shorter than that in the AH Plus group (P < .001). There were significant differences in pain grade (P = .015) and pain rate (P = .016) among the 3 groups, and the pain rate in the GuttaFlow group and the iRoot SP group was significantly lower than that in the AH Plus group (P = .016). The time-point effect, intergroup effect and time-groups effect of serum TNF-α and IL-6 were significantly different (P < .001), and the levels of the 3 groups after treatment were significantly lower than those before treatment (P < .05), and the levels were significantly lower in the GuttaFlow group and the iRoot SP group (P < .05). There were significant differences in efficacy grading and effective rate among the 3 groups (P = .028), and the effective rate of iRoot SP group was significantly higher than that of AH Plus group (P < .05). The iRoot SP or GuttaFlow as root canal sealant combined with warm gutta-percha vertical compression technique in the treatment of dental pulp disease is better than AH Plus, and the former one can shorten the filling time, relieve the postoperative pain and improve the inflammatory response, but the long-term apical sealing effect of iRoot SP is better than GuttaFlow.

Efficacy of lasers as an adjunct to chemo-mechanical disinfection of infected root canals: a systematic review.

The aim was to evaluate the efficacy of various types of lasers used as an adjunct to chemo-mechanical disinfection of infected root canals with the outcome measures 'normal periapical condition' or 'reduction of microbial load'. PubMed, CENTRAL and ISI Web of Knowledge literature searches with specific indexing terms and a subsequent hand search were made with stated limits and criteria. Relevant publications were retrieved, followed by interpretation. The quality of each included publication was assessed as high, moderate or low. The initial search process yielded 234 publications. All abstracts of these publications were read, and the reference lists of relevant publications were hand-searched. Ten articles were read in full text and interpreted according to a data extraction form. Five were included in the systematic review and were assessed. A meta-analysis was impossible to perform because the included studies were heterogeneous with regard to study design, treatment and outcome measures. Positive effects were reported; however, no concluding evidence grade could be made because each included study was judged to have low quality, primarily due to lack of a power analysis, blinding and reproducibility. The evidence grade for whether lasers can be recommended as an adjunct to chemo-mechanical disinfection of infected root canals was insufficient. This does not necessarily imply that laser should not be used as an adjunct to root canal treatment but instead underscores the need for future high-quality studies.

[A retrospective study of 693 children's dental treatment under general anesthesia].

OBJECTIVE: To retrospectively analyze the clinical features of children who received dental treatment under general anesthesia (GA) and the characteristics of dental treatment. METHODS: The records of 693 patients treated under GA in the Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology, between Jan. 2001 and Dec. 2012 were collected and analyzed. RESULTS: The numbers of patients treated under GA increased year-to-year. Most of them were under 4-year-old. The main reasons of dental treatment under GA were uncooperative and disabled. The average number of teeth treated was 12±4 for each child, and the average time for treating one tooth was 12 min. The 3 months follow-up rate was 60.31%, and the older, the fewer treated tooth number and out-of-town associated with the less follow-up rate. CONCLUSION: The main reasons of dental treatment under GA are uncooperative and disabled. GA is an effective and safe method for dental rehabilitation in children.

Bisphosphonate-related osteonecrosis of the jaws: a potential alternative to drug holidays.

In 2011, the American Dental Association Council on Scientific Affairs released an update by their expert panel on managing the care of patients receiving antiresorptive therapy for the prevention and treatment of osteoporosis. In this report, the panel found no study results that confirmed the effectiveness of drug holidays to prevent antiresorptive agent-induced osteonecrosis of the jaws without increasing the risks of low bone mass. The purpose of this article is to provide suggestions for a pattern of patient care for individuals who desire or require an invasive surgical procedure of the jaws, but who also have a skeleton that is at risk for osteoporotic fracture. The authors reviewed pertinent literature related to basic bone histology, the pharmacokinetics of the aminobisphosphonates (nBP), diagnostic criteria for osteopenia/osteoporosis, and clinical applications of the antiresorptive agents. The skeletal system demonstrates a mixture of resting surfaces (osteocytes, 85%), resorbing surfaces (osteoclasts, 2%), and forming surfaces (osteoblasts, 10%-12%). Deposition of nBP is not uniform, and is highly concentrated in areas of bone remodeling. A full understanding of bone remodeling and the pharmacokinetics of nBP allow for the modification of the antiresorptive therapy and the timing of the oral surgical procedure in a manner that minimizes the prevalence of osteonecrosis while at the same time continuing to protect the patient's skeleton from osteoporotic fracture. The lack of support for drug holidays by the ADA's expert panel is strongly consistent with the science behind bone remodeling and nBP pharmacokinetics. In spite of this, creative interdisciplinary patient care has the potential to dramatically reduce the prevalence of bisphosphonate-related osteonecrosis (BRON), while at the same time continuing to protect the skeleton of the osteoporotic patient. Creative interdisciplinary patient care may prove to be an effective intervention to reduce the prevalence of BRON of the jaws.

A review of pulp therapy for primary and immature permanent teeth.

The aim of pulp therapy in primary and young permanent teeth is to maintain a functional tooth so that arch integrity is preserved in a growing child. History, clinical evaluation and radiographic findings should be integrated to arrive at pulp diagnosis. Vital pulp therapy should be attempted whenever the pulp is diagnosed to be vital. Nonvital pulp therapy should be performed for strategically important primary teeth. Revascularization is an emerging technique for immature necrotic teeth.

Will mineral trioxide aggregate replace calcium hydroxide in treating pulpal and periodontal healing complications subsequent to dental trauma? A review.

Mineral trioxide aggregate (MTA) has over the last two decades begun to take the place of calcium hydroxide (CH) in the treatment of a variety of pulpal and periodontal healing complications following dental trauma. These conditions include teeth with: (i) exposed pulps, (ii) immature roots and pulp necrosis, (iii) root fractures and pulp necrosis located in the coronal part of the pulps, and (iv) external infection-related (inflammatory) root resorption. The main reasons for replacing CH with MTA in these situations have generally been the delayed effect when using CH to induce hard tissues, the quality of such induced hard tissues, and finally the dentin weakening effect of CH, which in some instances lead to cervical root fractures in immature teeth. MTA appears, from a relatively few clinical studies, to overcome these shortcomings of CH. The lack of long-term clinical studies, however, may warrant a certain reservation in an unrestricted replacement of CH with MTA. A definite need for randomized clinical studies comparing CH and MTA in trauma healing situations is urgently needed.

Natural tooth versus implant: a key to treatment planning.

Since time immemorial, man has constantly contrived to replace natural body parts that are either congenitally absent or lost subsequent to disease or injury, so as to maintain a perfect amalgam of form and function. Dental implants have recently become established as a standard treatment protocol for replacing missing teeth. Ostensibly, a dilemma has arisen whether the implant should obviate the necessity to preserve teeth with debatable restorative prognosis. This article attempts to review the work done hitherto and to formulate a combined perspective in such cases.