Success of root fillings with zinc oxide-ozonated oil in primary molars: preliminary results.

AIM: To evaluate the success rate of mixture of ozonated oil and zinc oxide as a primary teeth root filling material. STUDY DESIGN: Prospective randomised clinical study. METHODS: The study included 60 infected primary mandibular molars which were equally divided into study group (ozonated oil-ZnO) and control group (zinc oxide-eugenol). Pulpectomy procedure was performed and the children were followed at regular intervals. All the children were available for evaluation at the end of 12 months. The teeth were evaluated for success or failure based on clinical and radiographic criteria by a blinded investigator. STATISTICS: The proportional values were compared using χ(2) test. RESULTS: Clinical and radiographic evaluation suggested that teeth obturated with ozonated oil-zinc oxide demonstrated good success rate (93.3%) as compared to zinc oxide eugenol (63.3%). However, no statistically significant variation (p = 0.408) was observed between the groups. CONCLUSION: Ozonated oil-ZnO demonstrated a good clinical and radiographic success at 12 months follow-up and it can be considered as an alternative obturating material in infected primary teeth.

Radiographic healing after a root canal treatment performed in single-rooted teeth with and without ultrasonic activation of the irrigant: a randomized controlled trial.

INTRODUCTION: The aim of this study was to compare the outcome of a root canal treatment with and without additional ultrasonic activation of the irrigant. METHODS: Single-rooted teeth with radiographic evidence of periapical bone loss were randomly assigned to 2 treatment groups. In both groups syringe irrigation was performed, and in one group the irrigant was also activated by ultrasound. Ten to 19 months after treatment, the teeth were examined by using periapical radiography (PA) and cone-beam computed tomography (CBCT). Area and volume of the periapical lesions were measured, and the outcome was presented in 4 categories: absence, reduction or enlargement of the radiolucency, or uncertain. Lesions were classified as reduced or enlarged when the change in size of the radiolucency was 20% or more. RESULTS: The recall rate was 82%, and 84 teeth were analyzed. CBCT detected significantly more post-treatment lesions than PA (P = .038), but the percentages of absence and reduction of the radiolucency together revealed by CBCT and PA were similar (P = .383). The CBCT results showed that absence of the radiolucency was observed in 16 of 84 teeth (19%) and reduction of the radiolucency in 61 of 84 teeth (72.6%), but there was no significant difference between the results of the 2 groups (P = .470). Absence and reduction of the radiolucency together were observed in the ultrasonic group in 39 of 41 teeth (95.1%) and in the syringe group in 38 of 43 teeth (88.4%). CONCLUSIONS: Root canal treatments with and without additional ultrasonic activation of the irrigant contributed equally to periapical healing.

Impact of three radiographic methods in the outcome of nonsurgical endodontic treatment: a five-year follow-up.

INTRODUCTION: The periapical film radiograph (PFR) and digital periapical radiograph (DPR) techniques have some limitations in the visualization of small periapical lesions (PLs) when compared with cone-beam computed tomography (CBCT). However, the evidence supporting their effectiveness is very limited. This retrospective longitudinal cohort study evaluated the outcome of endodontic treatments measured/monitored by PFR, DPR, and CBCT during a 5-year follow-up and also determined the prognostic factors that influenced treatment success. METHODS: A total of 132 teeth (208 roots) with vital pulps received endodontic treatment. The periapical indexes with scores ≥2 for PFR and DPR and ≥1 for CBCT indicated the presence of PLs. Prognostic factors were determined by bivariate and multivariate analyses. Statistical significance was defined at a P level <.05. RESULTS: CBCT detected a higher number of PLs (18.7%, n = 39 roots), followed by DPR (7.7%, n = 16 roots) and PFR (5.7%, n = 12 roots). Likewise, CBCT was more sensitive than PFR and DPR in detecting deficiencies in extension and density of the root canal filling (P ≤ .001). Of the 17 prognostic factors evaluated, 4 were significantly associated with poor outcome to the treatment (P < .05): root canal curvature, disinfection of gutta-percha, presence of missed canals, and the quality of definitive coronal restoration. CONCLUSIONS: The success outcome of endodontic treatment after 5 years in teeth with vital pulps varied with each radiographic method: 94.3%/PFR, 92.3%/DPR, and 81.3%/CBCT.

Morphological features of the maxillary incisors roots and relationship with neighbouring anatomical structures: possible implications in endodontic surgery.

The purpose of this study was to investigate the relationship between the root apex of the upper incisors and neighbouring anatomical structures as well as the morphology of the root-end foramen after apicoectomy. Fifty-seven patients requiring endodontic surgical treatment for a maxillary anterior root were enrolled. A preoperative diagnostic computed tomography (CT) scan was analysed to determine: the distance between the anterior wall of the nasopalatine duct and the central (CI-ND) incisor root 4mm from the apex; and the distance between the floor of the nasal cavity and the tip of either the central (CI-NF) or the lateral (LI-NF) incisor root. After apicoectomy, root-end foramen endoscopic pictures were taken in order to characterize their morphology. Fifty-nine central and 26 lateral incisors were evaluated. The average CI-ND was 4.71 ± 1.26 (SD) mm. The average CI-NF was 10.62 ± 2.25 mm. The average LI-NF was 13.05 ± 2.43 mm. The foramen shape after apicoectomy was ovoid to circular in about 90% of cases in both central and lateral incisors. A sound knowledge of the anatomical relationships at the surgical site is essential for the clinician to perform a safe endodontic surgical procedure.

Efficacy of Ibuprofen and ibuprofen/acetaminophen on postoperative pain in symptomatic patients with a pulpal diagnosis of necrosis.

INTRODUCTION: The purpose of this prospective, randomized, double-blind study was to determine ibuprofen versus ibuprofen/acetaminophen use for postoperative endodontic pain in symptomatic patients with a pulpal diagnosis of necrosis and an associated periapical radiolucency who were experiencing moderate to severe preoperative pain. We also recorded escape medication use. METHODS: Seventy-one adult patients presenting for emergency endodontic treatment with a symptomatic maxillary or mandibular tooth with a pulpal diagnosis of necrosis, periapical radiolucent area, and moderate to severe pain participated in this study. The patients were randomly divided into 2 groups by random assignment and numeric coding. An emergency debridement of the tooth was completed with hand and rotary instrumentation. At the end of the appointment, the patients randomly received capsules of either 600 mg ibuprofen or 600 mg ibuprofen combined with 1000 mg acetaminophen (blinded to both operator and patient). Patients also received a 6-day diary to be completed after anesthesia wore off and every morning for 5 days. Patients were asked to record pain, symptoms, and the number of capsules taken. Patients received escape medication (Vicodin) if the study medication did not control their pain. Postoperative data were analyzed by randomization test and step-down Bonferroni method of Holm. RESULTS AND CONCLUSIONS: There were decreases in pain levels and analgesic use over time for the ibuprofen and ibuprofen/acetaminophen groups. There was no statistically significant difference between the 2 groups for analgesic use or escape medication use. Approximately 20% of patients in both groups required escape medication to control pain.

A prospective study of the factors affecting outcomes of nonsurgical root canal treatment: part 1: periapical health.

AIM: To investigate the probability of and factors influencing periapical status of teeth following primary (1°RCTx) or secondary (2°RCTx) root canal treatment. METHODOLOGY: This prospective study involved annual clinical and radiographic follow-up of 1°RCTx (1170 roots, 702 teeth and 534 patients) or 2°RCTx (1314 roots, 750 teeth and 559 patients) carried out by Endodontic postgraduate students for 2-4 (50%) years. Pre-, intra- and postoperative data were collected prospectively on customized forms. The proportion of roots with complete periapical healing was estimated, and prognostic factors were investigated using multiple logistic regression models. Clustering effects within patients were adjusted in all models using robust standard error. RESULTS: proportion of roots with complete periapical healing after 1°RCTx (83%; 95% CI: 81%, 85%) or 2°RCTx (80%; 95% CI: 78%, 82%) were similar. Eleven prognostic factors were identified. The conditions that were found to improve periapical healing significantly were: the preoperative absence of a periapical lesion (P = 0.003); in presence of a periapical lesion, the smaller its size (P ≤ 0.001), the better the treatment prognosis; the absence of a preoperative sinus tract (P = 0.001); achievement of patency at the canal terminus (P = 0.001); extension of canal cleaning as close as possible to its apical terminus (P = 0.001); the use of ethylene-diamine-tetra-acetic acid (EDTA) solution as a penultimate wash followed by final rinse with NaOCl solution in 2°RCTx cases (P = 0.002); abstaining from using 2% chlorexidine as an adjunct irrigant to NaOCl solution (P = 0.01); absence of tooth/root perforation (P = 0.06); absence of interappointment flare-up (pain or swelling) (P =0.002); absence of root-filling extrusion (P ≤ 0.001); and presence of a satisfactory coronal restoration (P ≤ 0.001). CONCLUSIONS: Success based on periapical health associated with roots following 1°RCTx (83%) or 2°RCTx (80%) was similar, with 10 factors having a common effect on both, whilst the 11th factor 'EDTA as an additional irrigant' had different effects on the two treatments.

Management of inflammatory external root resorption by using calcium-enriched mixture cement: a case report.

INTRODUCTION: Inflammatory external root resorption is one of the major complications after replantation of avulsed teeth. Here we report a case of inflammatory external root resorption in a maxillary left central incisor in an 11-year old male patient that was managed and treated by using calcium enriched mixture (CEM) cement. METHODS: The patient's chief complaint was mobility of avulsed and replanted maxillary left central incisor and pain in chewing on left central and lateral incisors. Radiographic examination showed progressive inflammatory external root resorption of the left central incisor with an inadequately obturated root canal treatment. Both teeth were immature and had periapical radiolucencies. Both teeth were irrigated copiously with 2.5% NaOCl and obturated with CEM cement. However, the central incisor was treated with calcium hydroxide 6 weeks before CEM cement obturation. RESULTS: The clinical and radiographic examinations at 3-, 6-, 12-, 24-, and 40-month follow-up showed that treated teeth were functional with normal mobility, the progression of the inflammatory external root resorption ceased, the resorptive lacunae were filled with newly formed bone, and periapical radiolucencies healed. CONCLUSIONS: Considering the biological properties of CEM cement, especially its alkalinity and sustained calcium hydroxide release, using this novel cement for treatment of inflammatory external root resorption and obturation of immature necrotic teeth might be an applicable choice.

Single-session use of mineral trioxide aggregate as an apical barrier in a case of external root resorption.

External root resorption may occur as a consequence of trauma, orthodontic treatment, bacterial infection or incomplete sealing of the root canal system (bacterial re-infection), and lead to crater formation on the resorbed apex. This would deform the root apex surface, and cause loss of apical constriction. Depending on the extent of the resorptive process, different treatment regimens have been proposed. A 34-year-old male patient presented with an intra-radicular retainer and an inadequate filling on tooth #21, as well as a radiographic image suggesting periapical bone rarefaction. After root canal retreatment, the defect was accessed coronally. The resorption area was chemo-mechanically debrided and since the apical end was very wide, a calcium sulphate matrix was made. Mineral trioxide aggregate (MTA) was used to fill the resorptive defect, and the coronal access was temporarily sealed. After 24 h, the quality of the apical seal was evaluated with the aid of an operating microscope, and then the root canal system was filled. A 12-month follow-up radiograph showed adequate repair of the resorption. Clinically, the tooth was asymptomatic. We concluded that MTA can be successfully used to avoid overextension of the filling material when treating a tooth with external resorption.

Retreatment of a resected tooth associated with a large periradicular lesion by using a triple antibiotic paste and mineral trioxide aggregate: a case report with a thirty-month follow-up.

INTRODUCTION: Trauma to the teeth and supporting structures is a frequent problem among children. Endodontic treatment is necessary for 41.3% of traumatized teeth. Two of the most important criteria for successful endodontic treatment are the elimination of microorganisms and apical sealing. A combination of antibiotic drugs (metranidozole, ciprofloxacin, and minocycline) is used to eliminate target bacteria, which are possible sources of endodontic lesions. For cases in which apical sealing is difficult, specific materials to plug the apical region have been advocated. Mineral trioxide aggregate (MTA) has become the material of choice because it is biocompatible and has bacteriostatic action. METHODS: This case report describes the nonsurgical retreatment of a traumatized tooth that had already undergone unsuccessful apical resection associated with a large periradicular lesion. A combination of antibiotic drugs was used as an intracanal medicament, and MTA was used to obtain a hermetic seal of the lateral tooth that had undergone unsuccessful apical resection. RESULTS: On follow up, the tooth was clinically and radiographically asymptomatic for 30 months. CONCLUSIONS: The results of this case show that MTA and triple antibiotic paste can be used clinically in the treatment of an unsuccessfully resected tooth associated with a large periradicular lesion.

Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate.

This study is a retrospective analysis of the outcome of initial nonsurgical root canal treatment of teeth with open apices, obturated with mineral trioxide aggregate when no apical barrier existed. One hundred sixteen patients from a single private endodontic office were treated between 1999 and 2006. Treatments on 144 teeth were completed either in one (92/144) or two visits with an interim calcium hydroxide interappointment medication (52/144). Fifty-four percent (78/144) of the teeth were available for recall (60.3% one visit and 39.7% two visits). The maximum time to recall was 4.87 years. The mean time to recall was 19.4 months. Of the cases recalled for period of 1 year or longer, 93.5% of teeth treated in 1 visit healed, and 90.5% of teeth treated in 2 visits healed.

Periradicular repair after two-visit endodontic treatment using two different intracanal medications compared to single-visit endodontic treatment.

The number of appointments necessary to treat infected root canals is one of the most controversial issues in endodontics. This study evaluated, in dogs, the response of the periradicular tissues to the endodontic treatment of infected root canals performed in a single visit or in two visits, using different interappointment dressings. Periradicular lesions were induced by inoculating Enterococcus faecalis in the root canals. After confirming that a periradicular lesion developed, the root canals were treated within one or two visits, using either ozonized oil or calcium hydroxide in camphorated paramonochlorophenol (CMCP) as an intracanal medication. After 6 months, the animals were sacrificed and the specimens were processed for histological and histobacteriological analysis. The root canals treated in a single visit showed a success rate of 46%. When a calcium hydroxide/CMCP-based interappointment intracanal medication was used, 74% of the cases were categorized as success. In cases where ozonized oil was used as the intracanal medication, a success rate of 77% was observed. These results of the present study demonstrated that the two-visit treatment offered a higher success rate compared to one-visit therapy. In addition, ozonized oil may potentially be used as an intracanal medication.

Periradicular repair after two-visit endodontic treatment using two different intracanal medications compared to single-visit endodontic treatment

The number of appointments necessary to treat infected root canals is one of the most controversial issues in endodontics. This study evaluated, in dogs, the response of the periradicular tissues to the endodontic treatment of infected root canals performed in a single visit or in two visits, using different interappointment dressings. Periradicular lesions were induced by inoculating Enterococcus faecalis in the root canals. After confirming that a periradicular lesion developed, the root canals were treated within one or two visits, using either ozonized oil or calcium hydroxide in camphorated paramonochlorophenol (CMCP) as an intracanal medication. After 6 months, the animals were sacrificed and the specimens were processed for histological and histobacteriological analysis. The root canals treated in a single visit showed a success rate of 46 percent. When a calcium hydroxide/CMCP-based interappointment intracanal medication was used, 74 percent of the cases were categorized as success. In cases where ozonized oil was used as the intracanal medication, a success rate of 77 percent was observed. These results of the present study demonstrated that the two-visit treatment offered a higher success rate compared to one-visit therapy. In addition, ozonized oil may potentially be used as an intracanal medication.

O número de sessões necessárias para tratar um canal radicular infectado é um dos assuntos mais controversos da endodontia. O objetivo deste estudo foi analisar, em cães, a resposta dos tecidos perirradiculares ao tratamento endodôntico de canais infectados em uma ou duas consultas, usando diferentes medicamentos entre as sessões. Lesões perirradiculares foram induzidas pela inoculação de Enterococcus faecalis nos canais. Após a confirmação do desenvolvimento de uma lesão perirradicular, os canais foram tratados em uma ou duas sessões, usando óleo ozonizado ou hidróxido de cálcio associado ao paramonoclorofenol canforado (PMCC) como medicação intracanal. Após 6 meses, os animais foram sacrificados e os espécimes processados para análise histológica e histobacteriológica. Os canais tratados em sessão única apresentaram uma taxa de sucesso de 46 por cento dos casos. Quando a medicação usada entre as sessões foi o hidróxido de cálcio associado com o PMCC, 74 por cento dos casos resultaram em sucesso. Nos casos em que o óleo ozonizado foi usado, uma taxa de sucesso de 77 por cento foi observada. Esses achados demonstraram que o tratamento em duas sessões oferece uma taxa de sucesso mais alta quando comparado à terapia em uma sessão. Além disso, o óleo ozonizado mostrou potencial para ser usado como medicação intracanal.

Influence of sodium hypochlorite-based irrigants on the susceptibility of intracanal microbiota to biomechanical preparation.

This study evaluated the microbiological conditions of root canals, using smears and culture from anterior teeth and premolars with necrotic pulps associated with chronic periapical pathologies, before and after biomechanical preparation (BMP). During double-flared instrumentation, 1, 2.5 and 5% sodium hypochlorite (NaOCl)-based irrigants were used in 3 groups: GI (n=39), GII (n=36) and GIII (n=36), respectively. Before BMP, all cultures were positive and the smears showed microbiologically diverse morphotypes, including fusiforms, pleomorphic, rods, cocci and filaments. Quantitatively, 20, 20 and 23 morphotypes were identified in GI, GII and GIII, respectively). After BMP, the percentages of negative cultures in GI, GII and GIII were 74.2%, 86.3% and 93.4% (p>0.05) and the number of morphotypes decreased to 14, 15 and 5, respectively. All teeth with 2 root canals and/or associated fistulas were microbiologically negative after BMP, regardless of irrigant concentration. Gram-negative morphotypes were more susceptible to the action of irrigants. After irrigation with 5% NaOCl, only structural arrangements consisting of Gram-positive cocci and bacilli persisted. Thus, BMP plus 5% NaOCl offered the best antiseptic potential because in the few positive cultures a significant reduction in the number of microbiological morphotypes was also shown (p<0.05).

Influence of sodium hypochlorite-based irrigants on the susceptibility of intracanal microbiota to biomechanical preparation

This study evaluated the microbiological conditions of root canals, using smears and culture from anterior teeth and premolars with necrotic pulps associated with chronic periapical pathologies, before and after biomechanical preparation (BMP). During double-flared instrumentation, 1, 2.5 and 5 percent sodium hypochlorite (NaOCl)-based irrigants were used in 3 groups: GI (n=39), GII (n=36) and GIII (n=36), respectively. Before BMP, all cultures were positive and the smears showed microbiologically diverse morphotypes, including fusiforms, pleomorphic, rods, cocci and filaments. Quantitetively, 20, 20 and 23 morphotypes were identified in GI, GII and GIII, respectively). After BMP, the percentages of negative cultures in GI, GII and GIII were 74.2 percent, 86.3 percent and 93.4 percent (p>0.05) and the number of morphotypes decreased to 14, 15 and 5, respectively. All teeth with 2 root canals and/or associated fistulas were microbiologically negative after BMP, regardless of irrigant concentration. Gram-negative morphotypes were more susceptible to the action of irrigants. After irrigation with 5 percent NaOCl, only structural arrangements consisting of Gram-positive cocci and bacilli persisted. Thus, BMP plus 5 percent NaOCl offered the best antiseptic potential because in the few positive cultures a significant reduction in the number of microbiological morphotypes was also shown (p<0.05).

Este estudo avaliou as condições microbiológicas dos canais radiculares, por meio de esfregaços e culturas de dentes anteriores e pré-molares com necrose pulpar associada à radiolucidezes periapicais, antes e após o preparo biomecânico (PBM). Utilizou-se a técnica de instrumentação biescalonada coadjuvada por soluções de hipoclorito de sódio (NaOCl) a 1, 2,5 ou 5 por cento nos grupos I (n=39), II (n=36) e III (n=36), respectivamente. Antes do PBM havia 100 por cento de culturas positivas e os esfregaços proveram diversificados morfotipos microbiológicos, sendo 20, 20 e 23 nos grupos I, II e III, respectivamente. Após o PBM, o percentual de culturas negativas nos grupos I, II e III foi 74,2 por cento, 86,3 e 93,4 por cento (p>0,05) e a incidência de morfotipos declinou para 14, 15 e 5, respectivamente. Todos os dentes birradiculados e/ou portadores de fístulas apresentaram-se microbiologicamente negativos após o PBM, independentemente do irrigante utilizado. Os morfotipos Gram-negativos foram mais suscetíveis à ação do PBM. Após o PBM persistiram apenas cocos e bacilos Gram-positivos no grupo III. Portanto, o PBM coadjuvado por solução de NaOCl a 5 por cento, proporcionou o melhor desempenho anti-séptico, pois, nas poucas culturas positivas, houve também significativa redução do número de morfotipos microbiológicos (p<0.05).

Clinical judgement and decision making in endodontics.

Clinical judgement in endodontics consists of much more than diagnosis and treatment planning for the affected tooth. The issues involved in clinical judgement and decision making can be summarised by three questions: 1. Is endodontic treatment appropriate for the patient? Endodontic treatment should be undertaken only as part of an agreed, comprehensive treatment plan that takes into account patient concerns as well as objective clinical findings. 2. How difficult is the endodontic treatment? The difficulty of the case should be balanced with the skill and experience of the dentist, in deciding whether to manage the case in general practice or to refer the patient to an endodontist. The use of a standard form for assessing the difficulty of each endodontic case will aid in consistent, systematic assessment of patients. An example of such a form is provided. 3. What is the prognosis for the tooth? The outcome of endodontic treatment depends not only on the endodontic treatment but on other factors such as restorability and periodontal status. The prognosis will be compromised by procedural problems and by restorative and periodontal factors. In all but routine cases, the steps involved in decision making may be more complex and less easily resolved than the practical clinical aspects of endodontic therapy.

Problems attaining local anesthesia with endodontic emergencies.

The attainment of profound local anesthesia in the management of pulpal and periradicular pain often eludes even the most skilled clinician; various reasons for this include, but are not limited to, localized inflammation, osseous and neural variations, and poor technique of the operator. This paper reviews these potential impediments while focusing on recognizing occurrences, understanding mechanisms, and applying clinical techniques to effectively eliminate their impact on dental pain management.

A prospective randomized trial on efficacy of antibiotic prophylaxis in asymptomatic teeth with pulpal necrosis and associated periapical pathosis.

A recent study from a private endodontic practice compared "prophylactic" antibiotic (high-dose, 1-day) regimens of penicillin V and erythromycin (base or stearate) for patients who had asymptomatic teeth with pulpal necrosis and associated periapical radiolucent lesions (PN/PL). A 2.2% flare-up incidence was found, with no statistically significant differences for penicillin (0.0%), base (2.9%), and stearate (3.8%). No hypersensitivity responses occurred, and gastrointestinal side effects were found primarily with the erythromycins (12.4%). To ascertain whether or not similar results would occur with student operators in a dental school clinic population, the current study was undertaken. One-hundred ninety-five patients with quiescent PN/PL were randomly given either penicillin V or erythromycin (base or stearate). A 2.6% flare-up incidence was found, with no statistically significant differences for penicillin (3.1%), base (1.5%), and stearate (3.1%). No hypersensitivity responses occurred, and GI side effects were found primarily with the erythromycins (17.7%). As can be seen, the results were very similar to those of the recent endodontic practice study. Hence, it can be concluded that the results of the previous endodontic practice study were not unique to any one clinician or method. A comparison was also made between the "prophylactic" penicillin group of the current study and the placebo control group of our previous dental school clinic, student operator study (in which the methods, population, and regimen were almost identical to those of the current study). The results showed that the "prophylactic" penicillin group had significant fewer flare-ups and non-flare-up-associated swelling and pain than did the placebo group. In view of these findings and those from studies from the literature in which "prophylactic" antibiotics were not used, it is our opinion that the antibiotic regimens used in the current study should be a component of clinical endodontic therapy for quiescent PN/PL.