An anatomical investigation of the mandibular second molar using micro-computed tomography.

PURPOSE: An understanding of root anatomy is an important foundation for providing successful endodontic treatment. The aim of this study was to use micro-computed tomography (micro-CT) to investigate the root anatomy of the mandibular second molar. METHODS: Eighteen mandibular second molars were scanned using micro-CT. Images were reconstructed, and measurements and observations were recorded regarding pulpal floor anatomy, canal configuration, root wall thickness along the root, presence of calcifications in the pulp chamber and in canals, and apical anatomy. RESULTS/CONCLUSIONS: The most frequently found mesial root canal configuration was Vertucci Type 7 (1-2-1-2), which was seen in 33.3% of samples. Distal canals were most frequently Vertucci Type 1 (one canal), with 61.1% of samples showing this configuration. 11.1% of samples had two canals, 44.4% of samples had three canals, 33.3% of samples had four canals, and 11.1% of samples had five canals at some point along the length of the roots. Average root wall thickness between the mesiobuccal canal and the furcation was 1.23 mm. Mesiolingual canal root wall thickness was on average 1.29 mm, and the distal root furcation wall thickness averaged 1.41 mm. 77.8% of samples had calcifications present in both the pulp chamber and within the canals.

Electrical Pulp Testing: Sources of Error.

INTRODUCTION: Accurate identification and assessment of an inflamed or necrotic tooth is essentialfor endodontic treatment. The purpose of this research was to investigate possible sources of error associated with the use of the electric pulp tester (EPT). METHODS: Forty-six intact teeth (23 tooth pairs) in 22 patients were evaluated in vivo. For the tooth pairs, one tooth had to have been previously endodontically treated and restored with a class II amalgam restoration. The restoration was required to have proximal contact with a class II amalgam of another vital posterior tooth. EPT was performed on pulpless and vital teeth for experimental groups (enamel, restoration, contacting, or isolated). RESULTS: The highest rate of false positive responses (82%) was found in the pulpless restored contacting group, suggesting that EPT impulses are able to travel through proximal metallic contacts and stimulate teeth distant from the EPT probe. All vital tooth groups had a high rate of positive responses with no significant diferences. CONCLUSIONS: If a tested tooth contains an interproximal restoration contacting adjacent restorations or the gingival, the teeth must be isolated (rubber dam) and the EPT probe should be placed in a region suspected to have uninterrupted tubule paths to the pulp.

The Incidence of Furcation Region Patency in Molars Before and After Simulated Periodontal Therapy.

PURPOSE: To determine if there is increased bacterial communication through the furcation region in molar teeth after simulated periodontal therapy. METHODS: Sixty-five extracted first and second molars were accessed and the roots were sectioned 4 mm apical to the furcation. The canals and external suface of the root were sealed except the furcation region. In Phase I, the teeth were sterilized and then suspended in Rogosa SL broth. A broth containing Lactobacillus casei was placed in the pulp chamber. The Rogosa SL broth in the bottom chamber was monitored daily for 30 days for turbidity, and once turbidly was noted, the broth was plated to confirm the presence of L. casei. In Phase II, the furcation regions were scaled and cementum removed, the teeth were sterilized, and the microbial leakage was repeated. RESULTS: The Phase I and Phase II median times to turbidity were 9.5 days and 4 days, respectively, and the difference was statistically significant (p = 0.0035). Phase I turbidity rate was 86.5%, and Phase II was 92.3%, which was not statistically significant (p = 0.25). CONCLUSIONS: The root canal system communicated with the furcation region an average of 86.5% and 92.5% after scaling and root planing during the 30 days of the experiment. The time of leakage between the two groups decreased from 9.5 to 4 days (p = 0.0035). CLINICAL SIGNIFICANCE: Periodontal instrumentation of the furcation region in molar teeth can increase the risk of bacterial contamination by 39% while shortening the time for bacterial penetration in teeth with exposed dentin or furcation canals. accessory canals, scaling, and root planing.

Palatal anesthesia: comparison of four techniques for decreasing injection discomfort.

INTRODUCTION: The aim of this study was to evaluate the patient's perceived pain response to injection and anesthetic deposition for the greater palatine nerve block. METHODS: Heft-Parker Visual Analog Scale (VAS) pain scale measurements were used to compare the following techniques for the injection: (1) control (no concurrent stimulation), (2) pressure, (3) pressure and topical anesthetic (20% benzocaine), and (4) pressure and cold (TFE). Forty-two volunteers, 21 male and 21 female, participated in the study. A bilateral model was used on each patient to give an injection on each side of the palate with two different techniques followed by the next appointment (> or = two weeks later), when the two other injection techniques were used. Following injection given in the supine position, the patients were returned to an upright position and asked to rate their pain on a VAS. RESULTS: Pain upon needle insertion appears less than that of anesthetic deposition. There was no statistically significant difference in perceived pain response among the four techniques, the visit, the order, the side, or patient gender at either time point. Following the application of Endo Ice, 81% of participants reported a sore on their palate occurring two to 48 hours after cold application and persisting for one to 10 days. The pain score for this injection had a mean value of 30% (51.4/170). CONCLUSIONS: This prospective, single-blind study evaluating three injection techniques to reduce posterior palatal injection pain to a control injection method showed no significant reduction in pain with any of the three techniques. Furthermore, 1,1,1,2-tetrafluoroethane placed with pressure for 10 seconds appeared injurious to the oral mucosa.

The effect of powder:liquid ratio and pre-mixing on sealing properties of Roth 801 sealer.

OBJECTIVES: To investigate the sealing ability of Roth 801 sealer mixed using two different powder/liquid ratios and prepared up to seven days prior to canal obturation. STUDY DESIGN: Of the 152 maxillary anterior teeth endodontically instrumented for this study, 144 were randomly assigned to the treatment group, and eight were assigned to the control group. Of the 144 teeth in the treatment group, 72 were obturated using gutta-percha and Roth 801 sealer mixed with a 10:1 ratio, while the remaining 72 were obturated with a sealer ratio of 7.5:1. Within both treatment groups, the teeth were further subdivided into six groups of 12 teeth based upon the amount of time between sealer mixing and canal obturation, which varied from 0 days to seven days. Teeth were analyzed with fluid filtration either immediately after obturation or 14 weeks after obturation. The data were analyzed using a three-way analysis of variance. RESULTS: For teeth tested at the time of obturation, leakage decreased for older sealer, p < 0.0001. After the 14-week storage period, there was no significant difference in leakage. No significant differences were noted between either powder/liquid ratios. CONCLUSIONS: Pre-mixed Roth 801 sealer maintained an apical seal when prepared up to seven days prior to canal obturation. Varying the powder/liquid ratio of Roth 801 sealer did not significantly affect the apical seal.

Endodontic diagnostic terminology update.

Determination of the etiology of the patient's chief complaint and a correct diagnosis are paramount prior to a recommendation of endodontic therapy. Reproduction of the patient's chief complaint is critical. If the chief complaint cannot be reproduced, consider consultation with or referral to an endodontist or orofacial pain specialist. The diagnostic terminology presented in this update provides for a more accurate description and communication of the health or pathological conditions of both pulpal and apical tissues. This information is summarized in Table I.

In Vitro Comparison of Porcelain Fused to Metal Crown Retention after Endodontic Access and Subsequent Restoration: Composite, Amalgam, Amalgam with Composite Veneer, and Fiber Post with Composite.

INTRODUCTION: The aim of this study was to evaluate the effect of different access opening restorative materials on crown retention. METHODS: Thirty-eight extracted molars were mounted in resin and prepared for porcelain fused to metal (PFM) crowns. The crowns were fabricated and cemented with zinc phosphate, and the force to displace it was measured with a tensile-testing machine before and after endodontic access preparations. The endodontic access area, crown preparation axial wall, and preparation surface area were measured for comparison. The crowns were then recemented, and access openings were restored with either amalgam or composite before displacement force was remeasured. The restorative material was removed from each access opening; access area was measured and restored again (amalgam with composite or fiber post with composite) for displacement force to be remeasured. Paired t test was used to compare the means of displacement between groups. One-way analysis of variance was used to compare the mean outcome measure within the groups. RESULTS: Statistical analyses showed retention after unfilled access was significantly lower than intact crowns. Amalgam, composite, amalgam + composite, and fiber post + composite increased retention beyond the original value. There was no statistical difference among the different restorative protocols. Qualitative results indicate that the restorative material remains in the crown after displacement regardless of the material used to restore the access. CONCLUSIONS: The results from this study suggest that an endodontic access cavity decreases retention of a PFM crown. However, subsequent restoration with amalgam, composite, amalgam + composite, or post + composite may increase the original retention of the crown.

Solubility properties of chlorhexidine salts.

Chlorhexidine (CHX) is effective in treating oral bacterial infections. The solubility was shown to be highly dependent on the salt present in solution. Gluconate enhances the amount of CHX diacetate in solution possibly through mixed micelles formation, because the solubility product is such that the concentration of CHX will exceed the critical micelle concentration. However, only low concentrations of CHX dichloride can be obtained, which is not appreciably solubilized by gluconate ions. The low concentration of CHX that can be achieved in physiological concentrations of chloride in the oral cavity may be problematic for dental, slow release formulations.

Relationship between Canal Enlargement and Fracture Load of Root Dentin Sections.

OBJECTIVE: To investigate the effect of endodontic instrumentation on fracture susceptibility of root dentin using experiments and stress analysis. METHODS: Root canals of lower premolars were enlarged with different tapers. After, teeth were cut into 2-mm sections. A metal rod of the same taper was pushed through the center of the sections using a universal test system to fracture them. The fracture load was determined from the peak load on the load-displacement curve. To determine fracture-causing stress, an axisymmetric FE model was created. An analytical solution was developed to understand the relationship between fracture load, geometrical and material parameters. RESULTS: For the same taper, increased root canal diameter did not lead to reduced fracture load. Both analytical and FE solutions showed positive linear relationship between fracture load and enlarged root canal diameter. The hoop stress was maximum at inner surface of enlarged root canal and reduced with increasing radial distance from the center. Bending of sections introduced further nonuniform stresses along the depth. Predictions for the fracture load based on the maximum hoop stress were closest to experimental values; however, account must be taken of the variation in fracture stress of dentin along the root length. Significance Our results rejected the hypothesis that fracture load of root dentin sections reduced with endodontic instrumentation size. However, the stress distributions in whole endodontically treated teeth are more complicated. Thus, caution is necessary when using thin root sections to investigate the effect of endodontic instruments on vertical root fracture.

Shaping abilities of two different engine-driven rotary nickel titanium systems or stainless steel balanced-force technique in mandibular molars.

The purpose of this study was to compare apical transportation, working-length changes, and instrumentation time by using nickel-titanium (Ni-Ti) rotary file systems (crown-down method) or stainless steel hand files (balanced-force technique) in mesiobuccal canals of extracted mandibular molars. The curvature of each canal was determined and teeth placed into three equivalent groups. Group 1 was instrumented with Sequence (Brasseler USA, Savannah, GA) rotary files, group 2 with Liberator (Miltex Inc, York, PA) rotary files, and group 3 with Flex-R (Union Broach, New York, NY) files. Pre- and postoperative radiographs were superimposed to measure loss of working length and apical transportation as shown by changes in radius of curvature and the long-axis canal angle. Sequence rotary files, Liberator rotary files, and Flex-R hand files had similar effects on apical canal transportation and changes in working length, with no significant differences detected among the 3 groups. Hand instrumentation times were longer than with either Ni-Ti rotary group, whereas the rotary NiTi groups had a higher incidence of fracture.

Factors affecting outcomes for single-tooth implants and endodontic restorations.

Initial root canal therapy and implant placement are both common treatment modalities, and, as such, prognostic factors that influence the treatment outcomes of these two restorations should be identified. In a retrospective chart review, 196 implant restorations and 196 matched initial nonsurgical root canal treated (NSRCT) teeth in patients were evaluated for four possible outcomes-success, survival, survival with intervention, and failure. Results showed that smokers had fewer successes and more failures in both groups (p = 0.0001), whereas NSRCT outcomes were affected by periradicular periodontitis (p = 0.001), post placement (p = 0.013), and overfilling (p = 0.003). Outcomes for both groups were not significantly affected by diabetes, age, or gender. Implant group outcomes were not affected by implant length (from 10 to 16 mm), diameter (from 3.25 to 5.5 mm), or an adjacent endodontically treated tooth, nor were NSRCT outcomes affected by the number of appointments for the procedure.

Retrospective cross sectional comparison of initial nonsurgical endodontic treatment and single-tooth implants.

Initial root canal treatment and the replacement of a single tooth with an implant are both viable treatment options, but various success rates have been reported for each treatment modality. This retrospective study compared 196 implant restorations and 196 matched initial nonsurgical root canal treatment (NSRCT) teeth in patients for four possible outcomes: success, survival, survival with subsequent treatment intervention and failure. Cross classifications/tabulations were analyzed using Pearson's chi2 test for association of the two classifications (endodontic vs implant and outcome). Polytomous regression with likelihood ratio tests were used in testing association with tooth location and outcome. Outcomes were as follows for implants and NSRCT respectively: success 73.5% and 82.1%; survival with no intervention 2.6% and 8.2%; survival with intervention 17.9% and 3.6%; and failure 6.1% and 6.1%. Location of the restoration in the mouth did not affect outcome. This study suggests that restored endodontically treated teeth and single tooth implant restorations have similar failure rates, although the implant group showed a longer average and median time to function and a higher incidence of postoperative complications requiring subsequent treatment intervention.

Chronic nerve growth factor administration increases the peripheral exocytotic activity of capsaicin-sensitive cutaneous neurons.

Nerve growth factor (NGF) plays an important role in inflammation and pain and has been suggested to regulate the responsiveness and sensitivity of nociceptive fibers. However, no study has evaluated whether chronic NGF alters the exocytotic capacity of peripheral terminals of peptidergic fibers. To test this hypothesis, rats were injected subcutaneously every other day with either murine recombinant NGF (mNGF; 1.0 mg/kg) or vehicle for 7 days; or mNGF (0.1 mg/kg), mNGF (1 mg/kg) or vehicle every other day for 13 days. Treatment of rats with NGF over a 13-day period produced a significant increase in capsaicin-evoked iCGRP release from isolated biopsies of hindpaw skin, as assessed by in vitro superfusion and RIA. This effect was dose-dependent and exhibited a temporal requirement, because the enhancement was only observed after 13 days of treatment and was not evident after 7 days of treatment. This NGF enhancement of capsaicin-evoked iCGRP release was not due solely to increases in peripheral iCGRP content since only the 1mg/kg dose of NGF elevated cutaneous pools of iCGRP, whereas both doses significantly increased capsaicin-evoked peptide release. Moreover, NGF also enhanced capsaicin-evoked thermal hyperalgesia under similar dose- and time-related conditions. Collectively, the chronic administration of NGF not only increases capsaicin-evoked hyperalgesia, but also significantly primes peripheral fibers to enhanced peptidergic exocytosis following activation of the capsaicin receptor. Collectively, these data are consistent with the hypothesis that persistently elevated NGF levels may contribute to enhanced neurogenic regulation of inflammatory and wound healing processes in injured tissue.

Retrospective cross sectional comparison of initial nonsurgical endodontic treatment and single-tooth implants.

Initial root canal treatment and the replacement of a single tooth with implants are both viable treatment options, but various success rates have been reported for each treatment modality. This study compared 196 implant restorations and 196 matched initial nonsurgical root canal treatment (NSRCT) teeth in patients for four possible outcomes- success, survival, survival with subsequent treatment intervention and failure. Cross classifications/tabulations were analyzed using Pearson's chi(2) test for association of the two classifications (endo vs. implant and outcome). Polytomous regression with likelihood ratio tests were used in testing association with tooth location and outcome. Outcomes were as follows for implants and NSRCT outcomes, respectively: success 73.5% and 82.1%; survival with no intervention 2.6% and 8.2%; survival with intervention 17.9% and 3.6%; and failure 6.1% and 6.1%. Location of the restoration in the mouth did not affect outcome. This study suggests that restored endodontically treated teeth and single-tooth implant restorations have similar failure rates, although the implant group showed a longer average and median time to function and a higher incidence of postoperative complications requiring subsequent treatment intervention.

Mandibular Canal Location: Cone-beam Computed Tomography Examination.

INTRODUCTION: The increased use of implants and potential endodontic misadventures can lead to nerve damage. The purpose of this study was to use cone-beam computed tomography (CBCT) measurements to investigate mandibular canal (MC) location in relation to mandibular posterior teeth, the dimension of the buccal and lingual bone over the MC, the diameter of the MC, and the anterior loop location near the mental foramen. METHODS: CBCT scans from 106 patients (age, 18-69 years) were used to evaluate measurements from 636 teeth and respective MC areas. RESULTS: Respective locations of MC to teeth (buccal, inferior, or lingual) were as follows: second molar (57% buccal, 40% inferior, and 3% lingual), first molar (18% buccal, 55% inferior, and 27% lingual), and second premolar (33% buccal, 55% inferior, and 11% lingual). Buccal bone thickness over the MC was thickest at mesial root of second molars and thinnest over the second premolar (5.4 versus 2.6 mm). The lingual bone next to the MC was thickest over the second premolar and thinnest at distal root of first molars (3.8 versus 1.7 mm). The average diameter of the MC along the length of the canal from second molar to second premolar was 3.03 mm on left and 2.91 mm on right. The anterior loop was present in 10.4% of patients, with the average depth below bone of 13.43 mm. The anterior loop was more often seen on the left side than right and occurred bilaterally 50% of the time. CONCLUSIONS: Mandibular bone thickness, nerve location, and dimension data all contribute to a useful knowledge base for practitioners. The application of CBCT imaging techniques aids in the surgical treatment, while offering advantages over conventional periapical and panoramic films.

Cone-beam Computed Tomography: Anatomic Analysis of Maxillary Posterior Teeth-Impact on Endodontic Microsurgery.

INTRODUCTION: It is imperative that the endodontic surgeon be knowledgeable of the anatomic dimensions of the surgical site. If cone-beam computed tomography is not available because of location/cost, it is prudent for the clinician to consult a knowledge base for the surgical site. An understanding of the root thickness of maxillary premolars and molars at the preferred level for root resection (3.0-3.6 mm), bone thickness over these roots, and the proximity of each root apex to the maxillary sinus will help the surgeon before and during the surgical procedure. METHODS: Cone-beam computed tomography scans from 155 patients were used to evaluate measurements from 505 teeth and respective areas. RESULTS: (1) Buccal bone was thinnest over the buccal root of the 2-rooted first premolar (0.66 mm) and the mesiobuccal (MB) root of the first molar (0.84 mm) and thickest over the MB root of the second molar (1.91 mm). (2) The palatal bone was thinnest over the palatal root of the maxillary first molar (1.24 mm) and thickest over the single-rooted second premolar (3.26 mm). (3) The longest distances to complete resection were found for the 2-rooted first and second premolars (8.81 mm and 9.14 mm, respectively) and the MB root of the second molar (7.40 mm). (4) The MB root of the second molar had the closest proximity to the sinus floor, with an average distance of 0.66 mm. CONCLUSIONS: An understanding of the maxillary posterior tooth anatomy for apical resection is beneficial to the endodontist.

A titration model for evaluating calcium hydroxide removal techniques.

OBJECTIVE: Calcium hydroxide (Ca(OH)2) has been used in endodontics as an intracanal medicament due to its antimicrobial effects and its ability to inactivate bacterial endotoxin. The inability to totally remove this intracanal medicament from the root canal system, however, may interfere with the setting of eugenol-based sealers or inhibit bonding of resin to dentin, thus presenting clinical challenges with endodontic treatment. This study used a chemical titration method to measure residual Ca(OH)2 left after different endodontic irrigation methods. MATERIAL AND METHODS: Eighty-six human canine roots were prepared for obturation. Thirty teeth were filled with known but different amounts of Ca(OH)2 for 7 days, which were dissolved out and titrated to quantitate the residual Ca(OH)2 recovered from each root to produce a standard curve. Forty-eight of the remaining teeth were filled with equal amounts of Ca(OH)2 followed by gross Ca(OH)2 removal using hand files and randomized treatment of either: 1) Syringe irrigation; 2) Syringe irrigation with use of an apical file; 3) Syringe irrigation with added 30 s of passive ultrasonic irrigation (PUI), or 4) Syringe irrigation with apical file and PUI (n=12/group). Residual Ca(OH)2 was dissolved with glycerin and titrated to measure residual Ca(OH)2 left in the root. RESULTS: No method completely removed all residual Ca(OH)2. The addition of 30 s PUI with or without apical file use removed Ca(OH)2 significantly better than irrigation alone. CONCLUSIONS: This technique allowed quantification of residual Ca(OH)2. The use of PUI (with or without apical file) resulted in significantly lower Ca(OH)2 residue compared to irrigation alone.

Nerve growth factor treatment enhances release of immunoreactive calcitonin gene-related peptide but not substance P from spinal dorsal horn slices in rats.

The effect of systemic nerve growth factor (NGF) on neuropeptide content and capsaicin-evoked release of neuropeptide from in vitro spinal cord dorsal horn slices was examined. Rats were injected subcutaneously every other day with murine NGF (mNGF) 1 mg/kg or saline for 7 days, or mNGF 0.1/kg, mNGF 1 mg/kg or saline for 13 days. Lumbar dorsal horn slices of the rat spinal cord from all groups showed a significant increase in immunoreactive calcitonin gene-related peptide (CGRP) release upon exposure to capsaicin. This release was enhanced in rats pretreated with mNGF 1 mg/kg for 7 days, but not after 13 days. No enhancement was seen after 7 or 13 days in any treatment group for immunoreactive substance P release. Upon examination of neuropeptide content in dorsal horn, no significant differences were noted between treatment groups. The increased iCGRP release from dorsal horn slices suggests a preferential release of CGRP and provides further evidence that NGF indirectly plays a role in the modulation of inflammation through the regulation of neuropeptide release.

Adrenergic regulation of capsaicin-sensitive neurons in dental pulp.

Alpha adrenergic agonists (e.g. vasoconstrictors) represent one of the most commonly used drug classes in dentistry. Although adrenergic agonists have potent vascular effects, recent studies suggest that capsaicin-sensitive nociceptors may express adrenoceptors, suggesting that these drugs may directly modulate the function of an important class of pain-signaling neurons in peripheral tissues. In this study, we tested the hypothesis that adrenergic agonists inhibit activation of peripheral terminals of capsaicin-sensitive fibers innervating dental pulp. Pretreatment with epinephrine or clonidine significantly inhibited capsaicin-evoked release of immunoreactive calcitonin gene-related peptide from superfused bovine dental pulp. These studies suggest that adrenergic agonists may reduce postoperative pain in part via a direct inhibition of capsaicin-sensitive nociceptors. This finding may lead to the development of selective, peripherally acting, adrenergic analgesics. Moreover, because neuropeptide release alters blood flow, it is possible that the vascular effects of these drugs are caused by both vasoconstriction and inhibition of peripheral neuropeptide release.