Impact of Case Difficulty, Endodontic Mishaps, and Instrumentation Method on Endodontic Treatment Outcome and Quality of Life: A Four-Year Follow-up Study.

INTRODUCTION: Root canal treatment (RCT) is often considered a difficult procedure for both the patient and treatment provider. The American Association of Endodontists case difficulty assessment form categorizes cases as minimal, moderate, and high difficulty level. We recently showed that endodontic mishaps occur frequently during treatment of teeth in high difficulty category. The aims were to investigate the clinical and radiographic outcome at least 4 years after RCT and to evaluate patients' perceived oral health-related quality of life (OHRQoL). METHODS: Two hundred thirty-four patients (257 endodontically treated teeth) who were previously included in a quality assurance study were offered a recall appointment at the Department of Clinical Dentistry, University of Bergen, Norway. Patients were given a thorough clinical, radiographic examination and asked to fill out the Oral Health Impact Profile-14 questionnaire. RESULTS: A total of 149 patients (160 teeth) attended the 4-year (range, 4-6 years) recall appointment. An unchanged or lower Periapical Index (PAI) score at recall visit was registered on 153 teeth (95.6%) (P < .001). Radiographic success rate (PAI score ≤ 2) was 87.5%, and clinical success (absence of clinical signs and symptoms) was 88.8%. Both radiographic and clinical success was observed in 78.8% of teeth. Teeth in high difficulty category, instrumented with engine-driven files, and molars presented with significantly more clinical signs and symptoms but not high PAI score (PAI score ≥ 3) (P < .05). Endodontic mishaps such as overinstrumentation and overfill with gutta-percha resulted in significantly high PAI score (P < .05). Patients with no clinical signs and symptoms after RCT and elderly had a significantly better OHRQoL (P < .05). CONCLUSIONS: Presence of clinical signs and symptoms rather than PAI score affected patients' OHRQoL.

A Comparison of Endodontic Treatment Factors, Operator Difficulties, and Perceived Oral Health-related Quality of Life between Elderly and Young Patients.

INTRODUCTION: The purpose of this study was to compare endodontic treatment factors, treatment difficulties, and oral health-related quality of life (OHRQOL) between elderly and young patients. METHODS: A total of 150 adults, 75 elderly (≥65 years) and 75 young patients (18-64 years), were recruited. Operators enumerated difficulties associated with communication, diagnosis, rubber dam application, access cavity preparation, canal localization, working length determination, instrumentation, and obturation after root canal treatment. The number of treatment visits, maxillary first molars with a second mesiobuccal canal, and the technical quality of the root filling were registered. Patients filled out questionnaires on pain, attendance of regular dental visits, esthetics, and masticatory function and the Oral Health Impact Profile-14. RESULTS: Significantly more elderly had necrotic pulp (P < .001) and needed root canal treatment on teeth with full-coverage crown/bridge abutment (P < .001). It was significantly difficult to perform access cavity preparation and localize root canals on the elderly and on teeth with a full-coverage crown/bridge abutment. In regression analysis, the elderly presented with difficulties only during canal localization (P < .05). Second mesiobuccal canals were obturated in 43.5% of the young patients and 23.1% of the elderly patients. There were no significant differences in the number of treatment visits or the technical quality of root filling between the 2 groups. There were no significant differences in pain sensation, esthetics, masticatory function, or regular dental visits between the 2 groups. Elderly patients reported a significantly better OHRQOL (P < .05). Patients experiencing pain, patients needing treatment on anteriors/premolars, and females reported a significantly poorer OHRQOL (P < .05). CONCLUSIONS: The elderly presented with treatment difficulty during canal localization and had better OHRQOL compared with young patients.

Acute Dental Pain and Salivary Biomarkers for Stress and Inflammation in Patients with Pulpal or Periapical Inflammation.

AIMS: To investigate whether acute dental pain due to pulpal or periapical inflammation is associated with increased expression of cortisol and inflammatory markers and mediators in the saliva, as well as changes in salivary flow rate. METHODS: Patients experiencing pain (n = 42) were recruited when seeking emergency dental treatment. A 0 to 10 numeric rating scale (NRS) was used as a measure of the severity of pain, and the number of days with pain sensation was also recorded. Unstimulated saliva was collected for 3 minutes (salivary flow measured in mL/minute) and stored at -80°C. Saliva was analyzed for the biomarkers cortisol, C-reactive protein (CRP), and cytokines interleukin-1ß (IL-1ß) and interleukin-6. In addition, the participants completed a simple questionnaire about stress-inducing factors such as insomnia, dental anxiety, or home/workplace stress. Patients received a dental examination and diagnosis (eg, symptomatic pulpitis/apical periodontitis or acute apical abscess), which was confirmed during dental treatment. The control group (n = 39) consisted of participants without any pain and no known medical or dental problems. RESULTS: Patients experiencing acute pain due to pulpal or periapical inflammation had a mean NRS score of 7.0 ± 2.59. The mean duration of pain was 6.5 ± 7.9 days. There was no significant difference in pain level between male and female subjects, tooth type affected, or diagnosis. Higher levels of cortisol, IL-1ß, and IL-6 and increased salivary flow were detected in patients with pain when compared to controls (P < .05). CRP was higher in patients with acute pain compared to control participants without pain, but this difference was not statistically significant. Stress at home or the workplace was reported by 79% of patients experiencing pain and by 28% of control participants. CONCLUSION: Acute dental pain due to pulpal or periapical inflammation was associated with an increase in salivary cortisol, IL-1ß, and IL-6 levels and in salivary flow rate. Stress arising from home or the workplace may aggravate a symptom-free pulpal or periapical inflammation to an acute phase. Inflammation in the pulp and periapical region can have effects in regions remote from the disease site.

Impact of Case Difficulty on Endodontic Mishaps in an Undergraduate Student Clinic.

INTRODUCTION: The aim of this study was to identify the effect of case difficulty on the number of endodontic mishaps and the number of treatment visits using 2 different instrumentation methods, hand files, and reciprocating engine-driven WaveOne files (Dentsply Maillefer, Ballaigues, Switzerland) in an undergraduate student clinic. METHODS: Endodontic treatment performed by fourth-year dental students using 2 different instrumentation methods was evaluated: hand files and reciprocating engine-driven WaveOne files. All cases were categorized according to the American Association of Endodontists case difficulty assessment form. Endodontic mishaps related to instrumentation and treatment visits needed to complete the treatment were recorded. RESULTS: Of the 257 teeth included in the study, 141 were instrumented with hand files and 116 with WaveOne files. Eighty-two teeth (31.9%) were registered with at least 1 endodontic mishap. The most frequent endodontic mishap was overinstrumentation (17.5%). This was followed by loss of working length (8.56%), obturation more than 2 mm from the radiographic apex (8.56%), overfill with gutta-percha (6.61%), canal transportation (4.28%), instrument separation (2.33%), and lateral or strip perforation (1.56%). Several endodontic mishaps were significantly correlated. Cases in the high difficulty category had significantly more endodontic mishaps (P < .001) and required more treatment visits (P < .01). There were no significant differences in endodontic mishaps or the number of treatment visits between the hand and engine-driven groups. Several endodontic mishaps were associated with significantly more treatment visits (P < .05). CONCLUSIONS: Case difficulty rather than the instrumentation method was the main determinant of endodontic mishaps in the undergraduate clinic. The American Association of Endodontists case difficulty assessment form is an important and valuable tool in undergraduate dental education to predict potential endodontic mishaps and the number of treatment visits.

High interstitial fluid pressure in rat tongue cancer is related to increased lymph vessel area, tumor size, invasiveness and decreased body weight.

BACKGROUND: Interstitial fluid pressure (IFP) in most tumors is high, and this high pressure has been correlated with poor prognosis. Measurements of IFP in normal tongue and in tongue cancer are lacking. Recent research suggests the existence of a relationship between increased peritumoral lymph vessels (PTLV) and survival, and a correlation of increased lymphatic vessel density with an unfavorable prognosis has been reported. MATERIALS AND METHODS: In the present study, tongue squamous cell carcinoma (SCC) was induced by adding the carcinogen 4-nitroquinoline oxide in drinking water for 19 weeks. The IFP was measured by micropuncture and immunohistochemistry was used to visualize lymph vessels. RESULTS: In normal tongue, IFP averaged 3.1 +/- 0.3 mmHg. The IFP, both in the tumor (29.1 +/- 2.9 mmHg) and 0.5 cm anterior to it (15.4 +/- 2.1 mmHg) was consistently increased (P < 0.005) with values ranging from 10 to 40 mmHg. The highest IFP values were measured in rats with large tumors (P < 0.05) and low body weight (P < 0.001), suggesting that IFP increases with cancer progression. Lymphatic vessel area (%), as determined with the lymphatic specific marker LYVE-1 antibody, was significantly increased in the peritumoral area when compared to intratumoral and control mucosa (P < 0.05). There was a significant positive correlation between IFP, PTLV area, tumor size and invasiveness. CONCLUSIONS: Our data show that IFP is increased in tongue cancer. Corresponding changes in PTLV area, invasiveness, tumor area and IFP suggest that the increased pressure is caused by defective lymph drainage and solid stress generated by tumor cells growing in a low compliant environment.

IL-1 alpha and TNF-alpha expression in rat periapical lesions and dental pulp after unilateral sympathectomy.

OBJECTIVES: Apical periodontitis is an inflammatory disease characterized by bone resorption, and sympathetic nerves are known to modulate bone resorption and bone remodeling. Higher numbers of osteoclasts and larger periapical lesions have been observed after sympathectomy in rats, but the mechanisms underlying the inhibitory effect of sympathetic nerves on osteoclasts are unknown. This study aimed to test the hypothesis that sympathetic nerves inhibit the production of the bone-resorbing pro-inflammatory cytokines IL-1 alpha and TNF-alpha in rat periapical lesions. METHODS: Rats were unilaterally sympathectomized and apical lesions were induced by exposing the dental pulp of molar teeth to the oral microflora. We quantified the cytokines IL-1 alpha and TNF-alpha by enzyme-linked immunosorbent assay, and immunohistochemical analysis was done for qualitative localization. Pulp from intact incisor teeth was tested as a control. RESULTS: We showed that IL-1 alpha was increased, but not TNF-alpha, in the periapical lesions on the sympathectomized side. Both IL-1 alpha and TNF-alpha were expressed in unexposed pulp. TNF-alpha was significantly decreased in the denervated incisor pulp, whereas the level of IL-1 alpha remained unchanged. CONCLUSIONS: This study suggests that sympathetic nerves have an inhibitory effect on IL-1 alpha in periapical lesions and a stimulatory effect on TNF-alpha in the intact rat pulp.

Sympathectomy causes increased root resorption after orthodontic tooth movement in rats: immunohistochemical study.

Accumulating evidence suggests that the sympathetic nervous system modulates inflammatory responses and bone remodeling. We have studied the effects of sympathectomy and orthodontic tooth movement (OTM) on root resorption, immunocompetent cell recruitment, neuropeptide, neurokinin-1 receptor (NK1-R), and interleukin 6 (IL-6) expression. Experimental rats (n=8) had the right superior cervical ganglion surgically removed, whereas control rats (n=6) underwent sham surgery. Three days later, all rats had the right maxillary first molar moved mesially by an orthodontic appliance. The rats were perfused 13 days later, and the right maxillae were processed for immunohistochemistry by using primary antibodies directed against ED1 antigen, CD43, substance P (SP), NK1-R, neuropeptide Y (NPY), and IL-6. Following OTM, sympathectomized (SCGx) rats had significantly more root resorption (P<0.01) and SP-immunoreactive (IR) fibers (P=0.01) in the compressed periodontal ligament (PDL) compared with control rats. There was a significant decrease in recruitment of CD43+ cells in the pulp after OTM in SCGx rats compared with control rats (P=0.02). An upregulation of NK1-R immunoreactivity was observed surrounding the hyalinized tissue, and an increase in the number of NK1-R IR cells and density of SP-IR fibers was present in first molar pulp of all rats. NPY-IR fibers were absent in the compressed PDL of SCGx and control rats. Thus, OTM induces remodeling not only around the periodontal tissues, but also in the dental pulp. The sympathetic nerves have an inhibitory effect on hard tissue resorption and a stimulatory effect on CD43+ cell recruitment after OTM.