Pulp Survival of Cracked Teeth with Reversible Pulpitis after Orthodontic Banding and Coronal Coverage - a Prospective Cohort Study with One Year Follow Up.

INTRODUCTION: The aim of this prospective study was to investigate the 1-year pulp survival of cracked teeth with reversible pulpitis managed with initial stabilization using orthodontic bands, followed by coronal coverage restorations. METHODS: One-hundred-and-twenty-five patients with a cracked tooth with reversible pulpitis each were recruited. Pre-operative patient and tooth data were collected. After definitive pulp diagnoses were determined following an interim period of orthodontic banding, coronal coverage restorations were placed. Cox and logistic regression analyses were used to assess possible prognostic factors and to correlate initial time to pulp stabilization while in orthodontic bands with eventual outcome. Pulp survival was determined using both clinical and radiographic findings. RESULTS: One-hundred-and-six cracked teeth were followed up at 1 year. Pulp survival based on clinical and radiographic findings was found in 81 teeth (76.4%). Out of 25 failures, 11 (44%) required root canal treatment (RCT) in the orthodontic band stage and 10 (40%) required RCT during the process of or after coronal coverage restorations. Four teeth (16%) had incidental findings of periapical radiolucencies at the one-year review without clinical symptoms. Teeth requiring RCT were found to have required longer periods in orthodontic bands prior to a definitive pulp diagnosis (p<0.05). CONCLUSION: A step-by-step approach by using orthodontic banding to monitor pulp status may reduce the incidence of RCT required through definitive coronal coverage restorations for cracked teeth with reversible pulpitis.

Characteristics of Cracked Teeth with Reversible Pulpitis After Orthodontic Banding-A Prospective Cohort Study.

INTRODUCTION: Cracked teeth with reversible pulpitis can be managed with orthodontic bands in the interim before definitive restorations. The aim of this study was to determine short-term outcomes of these teeth following orthodontic band placement. The time taken for definitive pulp diagnoses after orthodontic band placement and associated prognostic factors was also analyzed. METHODS: One hundred twenty-five patients with a cracked tooth with reversible pulpitis each were recruited. Preoperative data including patient and tooth factors were collected. Cracked teeth were banded and reviewed until symptoms resolved before referral for coronal coverage. Kaplan-Meier and Cox analyses were performed to analyze pulp survival of these teeth. Prognostic factors were investigated using Pearson's chi-square and Student's t-test. RESULTS: One hundred twenty-two cracked teeth were analyzed. One hundred thirteen (92.6%) teeth had the pulpitis resolved within 2 months (median 40.0; interquartile range 28-61). The median time taken for progression to irreversible pulpitis or pulp necrosis for teeth that required root canal treatment was 3 months (median 90.0; interquartile range 68-110). No prognostic factors were associated with the resolution of pulpal symptoms. However, higher preoperative triggered pain scores (P < .05, hazards ratio 1.547) and absence of a distal marginal ridge crack (P < .05, hazards ratio 0.638) were correlated with a longer duration before definitive pulp diagnoses. CONCLUSION: Following orthodontic band placement, a normal pulp diagnosis was achieved in 92.6% of cracked teeth with preoperative reversible pulpitis. Definitive pulp diagnoses could be determined in approximately 2 months. Teeth with higher preoperative triggered pain scores may require a longer review period.

Psycho-social perspectives of nonsurgical versus surgical endodontic interventions in persistent endodontic disease.

INTRODUCTION: Patients' experiences related to dental treatment could influence care-seeking behaviour and engender personal bias. Although endodontic retreatment and apical surgery are procedures often performed to manage previously treated teeth with persistent disease, there is lack of information regarding psycho-social perspectives of patients who undergo these treatments. Our aim was to compare experiences of patients who received these two treatment modalities using a qualitative approach. METHODS: A purposive sample of patients was taken from our previous study utilizing the Oral Health Impact Profile to compare oral health-related quality of life of 150 patients who received retreatment and apical surgery. Patients who reported impact and no impact were invited to participate in focus group discussions (FGDs). Eighteen patients from the retreatment group and 15 patients from the surgical group participated in six FGDs. Thematic analysis was conducted to identify key themes. RESULTS: Four themes emerged: (1) psycho-social disability associated with dental procedures, (2) physical disability associated with dental problems, (3) reliance on dentist's advice for treatment and (4) self-management to preserve treated teeth. Patients undergoing endodontic retreatment reported significant time loss from work and were less informed of alternative treatment options. However, they were pleased with the aesthetics of their teeth, especially if new crowns were made. Patients undergoing surgery experienced anxiety related to loss of control during surgery and apprehension on visualizing the wound post-surgery. They reported more impact on their diet, social interaction and sleep quality and some felt self-conscious due to post-treatment gingival recession. Patients in both groups placed great trust in professional advice and expressed a clear desire to maintain their natural dentition. There was low awareness regarding long-term care and future sequelae of their treated tooth. CONCLUSIONS: Patients reported different psycho-social and physical impacts following endodontic retreatment and apical surgery. Patients undergoing endodontic retreatment were more satisfied with aesthetic outcomes but experienced greater impact related to complexities and length of time taken for treatment. Patients undergoing surgery were better informed of treatment options but experienced greater physical and psycho-social disability during the recovery phase. Clinicians could consider incorporating findings from this study into the patient-dentist discussion.

Management of cracked teeth: Perspectives of general dental practitioners and specialists.

OBJECTIVES: The main aim of this study was to compare how general dental practitioners (GDPs), endodontists and prosthodontists diagnose, prognosticate, and treat cracked teeth. The secondary aim was to highlight factors influencing GDPs' referral practices of cracked teeth to specialists. MATERIALS AND METHODS: Questionnaires were used to collect information from GDPs, prosthodontists, and endodontists, on their use of diagnostic methods to identify cracked teeth, prognostication, and their management and referral practices for cracked teeth. Descriptive statistics were used to summarize the quantitative data. Pearson's Chi-Square test or Fisher's Exact test was applied to categorical variables while Kruskal-Wallis or Spearman's correlation coefficient was applied to continuous variables (p <0.05). Content analysis was performed for qualitative data. RESULTS: 207 dentists responded, resulting in a response rate of 83.5%. Endodontists used more diagnostic tools as compared to prosthodontists and GDPs. For pulpally involved cracked teeth, endodontists were more likely to recommend root canal treatment (RCT) and cuspal coverage compared to extraction, followed by prosthodontists then GDPs. Main reasons for referral of cracked teeth to specialists include uncertainty in diagnosis, difficulty in crack visualization after endodontic access, and cracked teeth indicated for RCT. CONCLUSION: GDPs, prosthodontists, and endodontists differ in terms of their diagnosis, prognostication, and treatment of cracked teeth. GDPs refer cracked teeth to specialists due to challenges faced in diagnosis and treatment. Future research and education are required to provide evidence-based guidelines in the management of cracked teeth so that patients with cracked teeth can receive standardized care.

Postobturation Pain Associated with Tricalcium Silicate and Resin-based Sealer Techniques: A Randomized Clinical Trial.

INTRODUCTION: The incidence of immediate postobturation pain associated with 2 sealer techniques was compared and potential prognostic factors identified. METHODS: Patients referred for endodontic treatment were recruited with informed consent. Root canals were debrided and teeth rendered asymptomatic before random allocation to receive TotalFill BC (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) or AH Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland). Patients blinded to the sealer reported their postobturation pain experience 1, 3, and 7 days after treatment. Blinded and calibrated assessors independently reviewed treatment quality, sealer extrusion, and radiographic data under standardized conditions. RESULTS: One hundred sixty eligible patients (163 teeth, 95.3%) returned their pain diary. No postobturation pain difference was found between the 2 sealers (P > .05), although the AH Plus sealer technique was significantly associated with extrusion beyond the apex (P < .05; odds ratio [OR] = 3.02; 95% confidence interval [CI], 1.39-6.57). Thirty-three (20.6%) patients reported pain on day 1 (median 1 = very mild pain), 16 (10.0%) on day 3 (median 1 = very mild pain), and 9 (5.6%) on day 7 (median 2 = mild pain). The prognostic factors were as follows: (1) moderate/severe preoperative pain (OR = 4.41; 95% CI, 1.42-13.76 on day 3 and OR = 5.16; 95% CI, 1.17-22.78 on day 7), (2) provoked preoperative pain (OR = 4.24; 95% CI, 1.40-12.78 on day 3 and OR = 5.35; 95% CI, 1.27-22.51 on day 7), (3) pulpless tooth (OR = 0.11; 95% CI, 0.02-0.57 on day 3), and (4) sonic activation during treatment (OR = 3.02; 95% CI, 1.39-6.57 on day 1 and OR = 3.01; 95% CI, 1.05-8.59 on day 3). CONCLUSIONS: There was no significant difference in pain experience between teeth filled using AH Plus or TotalFill BC Sealer 1, 3, and 7 days after obturation. Patient- and treatment-related factors could influence postobturation pain.

Factors Influencing Quality of Life after Surgical and Nonsurgical Interventions of Persistent Endodontic Disease.

INTRODUCTION: Nonsurgical endodontic retreatment and apical surgery are predictable procedures for the management of endodontically treated teeth with persistent disease. However, there is no information available that compares these treatment modalities based on patients' oral health-related quality of life (OHRQOL). The aims of this study were to compare the OHRQOL of patients who received nonsurgical endodontic retreatment versus those who received apical surgery and to identify correlations between OHRQOL, clinician-assessed healing outcome, and other factors. METHODS: Patients who received treatment at 2 dental hospitals with a recall period of 6-24 months were invited to participate. They underwent follow-up examination and were surveyed with the Oral Health Impact Profile (OHIP-14). Healing outcomes were determined by clinical and radiographic evaluation. Potential influencing factors for OHIP-14 scores were investigated. RESULTS: One hundred fifty patients (75 patients from each group) participated in the study. There were no differences in OHIP-14 scores between both groups at the follow-up. The overall adverse impact on OHRQOL was low, with patients experiencing greater impact in the domains of "physical pain" and "psychological discomfort." Women and patients who had preoperative pain reported a greater impact. There was an overall high healed and healing rate for both groups. No correlation was found between OHIP-14 scores and healing outcome. CONCLUSIONS: Patients who received nonsurgical endodontic retreatment and apical surgery reported comparable OHRQOL, with women and patients with preoperative pain reporting greater impact. Both treatments are viable options for the management of persistent endodontic disease based on clinician- and patient-reported outcome assessments.

An Immunofluorescence Study to Analyze Wound Healing Outcomes of Regenerative Endodontics in an Immature Premolar with Chronic Apical Abscess.

INTRODUCTION: Limited studies have examined tissue formation via immunofluorescence in regenerative endodontic procedures (REPs) performed on infected human teeth. This report investigated the immunofluorescent histologic outcomes of REPs in which repeated canal disinfection was required. METHODS: An 11-year-old girl presented with a fractured dens evaginatus (#29) with a sinus tract. Three visits involving chemical and mechanical disinfection were required before the resolution of clinical signs and symptoms was achieved and the REP could be performed. Healing of the periapical lesion was noted by 12 months, although the tooth remained unresponsive to sensibility tests. At 18 months, the tooth underwent orthodontic extraction. Histology and immunofluorescent techniques were used to stain for dentin sialophosphoprotein (DSPP), osteopontin (OPN), periostin, and myelin basic protein. RESULTS: Histology did not reveal a newly formed pulp-dentin complex. Neomineralized tissues were seen interlocked into preexisting dentinal tubules. Non-odontoblast-looking cells expressed different proportions of OPN and DSPP according to their location. Cells nearer to mineral trioxide aggregate expressed DSPP and OPN, but cells found apically expressed predominantly OPN. Myelin basic protein was found centrally within new tissues and did not extend to the coronal third. Periostin was highly expressed throughout the entire canal space, suggesting active repair processes instead of regeneration. CONCLUSIONS: This study shows the clinical effectiveness of REP in a tooth with recalcitrant infection with histologic demonstration of a reparative phenotype. De novo pulp regeneration in a clinical scenario may be limited by a complex interplay of host response factors.

Long-term Success and Survival of Endodontic Microsurgery.

INTRODUCTION: Healed rates of endodontic microsurgery (EMS) may decrease over time, but research on the long-term outcomes is scarce. The aims of this retrospective cohort study were to evaluate the 5- to 9-year healed and survival rates of EMS, to identify associations between prognostic factors and healing status, and to compare the short-term (1- to 2-year) with long-term (5- to 9-year) outcomes. METHODS: One hundred fifty-one eligible patients (166 teeth) who underwent EMS in 2007-2010 were invited for a follow-up examination. Eighty-three patients (94 teeth) participated in the study. Survival status and reasons for extraction of all teeth were determined, and survival rates were calculated by Kaplan-Meier analyses. Outcomes were determined on the basis of clinical and radiographic findings and associated with potential prognostic variables via multivariate Cox regression analyses. RESULTS: Thirty-two teeth were extracted: 6 because of endodontic failure, 20 for unrelated reasons, and 6 for unknown reasons. Outcomes were categorized as healed and not healed. Multivariate analysis revealed that adjusted hazard ratio for failure was 5.95 times higher (95% confidence interval, 1.54-22.91) for teeth treated with intermediate restorative material than with mineral trioxide aggregate and 3.38 times higher (95% confidence interval, 1.05-10.9) for teeth with no known history of nonsurgical retreatment. Teeth classified as healed in the 1- to 2-year review mostly remained healed at 5- to 9-year review (45/48 teeth); those with uncertain healing had varied outcomes at long-term review. CONCLUSIONS: EMS results in high long-term healed (78.3%, 72/92 teeth) and survival (95.2%) rates. Root-end filling material and nonsurgical retreatment before EMS may influence the long-term outcome.

Matrix Metalloproteinase Inhibitor as an Antimicrobial Agent to Eradicate Enterococcus faecalis Biofilm.

INTRODUCTION: Successful endodontic treatment outcomes require new strategies for the complete eradication of microbial biofilms in the root canal system. Matrix metalloproteinases (MMPs) are essential enzymes in microbial cell growth and homeostasis, and they require transition metal ion cofactors to function. Targeting MMP activity also preserves dentin collagen integrity. In this study, 1,10-phenanthroline-5,6-dione (Phendione), a metal chelator, was tested as a potentially novel antimicrobial agent against Enterococcus faecalis and inhibitor of human MMP in the root canal. METHODS: Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of Phendione on E. faecalis were determined. The antimicrobial properties of Phendione in the presence of dentin powder and various transition metal ions were examined. The ability of Phendione to inhibit human MMP-2 was subsequently tested. The efficacy of Phendione against E. faecalis biofilm was determined by exposure of 7-day-old E. faecalis biofilms to Phendione. RESULTS: The MIC and MBC of Phendione were 2.0 µg/mL and 16 µg/mL, respectively, whereas 64 µg/mL was required to kill E. faecalis biofilm. Phendione completely eradicated E. faecalis despite dentin preincubation. The presence of Zn(2+), and to a lesser extent Fe(2+), abrogated the antimicrobial effect of Phendione. In addition, Phendione at MIC and MBC significantly inhibited human MMP-2 activity. CONCLUSIONS: Phendione effectively eradicated E. faecalis biofilms and significantly inhibited human MMP-2 through its ability to chelate metal ions. The antibacterial property of Phendione was preserved in the presence of dentin. Phendione can potentially be applied in endodontic treatment as both an antimicrobial agent and MMP inhibitor.

Isolation of alkaline-tolerant bacteria from primary infected root canals.

INTRODUCTION: Alkaline-tolerant bacteria in primary infected root canals could have enhanced survival capacity against antimicrobials commonly used in root canal treatment. The aims of this study were to isolate and characterize alkaline-tolerant bacteria before endodontic treatment (S1), after chemomechanical root canal preparation (S2), and after calcium hydroxide dressing (S3). METHODS: Bacteriologic samples were obtained from 43 primary infected root canals. Samples were inoculated into culture media at a pH of 9 and incubated anaerobically. The identities of bacterial isolates were determined by 16S ribosomal RNA sequencing. RESULTS: All S1 samples were culture positive, with 70% harboring bacteria tolerating a pH of 9. Gram-positive bacteria Pseudoramibacter alactolyticus and Streptococcus spp were the most frequently isolated strains with a prevalence of 54%. Of 13 culture-positive S2 samples, 8 isolates tolerated a pH of 9, namely Streptococcus sanguinis, Enterococcus faecalis, Enterobacter cancerogenus, Streptococcus oralis, and Fusobacterium nucleatum. Seven of these 8 isolates (88%) were correspondingly isolated at S1. All 3 culture-positive S3 samples tolerated a pH of 9, namely S. sanguinis and E. faecalis, which were also isolated in the corresponding S1 and S2 samples. CONCLUSIONS: We showed that the presence of alkaline-tolerant Streptococcus and Enterococcus spp in primary infected root canals could lead to their persistence during and after root canal treatment and could pose a challenge to current treatment efficacy.

Prognostic factors relating to the outcome of endodontic microsurgery.

INTRODUCTION: The aim of this retrospective study was to evaluate the outcome of endodontic microsurgery and to examine prognostic factors related to healing. METHODS: The clinical records of all patients who had undergone endodontic microsurgery from 1997-2003 at the National Dental Centre of Singapore were examined. Teeth with a recall period of 1-2 years were selected. All surgical procedures, except for flap raising and suturing, were performed under a surgical operating microscope. Root-end cavities prepared with ultrasonic tips were filled with Intermediate Restorative Material (Caulk, Milford, DE) or mineral trioxide aggregate. Teeth were evaluated for clinical signs and symptoms after surgery. Preoperative and postoperative radiographs were evaluated independently by 2 endodontists. RESULTS: Of 243 root-end surgeries performed, 93 were eligible for the study. Outcomes were categorized as healed, healing, or persistent disease; 78.5% of teeth were assessed to be healed or healing, and 21.5% had persistent disease. The percentages of healed and healing teeth for anterior and posterior root-end surgeries were 76.5% and 80.4%, respectively, with no significant difference in the procedures (P = .8). Ordinal logistic regression showed a higher likelihood of healing in females compared with males (P = .001) and maxillary anterior teeth compared with mandibular anterior teeth (P = .03). Preoperative probing depths of ≤3 mm were significantly associated with healing (P = .05). CONCLUSIONS: The use of modern endodontic surgical techniques resulted in 78.5% healed and healing teeth with a recall period of 1-2 years. Prognostic factors affecting successful healing include sex, tooth type, and preoperative probing depths.

N-acetylcysteine inhibits growth and eradicates biofilm of Enterococcus faecalis.

INTRODUCTION: The aims of this study were to evaluate the antibacterial and biofilm eradication efficacies of N-acetylcysteine (NAC) on Enterococcus faecalis. METHODS: The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of NAC on E. faecalis were determined. In addition, the ability of dentin powder to neutralize the antibacterial activity of NAC was examined. Calcium hydroxide, a commonly used intracanal medicament, was included as a comparison. The efficacy of NAC on E. faecalis biofilms was tested by exposure of 21-day old E. faecalis biofilms to NAC. RESULTS: NAC was most bactericidal at pH 11 with MIC and MBC of 1.56 mg/mL and 12.5 mg/mL, respectively. Although preincubation of calcium hydroxide with dentin powder abolished its antibacterial effects, NAC completely killed E. faecalis regardless of dentin powder preincubation. In addition, prolonged incubation of NAC with dentin powder (up to 3 weeks) did not significantly reduce its antibacterial activity on E. faecalis. Furthermore, NAC also effectively eradicated E. faecalis biofilms. CONCLUSIONS: NAC was bactericidal against both the planktonic and biofilm forms of E. faecalis. This antibacterial property of NAC was unaffected by the presence of dentin.

The effect of EDTA with and without ultrasonics on removal of the smear layer.

This study evaluated in vitro effectiveness of 17% EDTA with and without ultrasonics on smear layer removal. One hundred and five extracted premolars randomly divided into seven groups were instrumented with different final irrigating protocols: group A (Sal3US), saline for 3 minutes with ultrasonics; groups B (Na3) and C (Na3US), 1% sodium hypochlorite for 3 minutes without and with ultrasonics, respectively; groups D (ED3) and E (ED3US), 17% EDTA for 3 minutes without and with ultrasonics, respectively; and groups F (ED1) and G (ED1US), 17% EDTA for 1 minute without and with ultrasonics, respectively. Specimens were examined under scanning electron microscope and scored for smear layer and debris removal. Statistical analysis showed that groups with EDTA and ultrasonic irrigation, groups E (ED3US) and G (ED1US), had significantly more specimens with complete smear layer and debris removal. There was no significant difference between groups E (ED3US) and G (ED1US). A 1-minute application of combined use of EDTA and ultrasonics is efficient for smear layer and debris removal in the apical region of the root canal.

Effect of EDTA with and without surfactants or ultrasonics on removal of smear layer.

This study compared the in vitro efficacy of Smear Clear (Sybron Endo, CA), a 17% ethylenediaminetetraacetic acid (EDTA) solution with surfactants, to 17% EDTA, with and without the use of ultrasonics, in removal of the smear layer. Seventy-five extracted teeth, randomly distributed into 5 test groups, were prepared by using ProFile rotary instruments (Dentsply Maillefer, Ballaigues, Switzerland) and subjected to different final irrigating regimes; group A, 1% sodium hypochlorite; group B, 17% EDTA; group C, 17% EDTA with ultrasonics; group D, Smear Clear; and group E, Smear Clear with ultrasonics. Samples were examined under the scanning electron microscope and scored for debris and smear layer removal. Statistical analysis showed that groups D and E did not perform significantly better than groups B and C. Group C performed significantly better than group B. Addition of surfactants to EDTA in Smear Clear did not result in better smear layer removal. The use of ultrasonics with 17% EDTA improved smear layer removal.