Buffered 1% Lidocaine With Epinephrine Can Be as Effective as Nonbuffered 2% Lidocaine With Epinephrine for Maxillary Field Block.

PURPOSE: Buffering local anesthetics with epinephrine (Epi) offers clinicians options not often considered. This study assessed outcomes for pulpal anesthesia, pain on injection, and time to midface numbness for buffered 1% lidocaine with 1:100,000 Epi versus nonbuffered 2% lidocaine with 1:100,000 Epi. MATERIALS AND METHODS: In this trial with a randomized, crossover design, buffered 1% lidocaine was compared with nonbuffered 2% lidocaine. Subjects were adult volunteers who served as their own controls. The predictor variables were alternate drug formulations. The outcome variables were subjects' responses to cold and electric pulp testing (EPT) stimulation of the maxillary first molar and canine, pain levels during the injection, and time to midface numbness. After maxillary field blocks with 40 mg of buffered lidocaine or 80 mg of nonbuffered lidocaine, subjects reported pain on injection and responses of the maxillary first molar and canine after cold and EPT stimulation. Teeth were tested before field block and at 30-minute intervals until a positive response was detected. Two weeks later, subjects were tested with the alternate drug combinations. For all outcome variables, assessment of treatment difference, calculated as 1% buffered minus 2% nonbuffered, was performed with the Wilcoxon rank sum test with significance at P < .05. RESULTS: More of the 24 subjects were women and Caucasian. The median age was 23.5 years (interquartile range, 21, 25 years), and the median body weight was 155 lb (interquartile range, 128.5, 176.5 lb). Pain levels during the injection were significantly lower for 1% buffered lidocaine, with P = .04. Times to response after injection were not significantly different between the 2 drug formulations for the cold test on a molar, with P = .08, or the cold test on a canine, with P = .22. However, times to response were significantly longer for nonbuffered drugs for EPT on the molar and canine, both with P = .01. CONCLUSIONS: Buffering 1% lidocaine with 1:100,000 Epi reduces the pain on injection with a maxillary field block and results in similar lengths of pulpal anesthesia tested with a cold stimulus as compared with nonbuffered 2% lidocaine with 1:100,000 Epi.

Buffered 1% Lidocaine With Epinephrine Is as Effective as Non-Buffered 2% Lidocaine With Epinephrine for Mandibular Nerve Block.

PURPOSE: To assess outcomes for pulpal anesthesia and pain on injection for buffered 1% lidocaine with 1:100,000 epinephrine (EPI) versus non-buffered 2% lidocaine with 1:100,000 EPI. PATIENTS AND METHODS: In a randomized cross-over trial approved by the institutional review board, buffered 1% lidocaine with 1:100,000 EPI was compared with non-buffered 2% lidocaine with 1:100,000 EPI. After mandibular nerve block with buffered lidocaine 40 mg or non-buffered lidocaine 80 mg, patients reported responses at the mandibular first molar and canine after cold and electrical pulp testing (EPT). Patients also reported pain on injection with a 10-point Likert-type scale. Teeth were tested before nerve block and at 30-minute intervals until a positive response returned. Two weeks later, patients were tested with the alternate drug combinations. The same outcomes were assessed. Predictor variables were alternate drug formulations. Outcome variables were patients' responses to cold and EPT stimulation of the mandibular first molar and canine and pain on injection. An assessment of treatment difference was performed using Wilcoxon rank-sum tests with Proc NPAR1WAY (SAS 9.3, SAS Institute, Cary, NC). Significance was set at a P value less than .05. RESULTS: Fifty-seven percent of patients were women and 43% were men. Seventy percent were Caucasian, 17% were African American, and 13% had another ethnicity. Median age was 25 years (interquartile range [IQR], 21-26 yr) and median body weight was 140 lbs (IQR, 120-155 lbs). After the cold test and EPT, the time to sensation return for the molar or canine was not statistically different between the 2 drug formulations. Patients reported significantly lower pain scores with the buffered versus non-buffered drug (P < .01). CONCLUSIONS: After mandibular nerve block, buffered 1% lidocaine with EPI can produce similar clinical outcomes for duration of pulpal anesthesia as non-buffered 2% lidocaine with EPI and lower pain on injections, which are a potential benefit to patients.

Cone-beam Computed Tomography Uses in Clinical Endodontics: Observer Variability in Detecting Periapical Lesions.

INTRODUCTION: The accurate interpretation of a cone-beam computed tomographic (CBCT) volume is critical in identifying the presence of disease correctly and consistently. The aim of this clinical study was to determine the effect of experience level on the detection of periapical lesions in CBCT volumes. METHODS: CBCT volumes of 22 maxillary molars were interpreted by 3 endodontic faculty, 3 endodontic residents, and 3 dental students. These groups were compared with the consensus opinion of 2 experienced oral and maxillofacial radiologists. The observers determined the presence or absence of apical radiolucencies for each root using a 5-point Likert scale. RESULTS: Compared with the radiologists, the average weighted kappa value for endodontic faculty was 0.49, for endodontic residents it was 0.35 and for dental students it was 0.32. Intrarater reliability for each group showed endodontic faculty having the highest average weighted kappa value of 0.68 followed by endodontic residents (0.48) and dental students (0.28). CONCLUSIONS: Clinicians' experience level appears to be correlated with their ability to correctly diagnose periapical disease in CBCT volumes. In addition, experience leads to better inter-rater reliability. In neither of these 2 categories was agreement found to be excellent, suggesting that more can be done to improve the CBCT interpretation skills of clinicians at various levels of experience.

Access to endodontic care in North Carolina public health and Medicaid settings.

OBJECTIVES: The purpose of this study was to investigate issues related to access to endodontic care in North Carolina for individuals who used dental public health resources such as public health clinics (PHCs) or private practices that accept Medicaid or other government-sponsored reimbursement programs private practices that accept Medicaid (PPM). METHODS: Surveys were sent to 1,195 dentists regarding frequency and type of endodontic conditions encountered, treatments provided, and perceived barriers to care. Results were analyzed using logistic regression with the level of significance set at 0.05. RESULTS: Five hundred forty-six surveys were returned for a 45.7% response rate. Of the respondents, 79% reported frequently encountering an endodontic condition, but only 34% reported performing any type of definitive endodontic procedure. Graduates after the year 2000 were significantly more likely to perform definitive endodontic procedures (P < 0.05). Lack of insurance was the greatest barrier to care with 89% considering it a moderate to major barrier, followed by cost of the endodontic treatment (87%) and cost of the restoration following treatment (86%). PPMs were more likely to consider cost and insurance a major barrier (P < 0.05). CONCLUSIONS: In North Carolina public health and Medicaid settings, the frequency of endodontic treatments provided was much lower than the frequency of endodontic conditions encountered that might have benefited from treatment. Graduation year was the best indicator for the provision of root canal therapy. Additionally, treatment patterns and perceptions of barriers to care are different for PHCs and PPMs.

Evaluating the paper point technique for locating the apical foramen after canal preparation.

OBJECTIVE: Despite not having been formally evaluated in the endodontic literature, claims have been made regarding the acceptability of the paper point technique (PPT) in estimating the location of the apical foramen (AF). Our aim was to investigate the repeatability and accuracy of PPT in estimating AF location in a cohort of dental patients. STUDY DESIGN: Root canals with

A six year evaluation of cracked teeth diagnosed with reversible pulpitis: treatment and prognosis.

The purpose of this investigation was to report on the clinical outcomes of cracked teeth diagnosed with reversible pulpitis (RP). Eight thousand one hundred seventy-five patients referred for evaluation and treatment during a 6-year period had medical and dental histories, radiographs, pulpal and periapical diagnosis, periodontal probings, direct identification of crack(s) with transillumination, and biting responses on various cusps recorded. All data were stored daily in a database. All cases were treatment planned according to the pulpal and periapical diagnosis. Cases with RP were treatment planned for crowns only, regardless of periapical diagnosis. All patients were recalled at 1 year unless root canal treatment was needed before the anniversary. Results indicated that cracks were identified in 9.7% (796 of 8175) of all teeth evaluated during this time period. Of 127 patients specifically diagnosed with RP, 27 converted to irreversible pulpitis (N = 21) in 58 days or to necrotic pulp (N = 6) in 149 days. To date, none of the original remaining 100 cases of RP have required root canal treatment. The outcomes of this study suggest that if a marginal ridge crack is identified early enough in teeth with a diagnosis of RP and a crown is placed, root canal treatment will be necessary in about 20% of these cases within a 6-month period.

Effectiveness of mouthguards in reducing neurocognitive deficits following sports-related cerebral concussion.

Although it is widely accepted that mouthguards decrease the incidence of dental injuries, there is a controversy among sports medicine professionals as to the effectiveness of mouthguards in decreasing the incidence or severity of sports-related cerebral concussion (SRCC). While some experimental data suggest that this may be the case, there exist a number of reports suggesting that mouthguards do not serve this purpose. These conclusions have been drawn, however, without actually measuring the extent of neurocognitive dysfunction in athletes following sports-related concussion. The purpose of this study was to determine whether mouthguard use reduces the neurocognitive and symptomatic impairments that follow an injurious episode of SRCC. Preseason baseline data were collected as part of an ongoing clinical program that uses a computerized neurocognitive test to assess various faculties of brain function and symptoms reported at the time of testing. Follow-up testing from 180 student-athletes who had sustained an SRCC was analyzed for the purpose of this study. These athletes were separated into one of two groups: those who reported using mouthguards and those who did not. Neurocognitive testing was accomplished using the Immediate Post-Concussion and Assessment Test (ImPACT). Results suggest that neurocognitive deficits at the time of the athletes' first follow-up assessment did not differ between mouthguard users and non-users, suggesting that mouthguard use does little to reduce the severity of neurocognitive dysfunction and onset of symptoms following sports-related head trauma. However, an interesting finding in this study was that athletes experienced significantly lower neurocognitive test scores and reported higher symptom scores following SRCC regardless of mouthguard use. This emphasizes a thorough clinical evaluation of athletes that have sustained an SRCC. Although it was found in this study that mouthguard use does not decrease the severity of concussion, it is important to note that the use of mouthguards is paramount in reducing maxillofacial and dental trauma and their use should continue to be mandated by athletic associations and supported by all dental and sports medicine professionals.

In vitro assessment of local computed tomography for the detection of longitudinal tooth fractures.

OBJECTIVE: To test the accuracy of local computed tomography (LCT) in detecting longitudinal fractures in comparison with conventional periapical radiographs. STUDY DESIGN: Longitudinal fractures were induced in 30 of 60 teeth. The teeth were placed in a dry dentate mandible with soft tissue simulation. A laboratory LCT unit was used to acquire 180 basis projections with 1 degree separation along a 180 degree arc. Conventional radiographs served as the control modality. Correlated axial, coronal, and sagittal views were presented to 10 observers. The observers determined the presence of a root fracture by using a 5-point receiver operating characteristic confidence scale. RESULTS: The mean A(z) for LCT was 0.91 (SD = 0.07). The mean A(z) for conventional radiography was 0.70 (SD = 0.07). The difference between the modalities was statistically significant (analysis of variance: P < .0002), whereas the differences between the observers was not (analysis of variance: P = .319). CONCLUSION: Local CT significantly improves the detection of longitudinal fractures in vitro compared with conventional periapical radiography.

Effect of root canal filling/sealer systems on apical endotoxin penetration: a coronal leakage evaluation.

Endotoxin, elaborated by gram-negative organisms, is an important factor in apical periodontitis. The objective of this study was to evaluate the magnitude of endotoxin penetration through root canal treated teeth using a dual chamber model system. Forty-four maxillary anterior teeth were prepared endodontically and canals filled either by lateral condensation or a warm thermoplasticized technique in combination with either Roth's 801 or AH 26 sealer. Teeth were suspended in the model system with a mixed anaerobic bacterial suspension in the upper chamber and HBSS in the lower chamber. The QCL-1000 LAL assay was used to measure endotoxin at 0, 1, 7, 14, and 21 days. Response feature analysis using trapezoidal area under the curve was performed; the four treatment groups were compared using nonparametric methods. Groups differed (p = 0.028), with thermoplasticized root canal filling/Roth's 801 sealer permitting the least apical endotoxin penetration. Results suggest that Roth's 801 sealer may have a role in inhibiting endotoxin penetration.

Diagnosis and treatment planning: cracked tooth.

This article discusses the cracked tooth, one of the five major classifications of longitudinal tooth fractures: 1) craze line; 2) cuspal fracture; 3) cracked tooth; 4) split tooth; and 5) vertical root fracture. The term "longitudinal tooth fracture" was first introduced by Rivera (Personal Communication, Iowa City, IA, 1996) and has two meanings. The first implies distance (length), particularly in the vertical (occlusal-cervical) plane, as illustrated by longitudinal lines on a map. The second indicates that these fractures occur over a period of time. Therefore, the term longitudinal tooth fracture applies to fractures that have both a distance and a time component. Thus, fractures are described that are not related to impact trauma (which occurs primarily in incisors), in which the distance (length) component may be similar, but is immediate instead of over a period of time.

Comparison of carbon dioxide versus refrigerant spray to determine pulpal responsiveness.

There is little evidence for which cold delivery method is most accurate in determining pulp responsiveness. This study compared carbon dioxide dry ice sticks (CO2) versus refrigerant spray (RS) to generate a patient response from different types of teeth restored to varying degrees. Fifteen human patients were selected. In each quadrant, three teeth were identified and the restoration type recorded. Blindfolded patients were randomly tested with either CO2 or RS in a crossover design at two different sessions. Responsiveness was recorded as yes/no and the interval (in seconds) from application to response was determined. Results showed that (a) CO2 and RS were equivalent in producing a pulpal response regardless of tooth and presence of restoration, and (b) CO2 took significantly (p < 0.05) longer to evoke a response than RS using paired t tests. In conclusion, RS and CO2 were equivalent in determining pulpal responsiveness, but the elicited response from RS was faster.

Sealer distribution in coronal dentin.

A major cause of tooth discoloration is sealer remnants in the pulp chamber after root canal treatment. The purpose of this study was to assess coronal distribution and color changes of four commonly used sealers placed in the pulp chamber after 2 yr. Fifty extracted premolars were cross-sectioned in the coronal third of the root. The chamber contents were removed, and instrumentation was via the canal; then freshly mixed sealer was placed in each chamber. Sealers evaluated were: AH 26, Kerr Pulp Canal Sealer, Roth 801, and Sealapex. The apical access was sealed with white sticky wax, and the tooth was maintained in a moist environment at 37 degrees C for 2 yr. Teeth were split longitudinally, and digital images of the exposed dentin were made, scrambled, and evaluated blindly by trained evaluators for color changes and for presence of sealer in dentin. There was no measurable penetration of sealer into dentin for all groups and no dentin discoloration occurred. The sealers displayed marked discoloration. At 2 yr, the sealers discolored and remained confined primarily to the pulp chamber.

Straight line access and coronal flaring: effect on canal length.

The object of this study was to determine if canal length is altered as a result of straight-line access (SLA) and coronal flaring (CF). Selected were 86 canals of extracted molars and premolars from two groups: straight or severely curved (Schneider curvature <5 degrees and >20 degrees). The reference cusp tip and root-end were flattened to produce reproducible measurements. A #10 file was placed such that the tip extended slightly beyond the apex, with the handle on the referenced cusp. The amount of file protrusion was measured with a stereomicroscope. Then, SLA and CF were performed and the corresponding file replaced to the same coronal reference position. Apical file protrusion was measured again. The change in canal length was determined by the difference in the pre- and post-SLA/CF measurements. A Wilcoxon signed rank test statistically verified that there was a measurable, significant (p < 0.001) change in canal length after SLA and CF. The mean change overall was slight, with a decrease of 0.17 mm. Severe curvature had a slightly greater, significant effect on the amount of change. Tooth type had no significant effect. Changes in working length from SLA and CF, although statistically significant, were very small and clinically unimportant.

The influence of dental operating microscope in locating the mesiolingual canal orifice.

OBJECTIVE: The purpose of this study was to evaluate the influence of using the dental operating microscope (DOM) for detection of the mesiolingual (ML) canal orifice in extracted maxillary molars compared with unaided vision (no loupes or headlamps). STUDY DESIGN: Using a clinical simulation model system, we mounted 39 maxillary molars in a dentoform and placed them into a mannequin. After rubber dam placement and preparation of standard access, 2 attempts were made to locate the ML canal with unaided vision. Then the teeth were examined by using a DOM. Finally, all teeth were sectioned, stained, and evaluated with the DOM for actual presence of an ML canal. RESULTS: ML canal orifices were detected in 20 of the teeth with a sharp explorer and mirror. In the remaining teeth, 12 ML canal orifice were located by using the DOM. Qualitative nonparametric comparisons were used. CONCLUSIONS: The results of this study indicate that the DOM provides increased opportunity for the dentist to detect canal orifices.