Project S.T.O.P (Stop the Over-ordering of Platelets): An initiative to reduce platelet wastages for pediatric open-heart surgeries.

INTRODUCTION: Due to a national policy change in the management of unused platelet units from September 2018, there was a drastic increase in the number of platelet units wasted in our institution. METHODS: Using Quality Improvement (QI) tools, platelet wastages from pediatric heart surgeries was identified as a priority area to work on. An intervention based on the creation of 'Order Sets' for pediatric open-heart surgeries was implemented, standardizing standby platelet orders based on type of surgery and patient weight. RESULTS: This intervention led to a dramatic improvement in the number of platelets ordered on standby, and consequently a decrease in platelet wastage from 47.6% to 16.9% for pediatric open-heart surgeries, without any reported adverse events. CONCLUSION: With the creation of Order Sets and continuous education, it was possible to eradicate the practice of requesting unnecessary standby platelets for surgeries. This is an effective patient blood management (PBM) strategy resulting in a significant decrease in platelet wastage rate and substantial cost savings.

Influence of root maturity or periodontal involvement on dentinal collagen changes following NaOCl irrigation: an ex vivo study.

AIM: To refine a FTIR protocol for detection of NaOCl-induced dentinal collagen changes using an ex vivo irrigation model, and to apply it to determine the collagen change within 0.5 mm of canal or root surfaces, with or without mature roots or periodontal involvement. METHODOLOGY: The root canals of extracted human roots were irrigated with control saline (n = 3) or 5% NaOCl (n = 3) and sectioned into transverse disks for FTIR analyses, 0.5 mm from both the canal lumen and root surface, before and after surface treatment with 17% EDTA. Amide I/phosphate and amide II/phosphate absorbance ratios were compared using the Wilcoxon sign rank test. Mature roots without periodontal involvement were irrigated with: saline (n = 7), 5% NaOCl (n = 7) or 5% NaOCl + 17% EDTA (n = 7); those with periodontal involvement (n = 7) or immature roots (n = 7) were irrigated with 5% NaOCl. Dentine disks were then prepared for FTIR analyses. The effects of irrigant/root maturity/periodontal involvement were analysed using linear mixed models. RESULTS: FTIR analyses of the irrigated samples revealed a significant (P < 0.05) reduction in collagen bands near the canal lumen after NaOCl irrigation using surface EDTA-treated samples. Irrigation with the test solutions resulted in significant (P < 0.0001) dentinal collagen changes in the mature roots, whilst those in the immature roots were significantly (P < 0.05) greater compared with the mature roots with or without periodontal involvement; but there was no difference between the latter groups. CONCLUSION: EDTA surface treatment of polished dentine surfaces enhanced FTIR detection of NaOCl-induced collagen changes. Both root maturity and irrigation protocol influenced the ability of NaOCl to alter dentinal collagen up to 0.5 mm from the canal lumen.

Disruption and bactericidal indices depicted in polygonal graphs to show multiple outcome effects of root canal irrigant supplements on single- and dual-species biofilms.

OBJECTIVES: The aims of this study were to (1) investigate the relative time-dependent disruption and bactericidal effects of detergent-type surfactants on single- or dual-species biofilms of root canal isolates and (2) to examine the utility of polygonal graphs for depiction of biofilm disruption and cell killing. MATERIALS AND METHODS: Single-species biofilms of Streptococcus sanguinis, Enterococcus faecalis, Fusobacterium nucleatum and Porphyromonas gingivalis were grown on nitro-cellulose membranes for 72 h and immersed in Tween®80, cetyltrimethylammoniumbromide (CTAB), and sodium dodecyl sulphate (SDS) for 1-, 5- or 10-min (n = 3 per test). The number of viable and non-viable bacteria "disrupted" from the biofilm and those "remaining-attached" was determined using a viability stain in conjunction with fluorescence microscopy. The data were analysed using non-parametric Kruskal-Wallis test with 5% significance level. RESULTS: Gram-negative obligate anaerobes were more susceptible to cell removal than gram-positive facultative anaerobes. The majority of cells were disrupted after 1-min of exposure; however, the extent varied according to the agent and species. CTAB and SDS were more effective than Tween 80™ at disrupting biofilms and killing cells but all agents failed to achieve 100% disruption/kill. CONCLUSIONS: Biofilm disruption and cell viability were influenced by the species, the test agent and the duration of exposure. CTAB and SDS were more effective in biofilm disruption than Tween 80™. Graphical depiction of biofilm disruption- and viability-outcomes provides an alternative means of simultaneously visualising and analysing relative efficacy in different domains. CLINICAL RELEVANCE: Surfactants were not as effective at biofilm disruption as NaOCl but may be added to other non-disruptive antibacterial agents to enhance this property.

Prevalence, predictive factors and clinical course of persistent pain associated with teeth displaying periapical healing following nonsurgical root canal treatment: a prospective study.

AIMS: To investigate the prevalence, pain catastrophizing and other predictive factors and clinical course of persistent pain/discomfort associated with teeth displaying periapical healing following nonsurgical root canal treatment (NSRCT). METHODOLOGY: One hundred and ninety-eight patients (264 teeth) who had NSRCT were reviewed at 5-14 months, postoperatively. Teeth with persistent post-treatment pain or discomfort, plus evidence of periapical healing were further monitored 0.5, 4 and 10 years later. Pain Catastrophizing Scale (PCS) and Short Form of the McGill Pain Questionnaire (SF-MPQ) were completed. Predictive factors were investigated using logistic regression models. RESULTS: Twenty-four per cent (60/249) of teeth displaying periapical healing at first review were associated with persistent pain or discomfort. Fifty-five teeth monitored 6-7 months later were associated with reduction in pain (17/30) or discomfort (7/25). Cone beam computed tomography (CBCT) of eight teeth with persistent symptoms and complete periapical healing (by conventional radiographs) revealed distinct, small apical radiolucencies (n = 3) or root apex fenestration through the buccal plate (n = 2). History of chronic pain (headache, temporo-mandibular joint, masticatory muscle, neck, shoulder or back pain; P = 0.005), preoperative pain (P = 0.04), responsive pulp (P = 0.009), tooth crack (P = 0.05) and small periapical radiolucency (P = 0.005) were significant predictive factors. The PCS revealed 16 patients (22 teeth) were catastrophizers (PCS ≥ 30), but this had no influence on post-treatment symptoms (P = 0.5). CONCLUSIONS: Persistent pain or discomfort associated with teeth showing periapical healing at the first review after NSRCT, decreased in intensity in most cases over the following 6 months. Longer-term follow-up revealed spontaneous improvement or symptom resolution in the majority of those with confirmed radiographic the absence of periapical disease. Five predictive factors (history of chronic pain, teeth with responsive pulps, association with pain, diagnosis of tooth crack before treatment and diameter of preoperative radiolucency) were identified.

Proof-of-concept study to establish an in situ method to determine the nature and depth of collagen changes in dentine using Fourier Transform Infra-Red spectroscopy after sodium hypochlorite irrigation.

AIM: To establish a method using Fourier Transform Infra-Red spectroscopy (FTIR) to characterize the nature and depth of changes in dentinal collagen following exposure to sodium hypochlorite (NaOCl) during root canal irrigation in an ex vivo model. METHODOLOGY: Fourier Transform Infra-Red spectroscopy was used to assess the changes in dentinal collagen when the root canal was exposed to NaOCl. The changes in dentinal collagen caused by NaOCl irrigation of root canals in transverse sections of roots, at 0.5 mm from the canal wall and 0.5 mm from the external root surface, were assessed by FTIR. The data were analysed using paired t-test with 5% significance level. RESULTS: Fourier Transform Infra-Red spectroscopy confirmed that NaOCl exposure caused alterations in the chemistry and structure of collagen in dentine. FTIR spectra obtained from dentine surfaces and dentine adjacent to root canals exposed to NaOCl, all consistently showed degradation and conformational change of the collagen structure. FTIR data from the ex vivo model showed that the depth of effect of NaOCl extended to at least 0.5 mm from the canal wall. CONCLUSION: In extracted human teeth, NaOCl caused changes in dentinal collagen that were measurable by FTIR. In an ex vivo model, the depth of effect into dentine extended at least 0.5 mm from the canal wall.

Non-surgical treatment of knee osteoarthritis.

Knee osteoarthritis is one of the most common degenerative diseases causing disability in elderly patients. Osteoarthritis is an increasing problem for ageing populations, such as that in Hong Kong. It is important for guidelines to be kept up to date with the best evidence-based osteoarthritis management practices available. The aim of this study was to review the current literature and international guidelines on non-surgical treatments for knee osteoarthritis and compared these with the current guidelines in Hong Kong, which were proposed in 2005. Internationally, exercise programmes for non-surgical management of osteoarthritis have been proven effective, and a pilot programme in Hong Kong for comprehensive non-surgical knee osteoarthritis management has been successful. Long-term studies on the effectiveness of such exercise programmes are required, to inform future changes to guidelines on osteoarthritis management.

The efficacy of supplementary sonic irrigation using the EndoActivator® system determined by removal of a collagen film from an ex vivo model.

AIM: To evaluate the efficacy of sonic irrigation (EndoActivator® ) using various polymer tips and power settings in a stained collagen ex vivo model. METHODOLOGY: The root canals of fifty human, straight single-rooted extracted teeth were prepared to size 40, .08 taper. The roots were split longitudinally; stained collagen applied to the canal surfaces, photographed and re-assembled. The canals were subjected to syringe without supplementary (group 1, n = 10) or with supplementary sonic (groups 2-5, n = 10) irrigation. EndoActivator® tip sizes (size 15, .02 taper for groups 2 and 3; size 35, .04 taper for groups 4 and 5) and power settings (low for groups 2 and 4; high for groups 3 and 5) were tested. After irrigation, the canals were re-photographed and the area of residual stained collagen was quantified using the UTHSCA Image Tool program (Version 3.0). The data were analysed using Wilcoxon signed rank test and general linear mixed models. RESULTS: Supplementary sonic irrigation using EndoActivator® resulted in significantly (P < 0.0001) less residual collagen compared with syringe irrigation only. Agitation of irrigant using the large EndoActivator® tip with high power resulted in significantly less (22.4% - 29.5%) residual collagen compared to other combinations (large tip/low power P = 0.001; small tip/low power P = 0.01; small tip/high power P = 0.04). There was no significant difference amongst the latter three groups (P > 0.5). CONCLUSIONS: Supplementary sonic irrigation using the EndoActivator® system was significantly more effective in removing stained collagen from the canal surface than syringe irrigation alone. EndoActivator® used with large tip (size 35, .04 taper) and high power setting in size 40, .08 taper canals was more effective than other combinations.

Estimated depth of apatite and collagen degradation in human dentine by sequential exposure to sodium hypochlorite and EDTA: a quantitative FTIR study.

AIM: To characterize chemical degradation of the principal constituents of dentine after exposure to NaOCl and EDTA using Infrared Spectroscopy (ATR-FTIR). METHODOLOGY: Ground dentine particles, from extracted permanent human molars, were passed through sieves of 38 to 1 000 µm to provide six size ranges. Portions (250 mg) of each size range were reacted with 5 mL of 2.5% NaOCl for 2-10 min; or 17% EDTA for 5-1440 min. Powders larger than 75 µm were also sequentially exposed to NaOCl/EDTA/NaOCl each for 10 min. All experiments were repeated five times. Reacted and unreacted powders were washed and dried. Particles larger than 75 µm were then reground. FTIR spectra of unground and reground reacted particles enabled assessment of particle surface versus bulk chemistry, respectively, plus estimation of reaction depth. Changes in the ratio of the 1 640 cm-1 collagen: 1 010 cm-1 phosphate peak height or its inverse were obtained. These were used to estimate surface and bulk fraction reacted and thus depth to which collagen or phosphate was reduced following immersion in NaOCl or EDTA, respectively. The data were analysed descriptively. RESULTS: Surface collagen fraction declined by ~40% within 2 min of NaOCl exposure, and plateaued at ~60% between 6-10 min. Bulk spectra showed average depth of collagen loss at 10 min was 16 ± 13 µm. Ten minute EDTA exposure caused ~60% loss of surface phosphate. Average depth of phosphate loss was 19 ± 12 µm and 89 ± 43 µm after 10 and 1 440 min EDTA immersion, respectively. Sequential NaOCl/EDTA immersion yielded a 62 ± 28 µm thick phosphate-depleted surface. Sequential NaOCl/EDTA/NaOCl treatment resulted in approximately 85 µm of collagen loss. CONCLUSIONS: Data revealed the sequential depletion of collagen by NaOCl and apatite by EDTA in dentine, simultaneously exposing the other moieties. Alternate exposure to NaOCl and EDTA therefore enhances the depth of erosion.

Extrapancreatic findings of IgG4-related disease.

IgG4-related disease is a systemic fibro-inflammatory condition, which includes autoimmune pancreatitis as part of the disease spectrum. Imaging has been demonstrated to play a major role in the diagnosis of autoimmune pancreatitis. Recognizing the wide spectrum of extrapancreatic manifestations of IgG4-related disease coupled with a high clinical index of suspicion will allow for an accurate and timely diagnosis to be made, thus avoiding unnecessary invasive procedures and ensuring that early effective corticosteroid therapy is commenced. This review aims to serve as a concise reference tool for both clinicians and radiologists in the diagnosis of extrapancreatic IgG4-related disease.

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.

A prospective study of the factors affecting outcomes of non-surgical root canal treatment: part 2: tooth survival.

AIM: To investigate the probability of and factors influencing tooth survival following primary (1°RCTx) or secondary (2°RCTx) root canal treatment. METHODOLOGY: This prospective study involved annual follow-up of 2 (100%) to 4 years (50%) of 1°RCTx (759 teeth, 572 patients) and 2°RCTx (858 teeth, 642 patients) carried out by Endodontic postgraduate students. Pre-, intra- and post-operative data were collected prospectively from consented patients. Information about extraction of the root filled tooth was sought from the patient, the referring dentist or derived from the patient's records and included the timing and reasons for extraction. Tooth survival was estimated and prognostic factors were investigated using Cox regression. Clustering effects within patients were adjusted in all models using robust standard error. RESULTS: The 4-year cumulative tooth survival following 1°RCTx [95.4% (93.6%, 96.8%)] or 2°RCTx [95.3% (93.6%, 96.5%)] was similar. Thirteen prognostic factors were identified. Significant patient factors included history of diabetes and systemic steroid therapy. Significant pre-operative factors included narrow but deep periodontal probing depth; pain; discharging sinus; and iatrogenic perforation (for 2°RCTx cases only). Significant intra-operative factors included iatrogenic perforation; patency at apical terminus; and extrusion of root fillings. Significant post-operative restorative factors included presence of cast restoration versus temporary restoration; presence of cast post and core; proximal contacts with both mesial and distal adjacent teeth; and terminal location of the tooth. The presence of pre-operative pain had a profound effect on tooth loss within the first 22 months after treatment [hazard ratio (HR) = 3.1; P = 0.001] with a lesser effect beyond 22 months (HR = 2.4; P = 0.01). Patency at the apical terminus reduced tooth loss (HR = 0.3; P < 0.01) within the first 22 months after treatment but had no significant effect on tooth survival beyond 22 months. Extrusion of gutta-percha root filling did not have any effect on tooth survival (HR = 1.1; P = 0.2) within the first 22 months but significantly increased the hazard of tooth loss beyond 22 months (HR = 3.0; P = 0.003). CONCLUSIONS: The 4-year tooth survival following primary or secondary root canal treatment was 95%, with thirteen prognostic factors common to both.

An ex vivo investigation of the relationship between apical root impedance and canal anatomy.

AIM: To investigate a possible relationship between apical root impedance and canal anatomy. METHODOLOGY: Twenty-three roots from human extracted teeth with different apical anatomy (classified by number of apical canal exits) were selected. After impedance measurements, the root canals were stained and the teeth cleared to confirm their division into simple (S - Vertucci type 1; n=12) and complex (C - various Vertucci canal types with multiple exits; n=11) root types. Impedance measurements were taken using a frequency response analyser at seven apico-coronal levels in each root (0.0, 0.5, 1.0, 2.0, 3.0, 4.0, 5.0 mm short of the apical terminus) at 14 frequencies ranging from 1120 to 100,000 Hz. Potential confounding factors were controlled. The impedance characteristics of individual roots were compared with 37 equivalent circuits to select best fit. The association between impedance characteristic (described by the selected equivalent circuit) and canal anatomy (S/C) was investigated using logistic regression with robust standard error to account for multiple data-sets from the same root. RESULTS: Canal anatomy had a significant (P= 0.046) effect on the equivalent circuit model. One circuit (model 10) occurred significantly more commonly in the simple canals. The odds of selecting circuit-model-10 were 2.2 times (odds ratio 2.17, 95% confidence interval 1.01-4.63) higher in canals with simple anatomy compared to those with complex anatomy. CONCLUSION: Canal anatomy had a significant effect on the equivalent circuit describing its impedance characteristics. It is theoretically possible to use impedance spectroscopy to clinically predict and image apical canal complexities.

An investigation of a potential confounder in ex vivo microbiological studies--the bulk flow of fluid through apical foramina during tooth extraction.

AIMS: To investigate the factors affecting bulk flow of dye and bacterial suspensions into and out of apical foramina during simulated tooth extraction, using an ex vivo model. METHODOLOGY: Sixty extracted, single-rooted, human teeth were accessed, root canals located and in 50 the pulps dissolved; 10 teeth with attached periapical lesions were preserved. The size of apical foramina was determined digitally. The teeth were mounted in vials with polyvinylsiloxane impression material. Part 1: different dyes were inoculated in the coronal half of root canals or cervical 'gingival' margin, respectively, in separate experiments using the same teeth. Tooth extraction movements were simulated and apical penetration of the dye solutions with and without coronal restorations were examined in each case (20 teeth re-used 4 × ). Part 2: the same procedures were repeated on 30 more teeth but using a standard inoculum of Acidovorax sp. Part 3: 10 teeth with attached periapical lesions were inoculated with Acidovorax sp. in the absence of coronal restorations. Bacterial leakage into the periapical lesions was assessed. RESULTS: Coronal restorations significantly reduced the flow of dyes (P=0.002) or bacterial suspension (P=0.001) out of the canals and bacterial suspension into (P=0.02) the canals during simulated tooth extraction. The 'size of apical foramina' were positively correlated with passage of bacterial suspension out of the canal (P=0.04) and from the gingival trough into the canal (P=0.008), in the presence of a coronal restoration. CONCLUSIONS: The presence of coronal restorations, the size of apical foramina and presence of native canal contents with attached periapical lesions, all influenced fluid flow into and out of canals during simulated tooth extraction movements.

The influence of a bisphosphonate on bone generation determined using a chick-femur model.

AIM: To determine the direct influence of a bisphosphonate (pamidronate) delivered by one of two carriers, on bone generation in chick-femurs supported by chick egg chorio-allantoic membranes. METHODOLOGY: Twenty chick femurs freshly harvested from fertilized eggs were randomly allocated to two groups: (i) Affi-Gel blue bead carrier (n=10); and (ii) hydroxyapatite bead carrier (n=10). The femurs in each group were further randomly divided into control (n=4) and experimental (n=6) subgroups. Carriers charged with PBS solution or 0.1 M pamidronate were delivered into the bone marrow of each femur at its mid-portion through a needle puncture. Each femur was then grafted onto the chorio-allantoic membrane of a chick egg and incubated for 7 days. Each experimental and control subgroup femur yielded four histological sections at the puncture site, constituting the test and inter-bone controls. In addition, two histological sections were also obtained from 400 to 450 µm away from each end of the experimental puncture site to act as the intra-bone controls. Bone generation was quantified and the ratio of cross-sectional area of bone marrow to circumference of bone (outcome measure) was determined using a software package, Image-Pro(®) Plus. The data were analysed using Mann-Whitney tests and Wilcoxon signed rank tests. RESULTS: The outcome ratio in the test group was significantly (P<0.001) smaller than both the inter-bone and intra-bone control groups. There was evidence of increased bone formation directly over the pamidronate-charged carriers. CONCLUSIONS: The test model established that pamidronate had a positive effect on bone generation over a period of 7 days, regardless of the carrier type.

Genetic diversity of the full length apical membrane antigen-1 of Plasmodium knowlesi clinical isolates from Peninsular Malaysia.

The Plasmodium knowlesi apical membrane antigen-1 (PkAMA-1) plays an important role in the invasion of the parasite into its host erythrocyte, and it has been regarded as a potential vaccine candidate against human knowlesi malaria. This study investigates genetic diversity and natural selection of the full length PkAMA-1 of P. knowlesi clinical isolates from Peninsular Malaysia. Blood samples were collected from P. knowlesi malaria patients from Peninsular Malaysia. The PkAMA-1 gene was amplified from DNA samples using PCR, cloned into a plasmid vector and sequenced. Results showed that nucleotide diversity of the full length PkAMA-1 from Peninsular Malaysia isolates (π: 0.006) was almost similar to that of Sarawak (π: 0.005) and Sabah (π: 0.004) isolates reported in other studies. Deeper analysis revealed Domain I (π: 0.007) in the PkAMA-1 had the highest diversity as compared to Domain II (π: 0.004) and Domain III (π: 0.003). Z-test indicated negative (purifying) selection of the gene. Combined alignment analysis at the amino acid level for the Peninsular Malaysia and Sarawak PkAMA-1 sequences revealed 34 polymorphic sites. Thirty-one of these sites were dimorphic, and 3 were trimorphic. The amino acid sequences could be categorised into 31 haplotypes. In the haplotype network, PkAMA-1 from Peninsular Malaysia and Sarawak were separated into two groups.

Tooth survival following non-surgical root canal treatment: a systematic review of the literature.

AIMS: To investigate (i) the effect of study characteristics on reported tooth survival after root canal treatment (RCTx) and (ii) the effect of clinical factors on the proportion of root filled teeth surviving after RCTx. METHODOLOGY: Longitudinal human clinical studies investigating tooth survival after RCTx which were published up to the end of 2007 were identified electronically (MEDLINE and Cochrane database 1966-2007 December, week 4). In addition, four journals (Dental Traumatology, International Endodontic Journal, Journal of Endodontics, Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics), bibliographies of all relevant articles and review articles were hand searched. Two reviewers (Y-LN, KG) assessed and selected the studies based on specified inclusion criteria and extracted the data onto a pre-designed proforma, independently. The criteria were as follows: (i) clinical study on RCTx; (ii) stratified analysis of primary and secondary RCTx available; (iii) sample size given and larger than 10; (iv) at least 6-month postoperative review; (v) success based on survival of tooth; and (vi) proportion of teeth surviving after treatment given or could be calculated from the raw data. Three strands of evidence or analyses were used to triangulate a consensus view. The reported findings from individual studies, including those excluded for quantitative analysis, were utilized for the intuitive synthesis, which constituted the first strand of evidence. Secondly, the pooled weighted proportion of teeth surviving and thirdly the combined effects of potential prognostic factors were estimated using the fixed and random effects meta-analyses on studies fulfilling all the inclusion criteria. RESULTS: Of the 31 articles identified, 14 studies published between 1993 and 2007 were included. The majority of studies were retrospective (n = 10) and only four prospective. The pooled percentages of reported tooth survival over 2-3, 4-5 and 8-10 years following RCTx were 86% (95% CI: 75%, 98%), 93% (95% CI: 92%, 94%) and 87% (95% CI: 82%, 92%), respectively. Substantial differences in study characteristics were found to hinder effective direct comparison of findings. Evidence for the effect of prognostic factors on tooth survival was weak. Based on the data available for meta-analyses, four conditions were found to significantly improve tooth survival. In descending order of influence, the conditions increasing observed proportion of survival were as follows: (i) a crown restoration after RCTx; (ii) tooth having both mesial and distal proximal contacts; (iii) tooth not functioning as an abutment for removable or fixed prosthesis; and (iv) tooth type or specifically non-molar teeth. Statistical heterogeneity was substantial in some cases but its source could not be investigated because of insufficient available information. CONCLUSIONS: The pooled proportion of teeth surviving over 2-10 years following RCTx ranged between 86% and 93%. Four factors (listed above) were identified as significant prognostic factors with concurrence between all three strands of evidence.

The effect of sodium hypochlorite and ethylenediaminetetraacetic acid irrigation, individually and in alternation, on tooth surface strain.

AIM: To evaluate the effect of irrigation regimens on tooth surface strain using saline, sodium hypochlorite (3% and 5% NaOCl) and ethylenediaminetetraacetic acid (17% EDTA), individually and in alternating combinations. METHODOLOGY: Single-rooted premolar teeth with single canals prepared to standardized dimensions were grouped by anatomical features and randomly distributed amongst six experimental groups (n = 12 each). The six groups were: (1) saline; (2) 5% NaOCl; (3) 3% NaOCl; (4) 17% EDTA; (5) 3% NaOCl and 17% EDTA; (6) 5% NaOCl and 17% EDTA. All groups underwent four (group 1) or five (groups 2, 3, 4, 5, 6) sequential 30-min irrigation periods following each of which the tooth was subjected to a standard regime of cyclic, nondestructive, occlusal loading. Tooth surface strain was measured during each loading cycle using electrical strain gauges mounted cervico-proximally. The data were analysed by Hierarchical anova and post hoc multiple comparisons. RESULTS: Irrigation with 5% NaOCl alone or alternating with 17% EDTA significantly (P < 0.001) increased the peak strain values for each of the irrigation periods compared with that of saline (group 1). The data for the other groups revealed no significant differences compared with those of saline. The strain increase after the fourth irrigation cycle was significantly higher for group 6 than for group 2. The measured canal morphology and dentine thickness parameters did not prove to have a significant effect on tooth surface strain. CONCLUSIONS: Irrigation with 5% NaOCl acting alone or alternated with 17% EDTA (used in 30 min cycles), significantly increased tooth surface strain. The alternated regimen showed significantly greater changes in tooth surface strain than NaOCl alone. Irrigation with 3% NaOCl and 17% EDTA individually or in combination did not significantly alter the tooth surface strain.

The effect of irrigation time, root morphology and dentine thickness on tooth surface strain when using 5% sodium hypochlorite and 17% EDTA.

AIM: To evaluate the effect of irrigation with 5% sodium hypochlorite (NaOCl) alone and in conjunction with 17% ethylenediaminetetraacetic acid (EDTA) on tooth surface strain (TSS) and to analyse the influence of irrigation time, root morphology and dentine thickness. METHODOLOGY: Thirty-six single-rooted pre-molars with single canals had their crown and enamel reduced and root canals prepared using a standardized protocol. Teeth were grouped according to anatomical criteria and randomly distributed to experimental irrigation groups: (A) saline (negative control); (B) 5% NaOCl (positive control); (C) 5% NaOCl alternated with 17% EDTA. TSS was measured using electrical strain gauges bonded to the cervico-proximal part of the tooth. Teeth, mounted in clear acrylic resin placed in a universal testing machine, were subjected to nine consecutive 10-min irrigation periods followed by non-destructive occlusal loading to record TSS. Statistical analysis was carried out using two-way hierarchical anova and post hoc multiple comparisons. RESULTS: Two groups showed an increase in TSS from the baseline (initial 10-min irrigation with saline). Group A showed a negligible reduction of 1.2% (343-339 muepsilon), which was not statistically significant (P = 0.7). Group B showed a highly significant (P = 0.001) increase in TSS by 53.7% (178-253 muepsilon), and group C showed a significant (P = 0.02) increase in TSS by 17.4% (163-192 muepsilon). The rate of change in TSS was significantly different between test groups. The length of the tooth (P = 0.04) as well as the mesio-distal (P = 0.05) width had significant effects on TSS. CONCLUSIONS: Irrigation with 5% with or without 17% EDTA increased TSS. The increase was significantly greater with 5% NaOCl alone than with 5% NaOCl alternated with 17% EDTA in contrast to previous findings with longer duration of irrigant exposure. Tooth length and mesio-distal root width significantly contributed to the increase in TSS.

Microflora in teeth associated with apical periodontitis: a methodological observational study comparing two protocols and three microscopy techniques.

AIM: The aim of this study was to compare two protocols to examine bacterial colonization in teeth associated with chronic apical periodontitis with acute episodes (ap), using light microscopy (LM), transmission electron microscopy (TEM) and scanning electron microscopy (SEM). METHODOLOGY: Nine root samples (seven teeth) were processed using either Eastman Dental Institute (EDI) (n = 4 teeth/4 roots) or Zurich (n = 3 teeth/5 roots) protocols. The roots were sectioned longitudinally; one root portion was viewed with SEM, descriptively dividing its length into apical, middle and coronal; semi-thin and ultra-thin transverse sections were viewed under LM and TEM from each third of the other root portion. Each root was therefore examined using all microscopy techniques. Observations of bacterial presence, description and distribution within the root canal lumen and root dentine were systematically recorded using pre-determined criteria. RESULTS: The Zurich technique gave a more predictable division of the root, but the surface was slightly smeared and demineralization was incomplete. The Eastman Dental Institute (EDI) approach appeared to provide better ultrastructural detail. Bacteria were detected in eight of the nine roots. Bacterial biofilms were commonly seen adhering to the root canal surface, containing various cellular morphotypes: rods, cocci, filaments and spirochaetes. Bacteria were more evident apically than coronally, associated with the canal wall but were more commonly evident coronally than apically within the dentinal tubules. Polymorphs (PMNs) were found in all the root thirds, especially apically, often numerous and walling off the bacterial biofilm from the remaining canal lumen. CONCLUSIONS: Both protocols had merits and de-merits. The combination of microscopy techniques offered complementary views of intra-radicular bacterial colonization. The perception of confinement of the host/microbial interface at the apical foramen is not entirely correct; PMNs may be found even in the coronal third of root canals containing necrotic pulp tissue.

The effect of NaOCl and heat treatment on static and dynamic mechanical properties and chemical changes of dentine.

OBJECTIVES: To determine the effect of heat on flexural strength (FS), maximum strain (MS), storage modulus (SM), tan delta (TD) and chemical changes through micro-Raman spectroscopy of dentine exposed to 2.5% NaOCl or saline. METHOD: ology: Dentine bars were randomly allocated to 8 test groups. Half (groups 2,4,6,8) were treated with NaOCl for 20 min; the rest (groups 1,3,5,7) remained in saline. FS/MS were measured in groups 1-4 (n = 15) (3/4 were also heated to 200 °C & re-hydrated in saline). Micro-Raman spectroscopy was performed on bars from groups 1-4. SM/TD were measured in 5-8: in 5/6 (n = 10), repeated after heating (200 °C), then following re-hydration; in 7/8 (n = 3) after heating to 25-185 °C. RESULTS: Increase in MS on heat and FS/MS on heat + NaOCl was not significant (P > 0.05). SM increased (P = 0.06) after heat treatment but reduced to initial state after rehydration (P = 0.03). TD did not change (P = 0.4) after heat (200 °C) treatment but rehydration increased it compared with pre-treatment state (P = 0.001). For dentine bars pre-treated with NaOCl, SM did not change (P = 0.6) after heat (200 °C) treatment or rehydration but TD significantly increased (P = 0.02) upon re-hydration compared with pre- (P=0.007), or post- (P = 0.03) heat-treatment states. SM and TD varied between 25-185 °C with no consistent trend amongst the NaOCl pre-treated bars. Micro-Raman only detected chemical changes following NaOCl treatment in the mineral phase. CONCLUSIONS: Exposure of dentine bars to heat and NaOCl produced only moderate changes to quasi-static but marked changes to viscoelastic properties, which may be explained by chemical alterations.