Endodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Topical treatments for avulsed teeth

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Saline solution provides just as good an outcome as doxycycline does when used as a topical treatment for a totally displaced (avulsed) tooth from its socket, research published in the January 8 online edition of Dental Traumatology reported.

Tooth avulsion is considered to be one of the most serious types of dental injuries in children, damaging the periodontal ligament (PDL), the pulp and sometimes the alveolar bone. Several factors must be considered when treating these patients, including age, medical status, development of the dentition and the face, as well as the status of the damaged tooth.

The ideal treatment outcome after replantation of the tooth in the alveolar socket is pulp revascularization and an intact PDL. Previous studies have shown that in both clinically and experimentally re-implanted immature incisors the frequency of complete pulp revascularization is only between 18% and 34%. Healing of the PDL is also considered low, at 24%, and the frequency of replacement resorption is high (61%).

Although the main reason for pulp necrosis is contamination of the infarcted pulp tissue with microorganisms, scientists in Sweden found no studies evaluating topical antibiotics on avulsed human teeth. In dentistry, the use of antibiotics has increased but the benefits are questionable, according to previous research cited by the authors. In this study, they compared the effect of topical treatment with doxycycline on avulsed permanent teeth in young individuals compared to treatment with only saline solution for periodontal healing and pulp survival.

Researchers studied 50 patients (34 males and 16 females, aged 6 to 18) who had been referred to the Eastman Institute in Stockholm between 1987 and 2011. Treatment with topical antibiotics was conducted at the Eastman Institute and saline treatment was provided at the Public Health Services in Stockholm. Altogether, scientists studied 54 central incisors, five lateral incisors, three canines, two lower central incisors and two upper first premolars, totaling 66 teeth in the retrospective case-control research. In 22 patients, 30 teeth were treated with topical doxycycline solution prior to replantation and in 28 patients, 36 teeth were treated with saline solution. The observation period varied from seven to 161 months, with an average of 48 months, and a minimum one year follow-up period.

Scientists found no significant differences between the two groups for pulp survival and periodontal healing. Teeth with immature root development showed significantly less pulp necrosis compared to teeth with full root formation regardless if treated topically with doxycycline or saline.

“The novel finding demonstrates that topical treatment with doxycycline does not have any beneficial effect on pulp survival and periodontal healing compared with avulsed teeth treated only with saline,” scientists said.



Consulting Editor: Dr. Susan Wolcott, DDS
Diplomate, American Board of Endodontics

Pain and quality of life

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The discomfort of more than half of all patients experiencing persistent pain after primary root canal therapy can’t be treated with further endodontic therapy, a study published in the December 2014 issue of the Journal of Endodontics reported.

Patients undergoing treatment at participating Practitioners Engaged in Applied Research and Learning (PEARL) Network practices completed a tooth sensitivity assessment and a standardized Oral Health Impact Profile-14 (OHIP-14). The PEARL Network, a National Institutes of Health sponsored network, was founded as a patient-centered dental practice-based research network whose practitioner-investigators conduct studies within their private practices. The OHIP-14 is the most widely used self-reported measure of oral health-related quality of life for adults in areas of functional limitation, pain, psychological discomfort, physical, psychological or social disability and handicap.

Of 1,323 patients enrolled in 64 network practices, scientists accepted 1,257 as subjects for analysis. Some 63 patients (5%), reported persistent pain three to five years after primary root canal therapy and scientists found no apparent odontogenic cause for 39 patients, which was 3.1% of the total patient population. Researchers described the 3.1% as a “small but significant” occurrence, “… clinically important because neuropathic pain typically does not respond to endodontic retreatment.

“However, some success in pain management has been reported with the use of tricyclic antidepressants such as imipramine and amitriptyline or, for patients who develop significant side effects, antiepileptics such as gabapentin,” authors said in discussion. They also cited previous research suggesting that prompt initiation of endodontic therapy and effective pain management during therapy may decrease incidence of neuropathic pain by decreasing the interval of acute pain.

Patients reported persistent pain in 37 of 359 (9.3%) of teeth treated by specialists versus 26 of 835 (3%), of teeth treated by general practitioners. Some 80 percent of teeth treated by specialists had multiple canals, suggesting that specialists tended to treat the more difficult cases, authors reported.

The results also showed that patients with pain upon percussion tended to experience pain with other stimuli that negatively impacted quality of life factors measured, including oral function and psychological discomfort and disability. Authors determined, “The presence of persistent pain was found to adversely impact the patient’s perceived oral health-related quality of life.”


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Gauging the effect of dental trauma on the pulp

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Correct diagnostics will frequently lead to a more conservative approach in the treatment of dental trauma cases, researchers publishing in the March 2015 issue of the Journal of Endodontics concluded.

Although pulpal reactions after acute dental injury are puzzling to many clinicians, researchers said it’s the race between cellular ingrowth and bacterial invasion that determines the fate of the damaged pulp after injury. They sought to demystify pulpal response in light of these two cardinal factors—blood supply to the dental pulp and bacterial invasion. Their goals were to enlighten clinicians about the biological foundation of dental trauma and appropriate treatment.

Investigators searched PubMed for literature that used multivariate analysis to identify the smallest set of factors containing the greatest amount of prognostic information with respect to pulpal necrosis. Much previous research using univariate statistical analyses of teeth subjected to acute dental trauma considered the frequency of pulp death in relation to one factor at a time and so could not account for the possible close associations between factors studied, such as age and root development, mobility/displacement of an injured tooth and the type of luxation (tooth displacement), authors said.

They investigated studies on pulpal reaction after acute trauma, including luxation, avulsion, root fracture and crown fracture and compared the results with early pioneering studies on the topics. The published report outlined processes that maintain a vital pulp and avoid inappropriate endodontic intervention.

 “The dental pulp is not an organ isolated from the rest of the body but an integral part of it with its neurovascular supply and immunologic defenses,” researchers concluded. “Compromise of the neurovascular supply can lead to altered function.”



New data on rotary systems

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Because the extrusion of intracanal debris can lead to post-operative pain and swelling after root canal treatment, a reduction in debris extrusion during canal preparation is desirable following endodontic treatment. Scientists in Turkey studied two rotary systems manufactured by the same company, the ProTaper Universal (PTU) and the recently introduced ProTaper Next (PTN).

With limited data available about PTN files, the researchers aimed to compare the amount of apically extruded debris after the preparation of root canals using the PTU and PTN in extracted teeth. They collected a total of 40 extracted human mandibular premolars with single canals. One operator completed root canal preparations while a second examiner, who was blind with respect to the experimental groups, assessed the debris. Researchers used distilled water as the irritant solution so as not to affect the quantitative values of the extruded debris.

They divided specimens randomly into two experimental groups of 20. Both PTU and PTN files were used according to the manufacturer’s instructions.

Results showed that all specimens were associated with apical debris extrusion. However, a significant difference was found between the groups. The PTU group had significantly greater amounts of extruded debris than the PTN group.

“ProTaper Next files were associated with significantly less apically extruded debris when compared to ProTaper Universal files,” researchers concluded.

The research was published in the March 2015 issue of the International Endodontic Journal.


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Save the date: AAE hosts Annual Meeting May 6-9 in Seattle

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The American Association of Endodontists Annual Meeting convening May 6-9 in Seattle, Wash., is a comprehensive endodontic education summit, vendor exhibition and networking opportunity. This year’s program, AAE15, focuses on future trends to help practitioners grow and prepare for the next generation of advancements in the art and science of endodontics. AAE15 will include more than 100 high-quality educational sessions in a variety of tracks including “Future Directions on Nonsurgical Root Canal Treatment, Surgical Endodontics—What Lies Ahead,” and “Where Will Biology and Technology Take Endodontics.” Attendees can register for hands-on workshops featuring leading experts in microsuturing, cone beam-computed technology and resorption. In addition, AAE15 includes the largest endodontic exhibit hall in the world, with nearly 100 vendors offering the latest in endodontic equipment, materials and supplies. For more information and to register visit www.aae.org/aae15.


Stay current with AAE newsletter

Read the AAE’s popular clinical newsletter, “ENDODONTICS: Colleagues for Excellence.” The latest issue, Standard of Practice in Contemporary Endodontics, highlights advancements in endodontic techniques and technologies. As endodontics evolves, every clinician must understand how those advances will impact patient care. Clinicians deservedly earn patient trust and respect by providing safe and excellent quality care utilizing high standards of practice. To read the Standard of Practice in Contemporary Endodontics and back issues of “ENDODONTICS: Colleagues for Excellence,” visit www.aae.org/colleagues.


Explaining endo is simpler with ADA brochures

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Most patients need guidance to understand the specifics of root canal, such as why the pulp needs to be removed and why merely extracting the tooth is not the best answer. The ADA’s time-tested brochure, “Root Canal Treatment Can Save Your Tooth,” conveys these points in a patient-friendly way, with step-by-step illustrations. The brochure also motivates patients to follow through with a permanent restoration.

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What is Specialty Scan?

This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on endodontics, the first in the series on this topic for 2015. Other specialty scan issues are devoted to oral and maxillofacial pathology, oral and maxillofacial radiology, orthodontics, pediatric dentistry, periodontics and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome your feedback on this and all specialty scan issues.

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