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JADA Specialty Scan - Endodontics
Endodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Adolescent pulp prognosis and complicated crown fractures

A new Chinese study examines pulp prognosis of permanent teeth with complicated crown fractures treated with conservative pulp treatment in adolescents.

Researchers published their retrospective study online April 5 in Dental Traumatology. They investigated direct pulp capping, partial or coronal pulpotomy, and direct pulp capping retreated by pulpotomy (partial or coronal) in adolescents to identify potential factors relevant to pulp prognosis.

“Children and adolescents are vulnerable to dental trauma,” said the authors. “Complicated crown fractures account for 8.5%-34.5% of all dental trauma injuries. Traumatic injuries resulting in pulp exposure in young patients present a challenge to treatment. The immediate objective should be the selection of a procedure designed to maintain the pulp, especially in young patients with immature teeth.”

Such patients often end up obtaining emergency treatment at hospitals where general dentists on duty may have difficulty assessing extent of pulp inflammation, noted the authors, who also wrote, that “They tend to treat the teeth conservatively by pulp capping and subsequently refer the child to a pediatric dentist or endodontist. Sometimes, the tooth needs to be retreated with a partial or coronal pulpotomy due to inappropriate direct pulp capping ... Few studies have observed the long-term prognosis of the pulp after this retreatment procedure.”

In their study, researchers collected dental records of patients with traumatized permanent teeth treated from January 1, 2000, through December 31, 2014, at the Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology, Beijing, China. The participants included in the study—209 males and 115 females, aged 6 to 16 years—first received treatment at the Dental Emergency Department or Department of Pediatric Dentistry at Peking University School and Hospital of Stomatology. Follow-ups occurred over at least 6 months, with a median of 23 months.

“There were 1216 teeth with a complicated crown fracture, and 615 of these teeth were treated with conservative pulp procedures,” wrote the authors. A total of 375 traumatized incisors from the collective 324 patients met the study criteria.

Researchers categorized pulp status as pulp survival, pulp necrosis, and infection or root canal calcification. They included patients’ sex, age, the time interval between dental injury and treatment, the stage of root development, type of pulp treatment, and coronal restoration as potential risk factors. “The stage of root development was determined by evaluation of radiographs using periapical bisecting angle exposures,” wrote the authors. “Roots with an apical foramen <1 mm in diameter were designated as ‘complete,’ while those with an apical foramen >1 mm in diameter were designated as ‘incomplete.’ ”

The authors evaluated the risk of pulp necrosis and infection using the Kaplan-Meier method and Cox regression.

Overall outcomes included the researchers’ determination that teeth with immature root development had a better pulp prognosis than those with mature roots. “Young permanent teeth have open apices, and the apical blood supply is abundant,” the authors wrote. “These factors could prevent bacterial invasion and the spread of inflammation.”

The authors’ conclusion was that direct pulp capping could be a good emergency treatment. However, good pulp prognosis in the long-term needs partial or coronal pulpotomy. “Partial or coronal pulpotomy, employed either as a primary pulp treatment or secondary to emergency pulp capping, had similarly satisfactory pulp survival rates,” wrote the authors.

Read the original article.


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

Sodium hypochlorite irrigation and postoperative pain

An investigation sought to clarify whether using sodium hypochlorite (NaOCl) as an irrigant impacts postoperative pain in patients after 1-visit endodontic treatments.

The Iranian and Australian investigators—associated with the Kerman University of Medical Sciences in Kerman, Iran, and the School of Dentistry at the University of Western Australia in Perth, Australia—published results of their triple-blind randomized clinical trial study online January 30 in International Endodontic Journal. They compared postoperative pain after applications of 2 different concentrations of NaOCl solution as treatment irrigants for mandibular molars with irreversible pulpitis. “The null hypothesis was that the NaOCl concentration has no significant impact on postoperative pain following one-visit root canal treatment,” they wrote.

They tested concentrations of 2.5% or 5.25% NaOCl, ultimately in 2 groups of 55 patients each. A total of 122 patients had been deemed eligible to participate in the study, but 12 participants from both groups were excluded owing to a variety of reasons: needing treatment that could not be completed in 1 visit, having root canal cement extruded beyond the apical foramen, not returning the numerical visual analog scale (VAS) form, or having partial necrosis of the pulp.

The remaining 110 participants met the inclusion criteria, which the investigators stated as “… individuals without systemic diseases and with a first and second mandibular molar diagnosed with irreversible pulpitis due to caries where the pulps were exposed during excavation, normal periapical radiographic appearance, mild sensitivity to percussion, no spontaneous pre-treatment pain, not having taken any medication for at least 6 h before the treatment visit, at least 18 years of age and no allergic reaction to lidocaine containing epinephrine at a concentration of 1:80,000 Gelofen (a gelatin form of ibuprofen) and NaOCl.”

Participants received treatments in the Postgraduate Clinic of the Endodontic Department at the Kerman Dental School, from January through May 2016. Researchers assigned the 122 teeth to the 2 groups using a random-digit table. Patients rated their pretreatment pain on a VAS ranging from 0 to 9.

A nurse prepared the 2 NaOCl concentrations of 2.5% and 5.25% and placed them in single-use syringes. “Neither the patients nor the practitioner was aware of the concentration of the irrigant used during the treatment visit,” the authors said.

Before the endodontic treatment, patients received 2 cartridges of 2% lidocaine with 1:80,000 epinephrine in an inferior alveolar nerve block injection. “Between instruments, the root canals were irrigated with 2 mL of either 2.5% or 5.25% NaOCl with a 30-gauge side-perforated needle (Endo-Top, PPH Cerkamed, Stalowa Wola, Poland). … At the end of root canal preparation and before canal filling, the smear layer was removed from the root canal walls by irrigating with 3 mL 17% ethylenediaminetetraacetic acid (EDTA; Asia Chimi Teb Co., Tehran, Iran) followed by 5 mL normal saline irrigation.”

After the procedures, each patient was given 2 forms to complete: the VAS form to record the severity of pain during the 7 days after treatment and a form to report analgesic use and any effect on the his or her pain after taking it.

During the first 72 hours after treatment, the patients who received 5.25% NaOCl reported “significantly lower” postoperative pain compared with the patients in the 2.5% NaOCl group. The patients treated with 2.5% NaOCl consumed a “significantly higher” number of analgesics than those treated with 5.25% NaOCl (P = .001).

The researchers concluded “Up to 3 days following root canal treatment, the use of 5.25% NaOCl as an irrigant was associated with significantly less pain than the use of 2.5% of NaOCl.”

Read the original article.


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Anesthesia, needle pain, and patient anxiety

A new South Korean study investigated relationships between topical anesthesia, needle insertion and injection pain, patients’ anxiety, and patients’ pain scores.

Researchers published results of the double-blind randomized controlled clinical trial in the March issue of Journal of Endodontics. Their investigation included 44 patients scheduled for apical surgery on their maxillary anterior incisors or canines from November 2013 through January 2015 at the Department of Conservative Dentistry, College of Dentistry, Yonsei University, Seoul, South Korea.

The study participants, all in good health and older than 19 years, received infiltration anesthesia on the right and left sides of the maxillary anterior labial mucosa for flap reflection. “The labial mucosa of the maxillary central incisors is thought to be 1 of the most painful sites in the body and is therefore appropriate to represent a sensitive condition,” the authors wrote.

Study participants completed the Modified Dental Anxiety Scale questionnaire and reported pain using the numeric rating scale (NRS) pain score. All of the patients were instructed on how and when to rate their NRS pain scores.

The trial procedure included 2 randomized topical applications of Xylocaine 10% pump spray (5 sprays per gauze application, or 50 milligrams) and tap water (5 sprays per gauze application). “After the 2 pieces of Xylocaine gauze and the 1 piece of water gauze had been prepared, an assistant doctor obtained a randomization number (1 or 2) … and applied 1 piece of Xylocaine gauze to the midpalatal mucosa” wrote the authors. “The other piece of Xylocaine gauze was applied to the right side of the labial vestibule below the central incisor when the randomization number was 1 and to the left side when the randomization number was 2. The piece of water gauze was applied to the contralateral side of the labial vestibule. All 3 pieces of gauze were removed after 2 min.”

Researchers recorded 4 scores pertaining to subsequent insertion of a needle followed by controlled injections of an anesthetic solution—lidocaine hydrochloride, and epinephrine—interspersed with NRS pain score inquiries to the patient. “The needle (30-G; Morita, Osaka, Japan) was inserted 5 mm into the labial mucosa of the right central incisor, and, immediately thereafter, the subject was asked to provide an NRS pain score,” wrote the authors. “An anesthetic solution … was then injected for 3 seconds with a speed of 0.432 [milliliters per minute] using iCT injection SE (Genoss, Suwon, Korea), and the subject was asked again to rate his or her NRS pain score. The needle was withdrawn and inserted 5 mm into the labial mucosa of the left central incisor, and, once again, the subject was asked to provide an NRS pain score. Finally, the anesthetic solution was injected for 3 seconds with a speed of 0.432 mL/min, and, immediately after, the subject was asked to report his or her NRS pain score.”

The ultimate findings were that topical anesthesia significantly reduced both the pain of insertion and injection during infiltration anesthesia in the maxillary central incisors. “Injection pain was significantly greater than insertion pain regardless of the topical anesthetic application, and the extent of pain reduction was greater for insertion pain than for injection pain,” wrote the authors. “Highly anxious patients reported higher pain scores; however, topical anesthetics reduced the effect of anxiety on increasing pain.”

Read the original article.


Systemic diseases and endodontic treatment outcomes

Researchers seeking a clearer perspective on associations between systemic diseases and endodontic treatment outcomes sought answers by conducting a systematic review of the dental literature.

The investigators—working from the Department of Endodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, OH, and from the Department of Endodontics, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC—published their findings in the April issue of Journal of Endodontics. They used a patient population, intervention, comparison, and outcome (PICO) framework. They developed a protocol that followed established guidelines and was prepared and registered on PROSPERO.

Their PICO question was, “When compared with medically healthy individuals, can systemic diseases influence endodontic clinical and radiographic healing outcomes?”

Previously, the reviewers conducted a systematic review and reported that a correlation may exist between some systemic diseases and some endodontic diseases’ pathogenesis. They determined that further investigation could yield “valuable information on the prognosis of endodontic treatment.”

“Several systemic diseases were found to be correlated with the outcome of endodontic treatment,” wrote the authors. “Diabetes mellitus was reported to be significantly associated with reduced endodontic healing treatment outcomes of teeth with preoperative infections, suggesting that diabetes may serve as a disease modifier. Also, both diabetes and hypertension were found to be significantly associated with reduced survival of endodontically treated teeth. Therefore, systemic conditions and disorders may have an influence in the healing outcome of endodontically treated teeth rather than just acting as a causative etiologic factor in endodontic infections.”

In their new systematic review, the authors focused on cardiovascular disease, diabetes mellitus, human immunodeficiency virus (HIV), and oral bisphosphonate-related osteonecrosis of the jaw, looking for any associations between endodontic treatment outcomes and the 4 systemic diseases.

The authors considered clinical trials, case-control studies, cross-sectional studies, and cohort studies published in English-language peer-reviewed scientific journals from 1997 through 2016. They excluded case series studies, cell culture laboratory studies, and animal studies.

Of the 18 articles identified, 16 articles met the authors’ inclusion criteria; 3 were about cardiovascular disease; 11 diabetes mellitus; 3 HIV, and 1 oral bisphosphonate-related osteonecrosis of the jaw. “The overall quality of the articles was determined to have moderate to high risk of bias, which indicates the true effect is likely to be close or substantially different from the estimate of the effect,” the authors wrote.

The results of the systematic review suggested that some systemic diseases might influence endodontic healing outcomes. However, the authors did not conclusively determine whether there is a relationship between the 4 systemic diseases and endodontic outcomes. They said, “longitudinal investigations with well-designed research methodologies are needed to address this question.”

Read the original article.

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Root Canal Awareness Week is May 7-13

Despite advancements in training and technology that make endodontic treatment virtually painless, Americans’ fear of pain is still their biggest worry when it comes to root canals. In a recent American Association of Endodontists (AAE) survey, 66% of respondents said fear of pain most concerns them about having endodontic treatment. Join the AAE in the celebrating endodontists as the superheroes of saving teeth during Root Canal Awareness Week, May 7-13, educating patients, and helping dispel the myths about endodontic treatment. The AAE's survey found that 77% of Americans want to avoid losing a permanent tooth. This year’s poster emphasizes that endodontic treatment can save teeth. The comics-themed poster highlights endodontists as the superheroes of saving teeth, thanks to their advanced training, specialized techniques, and superior technology.


AAE newsletter eyes clinical decision-making

Have you read the latest ENDODONTICS: Colleagues for Excellence newsletter from the American Association of Endodontists (AAE)? “Nonsurgical Retreatment: Clinical Decision Making,” by Dr. Robert S. Roda, explains the possibilities of saving the natural dentition through retreatment and highlights the decision-making process clinicians should undertake when considering retreatment. The newsletter covers advancements in endodontics such as the use of cone-beam computed tomography and operating microscopes that help clinicians identify reasons for initial failure such as untreated canals or perforations. Dr. Roda also explains the steps for nonsurgical retreatment: disassembly, repair of existing perforations, access to missed anatomy, shaping and disinfection of the canal system, and obturation. This newsletter was mailed to ADA members as in insert in the April 17 ADA News. Copies are available at


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JADA+ Specialty Scans and JADA+ Scans

JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. 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. View past issues here.

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