Treating intruded permanent teeth
A major obstacle in analyzing benefits of the 3 treatment options currently used to treat permanent teeth with intrusive luxation has been the lack of high-quality studies that include sufficient patient data. To address this shortage, Scandinavian scientists combined 3 studies, thereby increasing the total number of patients and intruded teeth. They conducted a retrospective cohort study to examine the data and published their findings online March 4 in Dental Traumatology.
To evaluate the survival of intruded permanent teeth scientists included data from patients who had received treatment for the problem in Copenhagen, Denmark; Stockholm, Sweden; and Oslo, Norway. They focused on the development of pulp necrosis and replacement resorption as it related to each of the currently used treatments: awaiting re-eruption, orthodontic repositioning, and surgical repositioning. Degree of intrusion was classified as mild, moderate, or severe, and root development was categorized into 3 groups: very immature, immature, and mature.
Ultimately, the total number of patients was 168 (107 boys and 61 girls) with 230 intruded permanent teeth (age range, 5-18 years; average age, 9.6 years).
Analyses showed that root development, degree of intrusion, and treatment all may influence the treatment outcome of intruded permanent teeth, the authors said explaining the results. Among findings, necrosis was diagnosed in 58% of teeth with mild intrusion, 74% with moderate intrusion, and 92% with severely intruded teeth. No teeth with mild intrusion showed any sign of replacement resorption (the worst healing complication). Replacement resorption was diagnosed earlier in the more severely injured teeth.
The number of teeth with pulp necrosis was significantly higher in the immature and mature groups than in the very immature group.
Pulp revascularization was apparent in 25% of the teeth. “This finding indicates that in intruded teeth with very immature and immature root development, endodontic treatment should be postponed until obvious signs of pulp necrosis are found,” the authors advised. They explained in discussion that disturbance of the blood supply to the pulp will inevitably result in nonvital pulp tissue. This nonvital state is, in some cases, reversible as traumatized teeth have a potential for spontaneous pulp revascularization. Pulp necrosis was found less frequently in very immature teeth than in immature and mature teeth. “In teeth with mild intrusion, less damage to the pulp tissue in the apical area of the tooth can be expected and this may facilitate pulp revascularization,” the authors deduced.
Also among results, scientists found that pulp necrosis was diagnosed more frequently in teeth with active treatment (orthodontic or surgical repositioning) than in teeth where re-eruption was awaited, indicating to them that leaving the tooth to re-erupt could facilitate pulp revascularization.
Likewise, replacement resorption was found less frequently in teeth awaiting re-eruption than in teeth with active treatment, indicating to scientists that leaving the teeth to re-erupt diminishes the risk of experiencing replacement resorption because of additional damage to periodontal ligament during treatment.
In conclusion, authors said that “choice of treatment, root development, and degree of intrusion play a role in the development of replacement resorption … especially in very immature teeth with mild intrusion.” For the development of pulp necrosis, root development and degree of intrusion may be important factors. Choice of treatment is not.
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Consulting Editor: Susan Wood, DDS
Diplomate, American Board of Endodontics
Among dental treatments, the incidence and severity of postoperative pain is most highly associated with root canal therapy. Many factors, including environmental, experiential, and attitudinal, make it challenging for clinicians to measure. Nevertheless, it is necessary to evaluate pain at the point of service and in clinical trials, scientists publishing in the June issue of Journal of Endodontics said. Therefore, they conducted a randomized clinical trial to evaluate the efficacy of paracetamol (that is, acetaminophen) alone and in combination with 3 other nonsteroidal anti-inflammatory drugs to control postendodontic pain.
Patients with moderate to severe spontaneous preoperative odontogenic pain were selected for the study because patients with this type of pain tend to experience greater pain during and after endodontic procedures than do patients with mild and no preoperative pain. Thus, included patients reported symptoms of irreversible pulpitis via confirmation of the exacerbation of pain by exposure to hot and cold. The sample of patients visited the clinics of the Faculty of Dentistry, University of Khartoum and the Khartoum Teaching Hospital emergency clinic in Sudan.
Each of the eventual 170 participants analyzed (66 men and 104 women) had an equal chance of taking any of the 5 different therapy options. These combinations were paracetamol alone, combined ibuprofen and paracetamol, combined mefenamic acid and paracetamol, diclofenac K and paracetamol, and placebo. After initial endodontic therapy, participants were asked to draw 1 sachet from a dark bag, and the capsules within were administered immediately after the initial phase of treatment and before leaving the clinic. Patients were given a pain chart and asked to make entries on the NRS-11 numerical rating scale every hour for the first 4 hours after taking the drug and then every 2 hours subsequently for a total of 6 entries over 8 hours. They were also asked to identify the verbal description on a verbal rating scale in the same time sequence as follows: no pain, slight pain, moderate pain, or severe pain.
In discussion authors said that the verbal rating scale and the numerical rating scale are most preferred by patients because they find them easy to use and have shown good psychometric properties. Scientists found that patients who received the combination of ibuprofen and paracetamol experienced a greater degree of postoperative pain relief than did participants in the 4 other therapy groups studied. The placebo group had the least pain reduction.
In discussion, the authors noted that there were no statistically significant differences between taking paracetamol and the placebo, indicating that paracetamol alone had no or little effect on postendodontic pain.
“It can be argued that the decrease in pain is logical and an expected consequence of endodontic management; however, it can also be argued that the statistical significance of the use of combination analgesics over the mono-analgesic or no analgesic was evident,” the authors said.
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Reviews of new Two-In-One Endodontic Irrigation Solution
Irritrol is a single-step endodontic irrigation solution formulated for use as a final rinse after sodium hypochlorite (NaOCl). Irritrol contains chlorhexadine (CHX) and EDTA to disinfect the root canal and remove the smear layer. The Two-In-One Endodontic Irrigation Solution was recently evaluated by 25 Dental Advisor consultants in 424 uses. Irritrol endodontic irrigating solution received a 91% clinical rating. The majority of consultants would recommend and/or switch to Irritrol.
For more complete details visit us.
MTA pulpotomy for children with irreversible pulpitis
Clinicians treating children and adolescents who are unable to cooperate with or afford the cost of traditional root canal therapy may consider mineral trioxide aggregate (MTA) pulpotomy as an option for cariously exposed permanent molars with clinical signs and symptoms that would traditionally contraindicate such conservative management.
The finding, published online February 22 in International Endodontic Journal, was found by scientists in Kuwait who located few studies investigating the use of MTA for this condition. Clinical studies examining the use of calcium hydroxide for preserving pulp vitality in cariously exposed teeth have shown inconsistent results. The evidence shows that advantages for using MTA include its favorable biocompatibility, sealing ability, antibacterial and antifungal properties, dentinogenic activity, and encouraging clinical outcomes, authors said.
Considering the published research about MTA and that few studies investigated pulpotomy as a treatment modality for cariously exposed permanent teeth diagnosed with pulpitis in young patients using MTA, scientists conducted a prospective study to investigate.
Sixteen participants (8 boys and 8 girls) ranging in age from 7.6 through 13.6 years who had a total of 23 permanent molars were included in the study. Most of teeth (91%) exhibited pulps that demonstrated signs and symptoms suggestive of symptomatic irreversible pulpitis, with 78% showing signs of symptomatic apical periodontitis.
The same endodontist followed a standardized operative procedure for all cases of irreversible pulpitis. Scientists scheduled patients for clinical and sensibility examinations at 3, 6 and 12 months and annually thereafter. Follow-up radiographs were taken at 6 and 12 months and annually thereafter.
Treatment was considered a failure if 1 or more or the following conditions were present at the end of the recall interval: history of continuous and persistent pain, exaggerated tenderness on percussion, pathologic mobility, swelling, or sinus tract related to the treated tooth. Radiographic signs of failure included evidence of increased periradicular radiolucency, furcal pathosis, root resorption, or lack of continuation of root development in immature molars.
Among results, all pulpotomies were both clinically and radiographically successful at the end of the follow-up period. Scientists noticed a hard-tissue barrier in 57% of teeth and that 43% of molars that had open apexes at the beginning of the study showed continued root maturation. Seven molars that showed apical radiolucencies resolved completely by the end of the study.
In discussion, authors said the advantages for permanent tooth pulpotomy in children include
- elimination of pain and infection;
- preservation of a grossly decayed and cariously exposed tooth;
- a procedure that is less demanding, is clinically inexpensive compared with root canal treatment, and is better tolerated by children.
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Outcomes of therapy for endodontists and other providers
Molars treated with nonsurgical root canal therapy (NSRCT) by nonendodontists will have a 39.4% higher likelihood of spontaneous failure at 10 years compared with molars treated by endodontists.
The finding was reported in the May issue of Journal of Endodontics by scientists at Marquette University School of Dentistry and Delta Dental of Wisconsin.
Although many factors have been associated with the long-term success of endodontic therapy, few articles have been published that focus on the effect of provider training on outcomes. Because uncertainty exists about how training level may affect outcomes of NSRCT as it relates to tooth type, scientists aimed to compare the outcomes of NSRCT provided by endodontists and nonendodontists as they relate to tooth type.
To explore this, they secured data from the electronic claims and enrollment database of Delta Dental of Wisconsin for 13,329,249 patient encounters from January 1, 2000, through December 31, 2013. Claims were searched for Code on Dental Procedures and Nomenclature (CDT) procedure codes that were considered to be triggering events. Of 487,476 initial NSRCT procedures during the 14-year period, scientists collected information about provider type and specialty status, as well as tooth number.
Success was defined as the absence of untoward events. Cases were followed and considered successful until CDT codes representing extraction retreatment or apical surgery were encountered. Cases were further subdivided into 1-, 5-, and 10-year follow-up intervals to aid in the comparison of survival over time.
Scientists found that the survival or absence of untoward events for all teeth collectively was 98% at 1 year, 92% at 5 years, and 86% at 10 years. The median follow-up time for all cases was 2.43 years.
Analysis showed that the significant relationship between tooth type and provider type existed for molars at 10 years. A hazard ratio of 1.394 was found when 10-year survival of molars treated by other providers was compared with the same subset of molars treated by endodontists.
In discussion, authors said it is important to note that the population studied was insured, as they may present different dental care access and expectations compared with populations of uninsured people and that might have an effect on outcomes.
However, despite any study limitations, the high long-term survival rates of endodontically treated teeth reconfirmed the predictability of endodontic treatment provided by the dental health system as a whole, the authors said. They further stated that the true survival rate of the sample was likely higher than demonstrated in this study because basing failure on untoward events yielded a higher percentage of overall failure than what was actually present. “The incorporation of nonsurgical retreatment and apical surgery into the criteria for failure generates a higher number of failed cases, even though these teeth are receiving adjunctive therapies that may ultimately result in tooth retention and function.”
They called for future research to include an evaluation of the time from completed endodontic therapy to final restoration and to discern whether this period has any correlation to failure rate.
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Endo hands-on course receives accolades from endodontists and GPs alike
“Best CE course I have attended in a very long time. Very hands-on!” - Arnie Mann, DDS, (Endodontist) Lewes, DE
“The course was very well-run, organized, and informative. It was truly a wonderful experience! I feel much more confidant performing molar endodontics as well as troubleshooting problems during root canal therapy.”- Jim Lu, DDS, Valhalla NY
Focusing on microscopes
The operating microscope has become an indispensable part of the endodontist’s armamentarium. The Dental Operating Microscope in Endodontics explains the history of microscope use in endodontics, describes the advantages of microscopes in nonsurgical and surgical endodontic treatment, and summarizes the impact of microscopes on endodontic outcomes. Published by the American Association of Endodontics, the ENDODONTICS: Colleagues for Excellence newsletter was written by Dr. Frank C. Setzer, an assistant professor in the Department of Endodontics at the University of Pennsylvania School of Dental Medicine.
Explain how root canal can save a tooth
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.
“Root Canal Treatment Can Save Your Tooth” is an 8-panel brochure sold in packs of 50. Brochure interior can be viewed here. The brochure is also available in Spanish or personalized versions. To order, call 1-800-947-4746 or go to adacatalog.org. Readers who use the code 16405E before June 30 can save 15 percent on all ADA Catalog products.
3D root canal instrumentation: Learn how to maintain the original canal anatomy while thoroughly cleaning the canal. Watch the short endodontic video to see just how easy and effective a 2-step instrumentation system can be. Click here to view.
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 second in the series on this topic for 2016. Other specialty scan issues are devoted to oral pathology, oral and maxillofacial radiology, orthodontics, 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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