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

Anesthesia and patients with a vital, inflamed pulp

Patients with symptomatic, irreversible pulpitis describe root canal treatment as being more painful than do patients with necrotic pulps and asymptomatic apical periodontitis. Clinicians find that achieving pulpal anesthesia can be challenging in these cases wherein a vital inflamed pulp is incapable of healing. For example, anesthesia may be sufficient to access the pulp chamber, but canal instrumentation may still result in severe pain for the patient.

A team of scientists from Oregon Health and Science University interested in the efficacy of Articaine compared with Lidocaine in reducing pain and adverse events conducted a systematic review and meta-analysis of the literature. They published their research in the November 2015 issue of the Journal of Endodontics.

The most commonly used anesthetic for dental use in the U.S., Lidocaine was introduced to the market in 1948. Articaine is the second most commonly used. It was introduced to the European market in 1976 and entered the U.S. market in 2000.  

Scientists searched electronic databases from 1976 and also conducted a manual search of major textbooks. They sought studies that evaluated the pulpal anesthetic solutions of 4% Articaine compared with 2% Lidocaine, delivered as a similar volume dose of at least 1.0 milliliters per injection in combination with vasoconstrictor. Subjects were adult patients with symptomatic irreversible pulpitis. Scientists’ primary interest was the reduction of pulpal pain to a level that would allow endodontic treatment to proceed within 20 minutes of administration of local anesthetic (one included study defined successful anesthesia as no response to the electric pulp tester). They presented data as successful or unsuccessful anesthesia in accordance with the methodology of each study. Secondary outcomes measured were adverse events.

Of 275 studies initially identified in the search, 10 double-blind, randomized clinical trials met the inclusion criteria, involving a total of 746 adult patients diagnosed with symptomatic irreversible pulpitis and anesthetized with either Articaine or Lidocaine. The trials were conducted in India, the U.S., Brazil and England. The mean age range of patients was from 23 to 38 years and no significant associations between anesthesia outcome and age or gender were found.

The central discovery was that there was a significant advantage to using Articaine over Lidocaine for supplementary infiltration after mandibular block anesthesia but no advantage when Articaine was used for mandibular block anesthesia alone or for maxillary infiltration. Only one of the ten studies reported the absence of adverse events, whereas the others studies made no mention of such occurrences. “It is important that future clinical studies incorporate the presorting of adverse events in their methodology,” authors said.

According to the authors, the main difference between their study and previous English language reviews was that all participants in the study were diagnosed with irreversible pulpitis compared with previous reviews that had a broader participant base (patients and nonpatient volunteers with or without pain).

Read the original article.


Consulting Editor: Susan Wood, DDS
Diplomate, American Board of Endodontics

Patient pain and foraminal enlargement

New research published in the Nov. 18, 2015, online edition of the International Journal of Endodontics reported that enlargement of the apical foramen during root canal treatment increased the incidence and intensity of postoperative pain for patients.

Bacteria in the apical foramen region have a high probability of survival due to constant nutrition from the periapical area. To obtain adequate root canal disinfection and ensure a favorable environment for healing, cleaning and shaping of the area may be necessary. Despite this potential advantage, some research has suggested that foraminal enlargement may lead to a higher incidence of postoperative pain from mechanical irritation of periapical tissues and/or extrusion of debris during preparation.

Considering that previous research involved maxillary teeth and with knowledge that posterior teeth are more difficult to manage, as well as evidence showing patients experience more pain in molars and in the mandibular arch, scientists conducted a randomized controlled trial. Their aim was to assess the incidence and intensity of pain following foraminal enlargement in mandibular first molars with necrotic pulps and compare it with the pain experienced when the foramen was not enlarged during preparation.

Scientists recruited subjects between May 2013 and March 2014 from patients referred to the Department of Conservative Dentistry at the Post Graduate Institute of Dental Sciences, in India, for primary root canal treatment. They selected patients with first permanent mandibular molars with pulp necrosis and radiographic evidence of apical periodontitis. Individuals with preoperative pain, those who had used antibiotics during the previous three months or during the previous 24 hours or those requiring antibiotic premedication, diabetic, immunocompromised and pregnant subjects were excluded.

Seventy patients were ultimately enrolled in the study and randomly and equally divided into two groups according to procedure — foramen enlargement (FE) and conventional nonforaminal enlargement (NFE).  There were no significant differences between the groups in terms of patient characteristics, such as age and gender or treatment quadrant.
One principal investigator performed the entire endodontic procedure on all patients using standardized protocols. In the FE group, instrumentation was performed to working length established at the apex reading of the electronic apex locator. In the control group, the canals were prepared to working length established 1 millimeter short of the apex reading.

Patients recorded their pain every morning for seven days following treatment on a scale of 0 to 10 where 0 referred to no pain and 10 indicated the worst pain imaginable. Researchers instructed patients to use 400 mg Ibuprofen if they required pain relief and to record their usage.

Scientists found that pain levels were significantly different between the two groups during the first four days but then insignificant except on the sixth day when they were again greater. However, throughout the study, mean pain in the FE group remained higher than in the NFE. For the FE group, a maximum pain intensity of 6 was reported on the first day. It was 4 in the NFE group. Nine percent in the FE group and 43 percent in the NFE did not complain of pain, a highly significant difference in pain prevalence. All patients in the NFE fell in the mild or no pain category by the third day. Two patients in the FE group continued to report moderate pain up to day five.  However, despite a significant difference in pain, there was no significant difference in prevalence of analgesic intake and number of doses.

Among comments in discussion, authors noted previous research demonstrating that the improvements in working length measurement techniques and the development of improved electronic apex locators have enabled accurate estimation of the apical constriction, while helping avoid the typical hazards associated with radiography. “Such precision has now made it possible to precisely prepare the apical foramen without overextending instruments in the periapical region.”

Root canals in the present study were enlarged to three sizes larger than the first apical binding. Authors said it has been suggested in a recent study that any enlargement beyond this does not provide significantly better success rates and larger preparation must be avoided as it may compromise the integrity of the tooth and lead to procedural complications.

Read the original article.


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Revascularization and treating immature permanent teeth

Revascularization treatments for the irreversibly damaged pulp of immature teeth should be considered “valuable, effective and reproducible,” according to new research published in the September 2015 issue of Dental Traumatology.

Conventional endodontic treatment has traditionally been difficult in immature teeth because of the absence of apical constriction. However, while previous studies demonstrated that revascularization could preserve the potential for continued root growth, a large amount of research citing a range of clinical protocols generated uncertainty as to the most effective approach for revascularization in immature permanent teeth. That’s why researchers aimed to appraise available protocols and generate a clinical best practice recommendation.

To study, they searched the PubMed database for scientific papers published between 2001 and 2014 using the keywords “pulp revascularization,” “pulp revitalization,” and/or “immature tooth.” With the addition of one article following a hand search of the literature, they selected 33 papers for review. Patient and diagnostic information, treatment and results in follow-up visits were evaluated.

Of 101 immature permanent teeth treated by revascularization, only four were considered failures because vital pulp tissue enabling continued root development with apical closure wasn’t preserved. Authors said such apexogenesis can be considered the key indicator of success or failure when evaluating revascularization and it was the primary outcome variable of this study.

“This technique, regardless of the individual methodology, can increase root development in correctly selected cases,” authors said. They reported that revascularization “showed marked increase in the root length, width and apical closure in the cases that were reported.”

Among conclusions, they called for further studies to assess the effect of revascularization on survival of the teeth, which was not considered a viable outcome variable of this study due to differences in follow-up periods when comparing previous studies. They also acknowledged author bias toward publication of successful treatment outcomes and subjectivity in the production and analysis of radiographic images as possible confounding variables.

“The ultimate objective of future studies should be to build an accurate large-scale database to promote the objective analysis of the reproducibility and utility of the revascularization technique in the clinic.”

Read the original article.


Measuring working length with electronic apex locators

It is well recognized that maintaining a correct working length during root canal treatment positively influences outcomes and prevents post-operative pain. Working length (WL) is typically defined as the distance between a coronal reference point and the point at which canal preparation and obturation should terminate. Therefore, clinicians aim to measure it as precisely as possible.

Common deviations from an idealized anatomy of the main apical opening (apical foramen) of the root canal make clinical identification of working length difficult to the extent that it has been described in previous literature as “practically impossible.” Additionally, there is a lack of consensus in the literature about the best location of the termination point of the apical preparation. The apical constriction (portion of the root canal having the narrowest diameter), is also variable, according to the literature.

Although numerous studies have been published about the precision of electronic apex locators (EALs) in determining working length, scientists found significant variability in their designs and terminology regarding the apical foramen anatomy and results. Seeking review and analysis according to evidence-based dentistry principles and strict inclusion criteria regarding the precision of EALs in determining working length, a team of scientists in Italy and Israel conducted a study. Their aim was to evaluate the precision of EALs in locating the apical constriction as well as the effects of possible influencing factors. To do this, they conducted a comprehensive systematic review of the literature and meta-analysis.

To study, the team searched the literature for all articles published in dental journals from 1966 to 2014. An electronic search of MEDLINE using the PubMed search engine, Embase, Scopus and Cochrane databases using the key words “apex locator” was performed. Researchers also conducted manual searches to obtain related articles.

The following variables were recorded from the data:

  • Distance between the file tip during the EAL measurement and the actual AC location as determined histologically.
  • Type of teeth tested (single-rooted vs. multi-rooted).
  • Type of EAL.
  • Status of the pulp (vital or necrotic).
  • Irrigant use and type.

From an initial 247 articles found, ten met the inclusion criteria. The included studies reported on a total of 1,105 measurements performed by four types of EALs.

Results showed the pulp status (vital or necrotic) had no significant effect on the precision of the EALs and varying levels of accuracy of working length depending on the type of device and irrigation used.

In discussion authors said, “The data presented in the evaluated studies support the use of apex locators for WL measurements, as do the latest studies published. However, the clinical implications of the differences in WL measurement between the apex locators reported in the present investigation are still unclear.”

The study is published in the November 2015 issue of the Journal of Endodontics.

Read the original article.

EDS Introduces Irritrol to irrigate, clean and rapidly disinfect the root canal in one step

Irritrol (Essential Dental Systems) is a single step disinfecting endodontic irrigation solution. Irritrol effectively disinfects, removes the smear layer and is gentle on dentin. This single step solution efficiently removes the smear layer less aggressively than conventional irrigants, therefore causing less demineralization of the dentin. By incorporating this single step solution into your practice you will work faster, smarter and more cost effectively; as you’ll save time and money over using EDTA and Chlorhexidine sequentially. Learn more here.

Save the Date: AAE16 to meet April 6-9 in San Francisco

Registration will open online in mid-December for the American Association of Endodontists annual meeting. This comprehensive endodontic education summit, vendor exhibition and networking opportunity includes surgical and nonsurgical endodontics education tracks, interdisciplinary care and endodontic derailments. Participants can learn about innovative products and services that may lead to new ways of treating patients and improving productivity. No matter how experienced you are in patient care and practice management, AAE16 has much to offer.


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 eight-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 Readers who use the code 15409E before December 18 can save 15 percent on all ADA Catalog products.


Tango-Endo Receives Top Product Award
Tango-Endo, the new 2-step instrumentation system by Essential Dental System, has recently received multiple dentistry awards. These awards include a 2015 Top Product Award and an Editor’s Choice Award. For an updated list of awards and product reviews please Click here.


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 fourth in the series on this topic for 2015. Other specialty scan issues are devoted to oral 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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Any statements of opinion or fact are those of the authors and do not necessarily reflect the views of the American Dental Association. Neither the ADA nor any of its subsidiaries have any financial interest in any products mentioned in this publication. Any reference to a product or service, whether in advertisements or otherwise, is not intended as an endorsement or as approval by the ADA or any of its affiliated organizations unless accompanied by an authorized statement that such approval or endorsement has been granted.

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