Endodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Treating single-tooth discoloration

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When a single front tooth is darker than the rest of the teeth, it draws even more attention to a smile’s imperfection than when all of the teeth are discolored.  Single-tooth discoloration is a common result of trauma.

Finding few clinical studies on the effectiveness of intracoronal bleaching in anterior discolored teeth, scientists in India conducted a study and published their findings in the April 10, 2014, online edition of Dental Traumatology.  Their aim was to determine patient satisfaction and clinical effectiveness of intracoronal bleaching, as well as patient awareness of treatment modalities for a traumatized, discolored, intact anterior tooth.

Subjects were selected from those who sought treatment for such teeth at the Department of Conservative Dentistry and Endodontics at the Government College of Dentistry in Indore, India. Patients who met the inclusion criteria totaled 41 (22 males and 19 females).  Each possessed a non-vital anterior, discolored, periodontally sound tooth and submitted to root canal treatment prior to the bleaching procedure. Patients filled out questionnaires about their medical history and knowledge of treatment protocols before the bleaching and about their satisfaction levels afterwards.

After scaling and root planning, scientists used a walking bleach technique—bleaching the tooth from inside the crown—to treat the discolored tooth. Patients returned each week for evaluation, and the bleaching procedure was repeated until patient and clinician were happy with the result or until the tooth was a shade lighter than the opposing one to compensate for post-treatment relapse. When the shade was sufficiently lightened, scientists sealed it with composite resin.

Scientists analyzed the results and found that 87.8 percent of patients described themselves as highly satisfied with the results, 7.32 percent said they were satisfied and 4.9 percent were not satisfied. The two patients who were not satisfied and discontinued treatment cited multiple appointments as the primary reason for their dissatisfaction.

Improvement of tooth coloration was the aspect of treatment most satisfying to patients followed by conservation of tooth structures. The most perplexing aspect for patients to understand was the unpredictability of the final shade and the potential lack of long-term color stability.

Most of the subjects—97.6 percent—were unaware that their single discolored tooth could be bleached, and about 95 percent also were unaware of veneer placement procedures, showing a “lack of awareness among the general public,” about treatment options, the authors said. The treatment option of which patients were most aware was crown placement after tooth reduction (78.1 percent) and extraction followed by replacement (48.8 percent).

In discussion, the authors also noted that teeth with a more recent history of trauma and teeth in young patients responded better to intracoronal bleaching and required fewer appointments to reach the desired shade. Also, the number of appointments necessary to achieve desired results was not dependent on the severity of the discoloration.

The researchers found it interesting that some patients were satisfied, even when a shade discrepancy remained after treatment and attributed those findings to the fact that most subjects were unaware a procedure that didn’t sacrifice tooth structure existed.

“The bleaching of non-vital teeth is a relatively low risk intervention to successfully improve the esthetics of endodontically treated teeth,” the authors concluded. They noted an average shade change of 12.0 for all satisfied patients.



Consulting Editor: Dr. Susan Wolcott
American Association of Endodontists

Material from the ‘90s still sets the pace

A material developed in the early 1990s that set new standards for repairing carious root perforations is maintaining and surpassing previous findings about its performance, a historical cohort study published in the June issue of the Journal of Endodontics reported.

Mineral trioxide aggregate (MTA) was considered prognosis-changing, particularly for larger or epicrestally located perforations because of its strengths in biocompatibility and sealing properties compared to other materials and techniques used before its introduction. However, available clinical studies were of limited value in assessing the long-term prognosis for MTA’s use. The number of cases reported in these studies was small, and follow-up periods were sometimes relatively short.

To assess the outcome—healed or diseased—for teeth with root perforations managed with MTA, scientists in Germany performed a second phase of a previously reported trial, the original identified as Phase 1. The results of Phase 1 showed that 86 percent of 21 teeth examined 12-to-65 months after treatment with MTA were healed.

For Phase II, scientists recruited 75 patients who had undergone root perforation repair with MTA at the Department of Conservative Dentistry at the University Hospital of Heidelberg, Heidelberg, Germany between 2000 and 2012.

All patients involved in Phase 1 were recalled for another follow-up examination in Phase II. Ultimately, scientists investigated 64 patients with 64 root perforations in different areas of the root. Forty-eight percent of the teeth (31 of 64) were assessed after recall periods of 1-2 years and 22 percent (14 of 64) after recall periods of 2–4 years. In addition, 30 percent of the teeth (19 of 64) were assessed after recall periods greater than four years and up to nine years (107 months) after treatment.

The calibrated examiners evaluated preoperative, intraoperative and postoperative factors. Teeth were categorized as healed or diseased.
Among the results, scientists found that of the 64 teeth examined, 86 percent were healed. Most disease outcomes occurred during the first four years, with few events thereafter. Only three of the 64 teeth with perforation repair were classified as diseased in the follow-up period, four-to-nine years after MTA treatment.

In discussion, authors noted that in addition to the larger number of teeth examined, further strengths of the Phase II study included the calibration of the radiographic and clinical assessment of treatment outcomes.

“Clinical calibration in endodontic outcome studies is less important than radiographic calibration, because only extreme interexaminer differences regarding the clinical assessments would affect the study results,” they said.

Scientists found the overall healed rate for all teeth with root perforations (86 percent) was in agreement with the results of Phase I of the project and other clinical studies. “The healed rate in the present study is considerably better than in the clinical studies of teeth with root perforations repaired with materials other than MTA.”

Scientists reported on evidence underscoring the importance of the treatment provider’s experience in the application of MTA to treatment outcome.

They noted that before the introduction of MTA, prognostic factors considered important for teeth after perforation repair were the time between the occurrence of the perforation and its repair, and the perforation’s size and location. Also, perforations at the crestal bone level and into the furcation of multirooted teeth used to have a poor prognosis.

“The results of the present study indicate that these historical prognostic factors for teeth after perforation repair are no longer as important as they were before the introduction of MTA. In the present study, lower success rates were found only with regard to the factor ‘size of perforation’ (> 3 mm).’”


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Effective protocols for pulp revascularization

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By stimulating root-end development and reinforcing root walls of immature teeth, revascularization therapy has emerged as a promising treatment. However, none of its benefits can occur when tissues around the roots are infected.

As a result, a variety of decontamination procedures have been discussed in the literature. Reports about sodium hypochlorite (NaOCI) as an irrigant solution used with triple antibiotic paste (TAP) as an intracanal medicament are common. Promising results also have recently been shown using chlorhexidine (CHX) as an irrigant solution and calcium hydroxide (CHP) as an intracanal medicament.

Scientists at the University of Campinas in Sao Paulo, Brazil, found research lacking about the most prevalent types of bacteria in immature necrotic teeth that had suffered dental trauma and efficacy of intracanal medicaments.  To fill this void, they conducted a study and published its findings in the June 2014 issue of the Journal of Endodontics.

They collected microbial samples from 15 upper incisor teeth with pulp necrosis from patients who were 7-17-years old and showed radiographic evidence of immature roots. The patients were divided into two groups according to the intracanal medicament used—seven in the TAP group and eight in the CHP group. Bacteria samples were taken during five treatment stages, counted and identified.

Scientists took the first microbial sampling before any treatment. The second (S2) was taken after canals were irrigated with sodium hypochlorite (NaOCI), and the third (S3) after canals were irrigated with 2 percent chlorhexidine gel (CHX), the fourth (S4) after intracanal dressing and the fifth (S5) after a final irrigation with 17 percent EDTA solution (ethylenediaminetetraacetic acid).   
The results showed that after irrigation with NaOCI (S2), all cases showed a significant reduction in bacteria counts. Irrigation with 2 percent CHX (S3) promoted further reduction in the bacterial counts, but not significantly reduced from the second sampling. There was no difference between bacterial counts after intracanal dressing (S4) in both groups, and the final irrigation with EDTA (S5) showed no viable bacteria in both groups or statistical differences between them.

In discussion, authors said the combination of two potent irrigant solutions (NaOCI and CHX) achieved a maximum elimination of microorganisms.
“Both solutions have demonstrated efficacy in disinfecting immature root canals in revascularization therapy, and the protocols combining these substances showed promising results,” the authors said. They added, “CHX presents extended antimicrobial properties and capacity of diffusion into dentinal tubules.”

The intracanal medicaments both showed reduction in bacterial counts without statistical difference, which concurred with the results of previous studies. The most prevalent bacterium—Actinomyces naeslundii—was detected in 10 of the 15 cases.

“The microbial profile of infected immature teeth is similar to that of primarily infected permanent teeth,” the authors said. “The greatest bacterial reduction was promoted by the irrigation solutions. The revascularization protocols that used the tested intracanal medicaments were efficient in reducing viable bacteria in necrotic immature teeth.”



Managing swallowed, aspirated foreign bodies

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A step-by-step process for improving patient outcomes after potential complications resulting from dental procedures was published in the May 2014 issue of The Journal of the American Dental Association.

Accidental swallowing or aspirating of dental prostheses and instruments can lead to mortal dangers including bowel perforation, abscess, obstruction and respiratory failure. Although the literature contains general guidelines for managing aspirated or ingested foreign bodies, clear directions for dental instruments are lacking, the Michigan-based authors said.

Their report illustrates a variety of situations supporting the proposed evidence-based algorithm for managing complications, including the experiences of five patients who had accidentally swallowed or aspirated dental instruments and findings from the literature review.

The first case they described as inappropriately managed centered on the experience of a 47-year-old female who swallowed a dental implant screwdriver. Two months after being reassured by her dentist that the instrument would likely pass in her stool, an abdominal radiograph confirmed it was impacted in the ileocecal valve—a thin portion of the bowel. It was removed during a colonoscopy. Although the patient remained symptom-free two years after the procedure, the risk of perforation can be as high as 35 percent if a sharp object reaches the ileocecal valve, the authors said.

They also recounted cases of swallowed endodontic files and aspirated crowns. Three of the five cases of foreign body aspiration or ingestion were caught early, and the patients were referred for endoscopic retrieval.

“Our review of case reports regarding an aspirated or ingested dental instrument indicates a steady increase in the use of endoscopy for successful retrieval,” the authors noted. However, two of these patients experienced prolonged symptoms that negatively affected their quality of life before diagnosis and healing intervention occurred.

The flow chart scientists proposed for managing aspirated and ingested foreign bodies advises endoscopy for successful retrieval of sharp objects and urgent bronchoscopy for aspirated dental prostheses.

In addition, the authors recommend that dentists take preventive measures such as using rubber dams and throat packs consistently. “In the event that preventive measures fail or were not practiced, following the proposed algorithm, may enhance patient safety in dental practices.”


The American Association of Endodontics includes a position statement on dental dams among its member resources for distribution to patients or referring dentists.


Joint symposium set for July

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Saving the natural dentition will be highlighted during the 2014 joint symposium entitled “Teeth for a Lifetime: Interdisciplinary Evidence for Clinical Success.”

         This program is presented by American Association of Endodontists, American Academy of Periodontology and the American College of Prosthodontists. It is scheduled for July 19-20 at the Swissotel in Chicago.  

For more information, visit www.aae.org/teethforalifetime


ADA offers brochure on root canal

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A brochure that will help dentists explain endodontic treatment to their patients is available in the ADA Catalog at a 15 percent discount through July 31, using the promo code 14358E.

            The brochure, Root Canal Treatment (W117), explains the causes of pulp damage, why it is necessary to remove injured or diseased pulp and why saving a tooth with endodontic treatment is a better option than extraction.

            Step-by-step graphics show the phases of treatment, from abscess to restoration with a crown. The eight-panel brochure is available to members starting in packs of 50 for $27; retail price is $40.50.

            Root Canal Treatment also can be personalized (DAB007) with your name or practice information. To preview the Root Canal Treatment brochure and a variety of other ADA brochures, visit adacatalog.org.

Discounted pricing is available for higher quantities.

            Orders can be placed online at adacatalog.org or by calling the ADA Member Service Center at 1-800-947-4746. Remember to use the promo code 14358E for the 15 percent discount.

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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 second in the series on this topic for 2014. Other Specialty Scan issues are devoted to prosthodontics, periodontics, orthodontics and oral and maxillofacial radiology. The ADA has engaged the specialty organizations in these areas as well as its own divisions of Science and Legal to assist with these newsletters. We welcome your feedback on this and all Specialty Scan issues.

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