Comparison of CaOH with MTA for Direct Pulp Capping: A PBRN Randomized Clinical Trial

Purpose:

Compare direct pulp capping success in permanent teeth between CaOHvs MTA

Materials/Methods:

Providers: 35 practices (16 CaOH, 19 MTA) in the Pacific Northwest. 70% in practice > 10 years.

Patients: N = 358 (175 CaOH, 183 MTA). Age 8-90yo; mean age mid 30s for both groups.

Follow up: phone follow up w/in 1 month, clinical/radiographic follow up q6 months up to 2 years.

Mean f/u (months): CaOH = 12, MTA = 15.

Randomization of practice using computer software; each practice completed equal # of cases. All dentists received training in material utilization.

Inclusion criteria: pulp exposure (carious, traumatic, mechanical), exposure site vital, no PARL, no h/o spontaneous or lingering pain. Each pt can only be included once in the study.

Treatment protocol: rinse pulp exposure with water to remove debris à cotton pellet moistened with 5.25% NaOCl placed over exposure for 1-2 mins until bleeding controlled à pulp cap material (CaOH or MTA) àVitrebond RMGI à restorative material (permanent or temporary).

Outcome measures: vital pulp, radiograph to assess pathology (pulpal – resorption, calcification, periradicular – PARL). Failure = extraction or NSRCT.

Results:

  • Crude failure rates: 25% (43/175) CaOH, 15% (25/183) MTA.
  • Probability of failure forecasted for 24 months: 30% CaOH, 20% MTA (ss).
    • One CaOH practice had 56% failure rate. If excluded, probabiity of failure: 27% CaOH, 20% MTA (not ss).
  • Additional data:
  • 85% cases had light bleeding at exposure site.
    • Size of pulp exposure:
    • CaOH:   ≤ 0.5 mm = 50%,  1 mm = 30%,   ≥ 1.5 mm = 20%
    • MTA:  ≤ 0.5 mm = 60%,  1 mm = 25%,   ≥ 1.5 mm = 15%
    • Location of pulp exposure:
    • Rubber dam use: [CaOH] no = 85%, yes = 15%. [MTA] no = 75%, yes = 25%.
    • Type of exposure: 90% carious, 10% non carious.

Clinical Significance:

MTA is a superior material to CaOH as a direct pulp capping material.

Efficacy of lasers as an adjunct to chemo-mechanical disinfection of infected root canals: a systematic review

Purpose:

To evaluate the clinical efficacy of lasers as an adjunct to chemo-mechanical disinfection

Materials/Methods:

  • 3 databases searched: PubMed, CENTRAL, ISI Web of Knowledge. Hand-searching review articles.
  • 3 independent authors assessed quality of studies
  • Inclusion criteria: in vivo, sample > 5 teeth, laser mechanism of action against bacteria (Nd:YAG via thermal, Er:YAG via strong water absorption, Diode via photosensitizer), key words
  • 278 results, 10 full texts assessed, 5 studies included in systematic review.

Results:

  • 4/5 studies reported a positive effect when laser treatment was used as an adjunctive to conventional chemo-mechanical treatment
  • All 5 studies considered to be of low quality
  • Reasons for low quality: no power analysis, no blinding, only one RCT, insufficient description of disinfection procedures, not specifying whether NaOCl was buffered, use of more than one photosensitizer, only one assessed outcome with radiographs.

Clinical Significance:

Due to the low quality of the studies, no recommendations can be made for or against the use of adjunctive lasers.

Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: a longitudinal trend analysis

Purpose:

To study associations between patient characteristics and hospitalization outcomes

Materials/Methods:

Data source: Nationwide Inpatient Sample (NIS) – collects data on US hospitalizations

Inclusion criteria: any patient billed out for a periapical abscess or periapical abscess + sinus involvement.

Variables examined: hospital charges, length of stay (days), age, sex, race, insurance status, comorbid burden severity, geographic region, hospital bed size, teaching status of hospital.

Study duration: 2000 – 2008

Results:

  • 61,439 hospitalization due to periapical abscess bw 2000-2008.
  • Sinus involvement: 3.2% of all cases.
  • Pt demographics – mean age = 37yo. 51% female. Race: white (61%), black (20%), Hispanics (13.5%), Asian (1.5%), Native Americans (0.5%).
  • Hospital demographics- region: South (40%), Midwest (25%), Northeast (20%), West (18%). Urban areas (85%). Mean hospital stay = 3 days.
  • 90% admitted as an emergency/urgent status. 66 patients died in the hospital.
  • Associations with hospital charges: ↑ cost due to: ↑ age, non-white, presence of sinus involvement, non-teaching hospital, non-West region, co-morbidities.
  • Associations with length of hospital stay: ↑ duration due to: ↑ age, non-white, Medicare or Medicaid insurance, present of sinus involvement, South region, large hospital, co-morbidities.
  • Trends (comparing overall data to 2000 data):
  • 40% increase in hospitalizations for periapical abscess.
  • Increase in billing to Medicare (33%), Medicaid (75%), private insurance (20%), self-pay (42%). Medicaid + Medicare paid 44% of all periapical abscess hospitalizations.
  • Taking into inflation, charges for hospital stay increased 99% from $66.3 million to $132 million. Charges per patient rose 36% from $12,158 to $16,521.

Clinical Significance:

Use of emergency services for periapical abscesses are a HUGE economic burden. Mean cost of root canal = $1112. Mean cost of extraction = $259. Efforts need to be made to increase access to preventative & routine dental care.

Exuberant biofilm infection in a lateral canal as the cause of short term endodontic treatment failure: report of a case

Purpose:

Report a source of persistent infection

Materials/Methods:

CC: spontaneous pain with intermittent swelling in anterior maxilla.

#7 gross M & D decay

Sinus tract opening between the roots of #6 & 7. Swelling in vestibule + pus drainage upon palpation. Negative to cold & EPT. Sensitivity from both vertical & lateral percussion. PARL 13 x 14.5mm. #6 & 8 normal to sensibility tests & radiographically.

Treatment: 5 instrumentation sessions with > 106 days of CaOH using various [NaOCl]s, and manual dynamic irrigation for 60 seconds at each visit. Persistent sinus tract and pain remained. Canal obturated. Apico completed and root tip analyzed histologically.

Results:

  • 7 days after surgery, sinus tract healed and symptoms improved.
  • Complete bone fill-in of defect by 12 months.
  • Lesion was a cyst.
  • No bacteria present in the main canal & dentinal tubules at all levels of canal.
  • No bacteria colonization along the cyst wall.
  • Canal well-prepped, round, no irregularities, & free of debris.
  • Large lateral canal with the proximal half free of debris and the distal half clogged with thick biofilm.

Clinical Significance:

Case report of a short-term failure of RCT from a persistent lateral canal infection

Coronal tooth discoloration and white mineral trioxide aggregate

Purpose:

Quantify coronal tooth discoloration by wMTA

Materials/Methods:

N = 44 single rooted unrestored extracted teeth

All staining removed. Apical 3mm of root resected. Canals c&s from apex to pulp horns to eliminate coronal microleakage variable. NaOCl & EDTA used. Whole blood collected from volunteer. 3mm wMTA was placed in the most coronal part of preparation. Cotton pellet was placed over wMTA, then either blood or saline was used to saturate the cotton pellet. Photographs were taken at specified time points, then randomized to the researcher when assessing shade of tooth.

Experimental groups (n = 18 each): (1) wMTA + saline. (2) wMTA + blood.

Positive/negative control (n = 4 each): (+) blood only. (-) saline only.

Criteria of evaluation:

  • CIE L*a*b* color space tooth shade assessment.
  • L* = lightness, a* = green to red gradient, b* = blue to yellow gradient.
  • Evaluation at 3 time points
  • T0 = baseline, T1 = 1 day after material placement, T35 = 35 days after material placement.

Results:

  • Positive control (only Blood) had the most statistically significant color discoloration.
  • Teeth with wMTA, regardless of the presence of saline or blood, had statistically significant more discoloration in the cervical 1/3 of tooth than negative control.
  • Significant changes only observed describing lightness of tooth. No ss changes in hue or chroma.

Clinical Significance:

  • wMTA can discolor ex vivo teeth
  • Presence of blood adjacent to wMTA can exacerbate the degree of discoloration.
  • Inform your patients the possibility of discoloration if using wMTA – regeneration, perforation repairs, etc.

Quality of life and satisfaction of patients after nonsurgical primary root canal treatment provided by undergraduate students, graduate students and endodontic specialists

Purpose:

Investigate the question: Can RCT improve patient’s quality of life?

Materials/Methods:

Subjects: Adult patients 18-60 years, mentally fit, systemically healthy and legally capable of signing consents.  Excluding criteria: Diabetes, blood disorder, pregnancy, orthotx

N= 302 Jordinian patients treated with RCT: 101 undergrad, 100 grad, 101 specialists

Survey consisting : personal and demographic data, modified Oral Health Impact Profile (OHIP) (Dugus 2002), 7 semantic differential scales. Data analyses included descriptive statistics and nonparametric analyses

Systematic sampling every 10th patient

Experimental Design: interview before RCT then 2 weeks after RCT

Results:

  • Prior to tx, pts were most concerned about comfort during eating, altering the temp of foods, and difficulty relaxing; > 97 % saw improvement in these factors , not related to provider
  • > 90 % of subjects reported improvements in the sense of taste, pain, self-consciousness, waking up during sleep, interruption of meals, and difficulty to sleep àNo difference in improvement of these factors between providers
  • Between 75 % and 90 % noted improvement in unsatisfactory diet and difficulty doing jobs
  • Satisfaction with specialists was significantly improved in terms of time involved, intraoperative pain, pleasantness, and general satisfaction as compared to undergrad
  • Satisfaction with specialists was significantly lower in terms of treatment cost as compared to grad or undergrad
  • Degree of improvement was
  • Non-significant for the following factors: age, gender, tooth type, arch, density or length of obturation, restoration after tx, occupation, or income
  • Significant for the following factors: taperness of obturation, pulpal status (necrotic vs. vital), gingival inflammation, and missing teeth

Clinical Significance:

The impact of root canal treatment on the quality of life was apparent.  Satisfaction with RCT approximates 8 on the differential scale. Preference for specialists over dental students.

An anatomic investigation of the mandibular first molar using micro-computed tomography.

Purpose:

Examine the anatomy of mandibular 1st molars using micro CT.

Materials/Methods:

Subjects: Extracted Mandibular First Molars

N = 22

Micro-CT was scanned, reconstructed, and linear measurements were made to determine the following:

1. Assess the relationship of canal orifices to one another just below the pulpal floor to aid in canal identification upon orthograde access

2. Verify the cross-sectional width of the canals along the length of each root to advance the understanding of the working width in this tooth

3. Measure the thinnest area of dentin on the furcal aspect along the length of each root

4. Document the presence of lateral canals and apical ramifications in each root

5. Record the presence, type, and location of isthmuses in each root

Results:

1. Pulpal floor anatomy:  Distances between canals

  • M canals ranged 1.4 -3 mm
  • D and M canals averaged 4.4 mm

2. Furcation Dentin thickness:

  • M- average minimum= 1.28 mm
  • D- apical 6 mm ranged 0.25- 1.5 mm

3. Canal dimensions: BL consistently wider than MD in both roots

4. Canal morphology:

  • M canals highly variable: 23% 2 canals, 9% 1 canal, 36% more than 2 canals
  • Distal: 82% single canal and 9% two canals.

5. Isthmuses: 100% in M and D (those w/2 canals), ranging 3- 8 mm from apex

6. 79 % of apical and lat canals will exit in the apical 3 mm of M and 91 % in D

Clinical Significance:

  • The furcal aspect of the entire mesial root should be considered a “danger zone”
  • Mesial canals were found to be much more variable than distal canals in morphology, though orifice location remains relatively consistent
  • Root-end resection of 3 mm would remove the majority of lateral canals and apical ramifications.

Can apical periodontitis modify systemic levels of inflammatory markers? A systematic review and meta-analysis.

Purpose:

Answer the research question: Can apical periodontitis (AP) modify systemic levels of inflammatory markers (IM)?

Materials/Methods:

  • The MEDLINE (Ovid), Embase, PubMed, and Cochrane Library databases were searched for human studies published between 1948 and 2012. Two independent reviewers rated the quality of each study (Newcastle-Ottawa Scale)
  • Quality Assessment and Data Extraction – The primary outcome variable was determined by the serum levels of different IMs in AP subjects versus the healthy control group or AP subjects before treatment versus AP subjects after treatment

Results:

  • 531 papers found. 0nly 20 were included: 9 were interventional, 8 cross-sectional and 3 case controls.
  • Thirty-one IM’s were analyzed [immunoglobulin (Ig) A, IgM, IgG, and C- reactive protein (CRP) most commonly studied]
  • Most studies showed several IMs (CRP, interleukin (IL)-1, IL-2, IL-6, assymetricaldimethylarginine, IgA, IgG, and IgM) elevated in pts with AP compared to controls
  • IMs CRP and IgE were also not significantly different before and after tx (p> 0.05)

Clinical Significance:

  • Available evidence suggests that AP is associated with increased levels of some systemic inflammatory mediators in humans.
  • Untreated AP may have a pro-atherogenic effect with a potential role in patient’s global vascular risk.
  • Suggests AP may contribute to systemic inflammation, and not be localized to the lesion

The effect of endodontic procedures on apical crack initiation and propagation ex vivo.

Purpose:

Answer the research question: Can endo initiate or propagate apical cracks?

Materials/Methods:

Subjects: Extracted max single-rooted PM with 2 canals

N= 40

Exclusion criteria: teeth with fracture lines, open apices and anatomical irregularities

Experimental Design:

Apical 1.5 mm was ground and polished for all groups

B canal prepared with GG and K-files to size 40/02 Groups A, B, and C

  • A filled with LC+ WVC without sealer
  • B filled with LC
  • C unfilled
  • Group D unprepared and unfilled

Criteria of evaluation:

  • Teeth inspected and photographed under microscope for presence of cracks at baseline, preparation,  obturation, and after 4 weeks of storage
  • Logistic regression and Fisher’s exact test statistical analysis

Results:

Logistic Regression- Crack Initiation

  • A significant effect of preparation/ instrumentation (P < 0.05)
  • No significant effect of filling or 4-week storage (P > 0.05)

Fisher’s exact test- Crack Progression

  • A significant effect of filling (P < 0.05)
  • No significant effect of 4-week storage (P > 0.05)

Clinical Significance:

Root canal procedures can potentially initiate and propagate cracks from within the root canal in the apical region

Area and 3-dimensional Volumetric Changes of Periapical Lesions after Root Canal Treatments

Purpose:

Answer the question: Is the outcome measured by PA and CBCT the same?

Materials/Methods:

Subjects: RCT teeth with pre-operative PARLO

Experimental Design: PA and CBCT taken post-op and at recall. The lesion area was measured in mm squared for PA and lesion volume was measured in mm cubed for CBCT and then compared.

Criteria of evaluation: 4 categories: lesion undetected, decreased, unchanged or enlarged.

Statistically compared with McNemar and chi-squared tests

Results:

  • The 4-category diagnosis made using both methods were in agreement in 54.9 % roots, whereas disagreement was observed in 45.1 % roots (P < .001).
  • Lesion was absent in 15.5 % roots on CBCT scans and 45.1 % roots on PA (P < .001)
  • When success was defined as the absence of a lesion or a reduction in size of a lesion, no statistical difference (P = 0.073) was found between the methods .

Clinical Significance:

Lesion changes after root canal treatments determined with 3D volumetric CBCT data and 2-dimensional PA data were different, and outcome determined with PA could be untrue (This statement is not supported by author’s result).