Conventional Endodontic Treatment Research Articles

Nanofibrous spongy microspheres for the delivery of hypoxia-primed human dental pulp stem cells to regenerate vascularized dental pulp

Dental pulp infection and necrosis are widespread diseases. Conventional endodontic treatments result in a devitalized and weakened tooth. In this work, we synthesized novel star-shaped polymer to self-assemble into unique nanofibrous spongy microspheres (NF-SMS), which were used to carry human dental pulp stem cells (hDPSCs) into the pulp cavity to regenerate living dental pulp tissues. It was found that NF-SMS significantly enhanced hDPSCs attachment, proliferation, odontogenic differentiation and angiogenesis, as compared to control cell carriers. Additionally, NF-SMS promoted vascular endothelial growth factor (VEGF) expression of hDPSCs in a 3D hypoxic culture. Hypoxia-primed hDPSCs/NF-SMS complexes were injected into the cleaned pulp cavities of rabbit molars for subcutaneous implantation in mice. After 4weeks, the hypoxia group significantly enhanced angiogenesis inside the pulp chamber and promoted the formation of ondontoblast-like cells lining along the dentin–pulp interface, as compared to the control groups (hDPSCs alone group, NF-SMS alone group, and hDPSCs/NF-SMS group pre-cultured under normoxic conditions). Furthermore, in an in situ dental pulp repair model in rats, hypoxia-primed hDPSCs/NF-SMS were injected to fully fill the pulp cavity and regenerate pulp-like tissues with a rich vasculature and a histological structure similar to the native pulp. Statement of SignificanceVascularization is key to the regeneration of many vital tissues. However, it is challenging to create a suitable microenvironment for stem cells to regenerate vascularized tissue structure. This manuscript reports a novel star-shaped block copolymer that self-assembles into unique nanofibrous spongy microspheres, which as an injectable scaffold recapitulate the cell–cell and cell–matrix interactions in development. Using a clinically-relevant surgical procedure and a hypoxic treatment, the nanofibrous spongy microspheres were used to deliver stem cells and successfully regenerate dental pulp with a rich vasculature and a complex histologic structure similar to that of the native dental pulp. The novel microspheres can likely be used to regenerate many other vascularized tissues.

Effect of Diode Laser on Bacteria Beyond the Apex in Relation to the Size of the Apical Preparation - An In-Vitro Study.

Microorganisms causing periapical infection are usually difficult to eradicate after conventional endodontic treatment or even in retreatment resulting in poor outcomes. So the purpose of the study was to assess whether disinfection of root canal with laser had any effect on bacteria in the periapex region. The aim of the present study was to evaluate the effects of a diode laser when activated in root canals with varying apical diameters, on the bacteria present beyond the apex of the teeth. Total 30 intact single rooted teeth were taken and decoronated to standardize the root to a length of 12mm. They were divided into three groups depending on last file size used for instrumentation at apex i.e., size 30, 40 and 50 respectively. The samples were then mounted on test tubes such that roots of teeth were in contact with fresh broth of Escherichia coli (ATCC 25922) and left for incubation. Later a diode laser (Ezlase 940, Biolase) was used for disinfection of root canals of the samples. Following this the bacterial inoculums from each test tube were cultured and CFU were obtained from which the mean log values were obtained. Statistical analysis was done using Kruskal Wallis ANOVA test to compare mean CFU in three groups. Mann-Whitney U test with Bonferroni correction was used to compare inter-group differences. There was statistically significant difference in mean log values of CFU in all the three study groups. Inter-group comparisons showed that, Group A had significantly lower mean CFUs than Group B and C respectively. The study showed that intracanal irradiation with diode laser had an effect on the bacteria present beyond the apex, and it was influenced by the size of the apical preparation i.e., smaller apical size led to a greater reduction in the bacterial count.

Non-surgical endodontic retreatment and follow-up of an endo – perio lesion: a case report

Endo-perio lesion is a clinical dilemma and may be the most complex, refractory problem we encounter, even for the most experienced hands, and should not be underestimated. When a primarily endodontic pathology changes into a secondary periodontal lesion the clinical features become more unusual. This may delay the diagnosis and the correct treatment. This case report evaluates 6 months follow up of non surgical endodontic retreatment of an endo – perio lesion, which was treated before with conventional endodontic treatment and aims to show importance of obturation technique in lateral canals involved endo perio lesions.

CLINICAL AND RADIOGRAPHIC EVALUATION OF HEALING EFFECT OF LOW LEVEL LASER THERAPY ON CHRONIC APICAL LESIONS

Objective: This study evaluated clinically and radiographically, the healing in chronic apical lesions using low level laser therapy (LLLT). Methods: Twenty female patients between the ages of 20 and 30 years with chronic apical lesions in anterior maxillary teeth diagnosed on the basis of their clinical signs and symptoms and radiographic findings were included in the study. The patients were randomly divided into two main groups according to treatment plan: group I; received conventional endodontic treatment only, group II; received conventional endodontic treatment and then LLLT was used. The low level laser was applied for 120 seconds in the session for three sessions in week for four weeks and the selected parameters were (200 mw, 810 nm, CW). The healing was evaluated clinically, radiographically. Clinically to record pain, swelling, or any other adverse event that occur after treatment for one week. Radiographically to evaluate bone density and area of periapical lesions using cone beam computed tomography (CBCT) and image fusion. Images were obtained immediate after obturation and after the three follow up periods (1, 3 and 12 month) . Results: clinical signs and symptoms decreased in the lased group faster than conventional group. Pain reduction in the laser group was more effective than the conventional group without significant difference. Bone density analysis showed that Laser had significantly higher bone density after 1 ,3 and 12 month evaluation periods compared to control group (P<0.05). Comparing the area values of control and laser groups, a significant difference was found throughout the three evaluation periods compared to the area immediate after obturation. Conclusions: Based on the results of this study; LLLT favored the healing process of apical lesions especially when combined with nonsurgical endodontic treatment. Image fusion and CBCT can provide an accurate and reproducible method for assessment the healing of periapical lesions.

Endodontic treatment of the maxillary central incisor with sequelae of dental trauma

Dental trauma in immature teeth with necrotic pulp and apical foramen with large thin and fragile walls becomes a challenge to treat conventional endodontic treatment. The objective of this report is to demonstrate a clinical case in which the apexification through calcium hydroxide-based dressing, succeeded in forming a calcified apical barrier. It concluded that a barrier with mineral trioxide aggregate superimposed with the endodontic obturation of gutta-percha advocated in the central incisor led to a successful endodontic procedure.

Nonsurgical Endodontic Management of a Molar-Incisor Malformation-affected Mandibular First Molar: A Case Report

A molar-incisor malformation (MIM) is a newly reported type of dental anomaly that involves a characteristic root malformation in permanent first molars and deciduous second molars and a crown defect in permanent central incisors. This case report describes a nonsurgical root canal treatment of a MIM-affected molar by aid of a reformatted axial view of the tooth cone-beam computed tomography (CBCT). A MIM-affected molar has calcified canal orifices and a few immature accessory furcal canals. Conventional root canal treatment with the aid of CBCT followed by resin restoration was performed on the tooth. The malformed roots of MIM teeth generally make it difficult to apply conventional endodontic treatment; however, it was possible to do with the aid of the reformatted axial view of the CBCT.

Influence of preoperative pain intensity on postoperative pain after root canal treatment: A prospective clinical study

ObjectivesThe aim of this prospective study was to investigate the correlation between the intensity of preoperative pain and the presence of postoperative pain, taking into account the variables sex, tooth type, arch, and tooth vitality. MethodsTwo hundred and seventy patients with pulpal pathology who were scheduled for routine endodontic treatment were enrolled in this study. Conventional endodontic treatment was carried out in a single visit. The chemomechanical preparation of root canals was performed with ProTaper instruments, and canals were obturated with a warm gutta-percha obturation technique. A structured questionnaire was used to record data on sex, age, type of tooth, location and pulp diagnosis. Patients were asked to record their preoperative and postoperative pain using a 10-cm visual analogue scale (VAS). Postoperative pain and the need for analgesic consumption were assessed at 4, 8, 16, 24, 48 and 72h post-treatment. The data were analyzed using the Mann–Whitney U and chi-square test, and the significance was set at P<.05. ResultsThe mean level of pain after root canal treatment was 2.58±2.80 on a VAS between 0 and 10. Variables that were associated with a higher preoperative pain intensity (female, mandible and molar) also had a higher value of postoperative pain (P>.05). ConclusionsWithin the limitations of this study, it can be concluded that the presence of preoperative pain is the variable that most influences the prevalence of postoperative pain. Clinical significancePain management should be an integral part of dental treatment. The present study analyses the incidence of postoperative pain that should be expected by patients with different intensity of pain before root canal treatment.

Comparison of the Incidence of Postoperative Pain after Using 2 Reciprocating Systems and a Continuous Rotary System: A Prospective Randomized Clinical Trial

IntroductionThe objective of the present study was to clinically compare the incidence of postoperative pain and the intake of analgesic medication (frequency and quantity) after endodontic treatment of posterior teeth using 2 reciprocating systems and a continuous rotary system. MethodsIn a prospective randomized clinical study, 210 patients with vital teeth indicated for conventional endodontic treatment were treated by 5 specialists according to a pre-established protocol. The teeth were randomly assigned to 1 of 3 groups (n = 70) according to the instrumentation system used: ProTaper Next (Dentsply Tulsa Dental Specialties, Johnson City, TN), WaveOne (Dentsply Tulsa Dental Specialties), or Reciproc (VDW, Munich, Germany). Treatments were performed in a single visit. After the visit, the patients were given a prescription for ibuprofen 400 mg to be taken every 6 hours if they experienced pain. Participants were asked to rate the intensity of the postoperative pain on a visual analog scale according to 4 classes (no pain, mild pain, moderate pain, and severe pain) after 24 hours, 48 hours, 72 hours, and 7 days. Patients were also asked to record the number of prescribed analgesic medication tablets taken at these time points. ResultsNo statistically significant difference was found among the 3 groups in relation to postoperative pain or analgesic medication intake at the 4 time points assessed (P > .05, Kruskal-Wallis test). ConclusionsThe reciprocating systems and the continuous rotary system were found to be equivalent in regard to the incidence of postoperative pain and intake of analgesic medication at the time points assessed.

Hypochlorite-induced severe cellulitis during endodontic treatment: case report

Sodium hypochlorite is a solution used in endodontic treatment, and if an accidental apical extrusion occurs, serious complications may affect soft tissue. Objective: The aim of this article is to present a case of apical extrusion of sodium hypochlorite (NaOCl) during root canal system instrumentation. Case report:A 28-year-old woman sought a local dental service for root canal treatment of tooth #24. Conventional endodontic treatment was adopted, which consisted of the use of 2.5% NaOCl solution as irrigation solution applied with a 10-ml syringe and 22G hypodermic needle. At that time, the patient reported extreme pain and a burning sensation in the left maxillary region, followed by the formation of intense edema. A clinical diagnosis of hypochlorite-induced cellulitis was made. The patient was treated immediately with amoxicillin (500 mg, orally) at intervals of 8 h for 7 days and dexamethasone (4 mg, intramuscularly) at intervals of 24 h for 3 days. In the subsequent endodontic treatment, 2% chlorhexidine gel applied with a 5-ml syringe and 24G needle was used as irrigation for a better control of treatment and to prevent new accidents. The root canals were instrumented using adequate crown-down technique, which provides a conical shape, and filled by lateral condensation technique. The patient was symptom free at the 8-month clinical follow-up. Conclusion: Dentists should always carefully follow all stages of dental treatment planning without neglecting any of them, paying attention to the solutions used and their storage as well as performing a specific technique with maximum accuracy. If an accident occurs, the appropriate handling of the situation will enable the satisfactory completion of treatment.

Photoactivated disinfection (PAD) of dental root canal system – An ex-vivo study

AimTo investigate the efficacy of photo activated disinfection (PAD) in reducing colony-forming unit (CFU) counts of Enterococcus faecalis (E. faecalis) in infected dental root canals. The study compared the efficacy of PAD with conventional endodontic treatment (CET) and also a combination of CET along with PAD. Material and Methods53 maxillary incisors were taken for the study. Teeth were divided into 3 groups, CET (Group I) (n=11), PAD (Group II) (n=21), and a combination of CET and PAD (Group III) which consisted of (n=21) samples, Group II and Group III were further divided into 2 subgroups, Group IIa, IIb and Group IIIa, IIIb. Strains of E. faecalis were inoculated in all the root canals. CET group samples were treated by chemo-mechanical preparation (CMP) alone, PAD samples were treated with laser alone at 2 different exposure time (4min and 2min). In the combination treatment, samples were treated initially by CET and then by PAD for a time period of 4min and 2min. Contents of the root canal were aspirated, diluted and plated in Tryptone Soya Broth (TSB) and plates were incubated for 24h to observe the bacterial regrowth. ResultsShowed PAD used along with CMP reduced the bacterial load of E. faecalis by 99.5% at 4min and 98.89% at 2min. ConclusionPAD may be an adjunctive procedure to kill residual bacteria in the dental root canal systems after standard endodontic root canal preparation.

Restoration of Long Standing Traumatized Teeth: A Case Report.

Children are uniquely susceptible to craniofacial trauma. Injuries to the teeth occur often as a result of falls and sport activities. The pulp often gets infected after dental trauma resulting in to numerous complications. The authors present a case report of successful restoration of traumatized teeth with open apex which were weakened due to long standing infection and internal resorption. Initially antibiotic combination of 3- mix was used to disinfect the root canals. One tooth is treated with conventional endodontic treatment and the other tooth with open apex and perforation is managed by MTA apexification followed by canal reinforcement using glass ionomer cement and fiber reinforced composite post. Core build up is done using light cure composite resin followed by aesthetic crowns. The patient also presented with the peg shaped lateral incisors, which were built to an aesthetic appearance using light cure composite resins.

Endo- Perio management of maxillary first premolar with three distinct roots and three canals diagnosed with Cone Beam Computed Tomography– A rare case report

Many of the difficulties found in endodontic therapy are caused by variations in root canal anatomy. Any pre-assumptions regarding the root canal morphology will eventually lead to endodontic failure. Maxillary first premolars show a considerable variation in root canal morphology but the presence of three roots is rare. The incidence shown in the literature for three rooted maxillary first premolar is 0.5 to 6%. Endodontic–periodontal lesions offer a constant challenge to the clinician for diagnosis, treatment and prognosis. Treatment and prognosis of endodontic–periodontal diseases vary depending on the cause and the correct diagnosis of each specific condition. Management of such lesions needs a multidisciplinary approach. Use of three dimensional imaging technology like Cone Beam Computed Tomography (CBCT) has proven to be an essential tool for successful diagnosis of such lesion and higher magnification using the Dental Operating Microscope (DOM) should always be given preference during the clinical procedure. This case report describes the treatment performed on a maxillary first premolar having three independent roots and threedistinct root canals with furcation involvement. Special care needs to be taken during clinical examination, refining the access cavity, locating the orifices of the root canals on the pulpal floor and cleaning, shaping and obturating all identified root canals. The tooth was successfully managed by conventional endodontic treatment and regenerative periodontal surgical intervention.

Management of Non-Vital Tooth with Open Apex using MTA as an Apical Plug – a Report of 2 cases

Management of non-vital teeth with open apices is a challenge to dental practitioners. In this clinical scenario, it is difficult to maintain the obturation material within the confines of root canal without encroaching into periapical area. Thin dentinal walls of the root canal are also a matter of concern. These cases cannot be managed by conventional endodontic treatment and need customized treatment plan. Treatment of such teeth with calcium hydroxide may demand long time and patient compliance. But with MTA same treatment can be done in reasonably less time with predictable results. These two cases present the use of MTA to form a apical plug and then condense gua-percha against it.

Nonsurgical retreatment and reinforcement of an immature permanent tooth with periapical lesion of endodontic origin

Endodontic management of immature traumatized teeth usually involves carrying out conventional (apexogenesis and apexification) or regenerative endodontic treatment. While continued development of the radicular tooth structure should be the desired outcome of treating teeth with open apex, in cases of necrotic teeth or retreatment procedures, the formation of apical barrier via apexification is a more feasible approach. A 21-year-old boy reported with a traumatized maxillary central incisor with incomplete root development, previously treated 13 years ago; it was decided to retreat the tooth endodontically and carry out rehabilitation via reinforcement of the root using fiber post. The post was customized by relining it with direct, visible-light-cured composite resin and final cementation was carried out using dual cure composite resin. This paper aims to present and discuss different treatment modalities possible in a young traumatized tooth.

Ineffectiveness of Antibiotic-Based Pulpotomy for Primary Molars: a Survival Analysis

Objective: To investigate the two-year survival rate of primary molars treated with non-instrumentation endodontic treatment with mixed antibiotic paste containing chloramphenicol, tetracycline, zinc oxide and eugenol (CTZ pulpotomy), and compare it to the conventional root canal treatment with calcium hydroxide paste. Material and Methods: Thirty-six children, mean age 6.2 years old (standard deviation, SD=1.5), presenting at least one primary molar with irreversible pulpitis or necrotic pulp, were included in this prospective clinical study. Teeth were assigned to CTZ pulpotomy (Group I) or calcium hydroxide pulpectomy (Group II) and assessed clinically and radiographically for up to 26 months. Data were analyzed using descriptive statistics, Chi-square test, Kaplan-Meier survival analysis and Log-rank test. Results: Fifty-three primary molars were treated in Group I (n=37) or Group II (n=16). Children were followed up for 1 to 26 months (mean=12.0; SD=7.1). Treatment failure rates were 73.0% in Group I and 31.3% in Group II. Overall, mean survival time was 15.2 months (95% confidence interval, CI 12.6–17.9); Group I (mean 13.2; 95% CI 10.2-16.3) had a lower survival rate than Group II (mean 18.9; 95% CI 14.5-23.2) (p=0.02). Necrotic pulp treatments had significantly lower survival rates (p=0.01) than pulpitis treatments. Conclusion: Non-instrumentation endodontic treatment of primary molars with CTZ paste resulted in a low survival rate in a two-year follow-up; its radiographic ineffectiveness discourages its use instead of conventional root canal endodontic treatment.

Unusual Endodontic Treatment: A Surprise

Failures of endodontic treatment can be related to various causes. In this case, it was probably due to foreign body reactions that caused by the periapical extrusion of an improper endodontic material. An apicoectomy is performed to eliminate the infection at the tip of the tooth that conventional root canal treatment cannot reach. This procedure involves surgical removal of the tip of the tooth’s root, along with any infected tissue. This is a clinical case report of a tooth with failure of conventional endodontic treatment, leading to persistent periapical lesion and sinus tract. It was chosen to retreat the tooth and perform apicoectomy. The treatment was perceived successful due to healing of sinus tract due to periapical bone repair.

Curetaje apical y obturación retrógrada sin apicectomía. Presentación de un caso clínico

Apical curettage with apicoectomy is a component of many endodontic surgical procedures. It purports the aim of removing any contents present inside the surgical cavity, such as granulation tissue, cystic membrane remnants, or foreign bodies, as well as removing the involved dental apex. Nevertheless, in some cases, performing an apicoectomy can negatively influence the restoration’s stability; in these cases an alternative treatment could be performing apical curettage without apicoectomy. The present article documents a clinical case where apical curettage and retrograde obturation with mineral trioxide aggregate cement were performed on a tooth where previous conventional endodontic treatment had failed.

Manual and Rotary Instrumentation Ability to Reduce Enterococcus faecalis Associated with Photodynamic Therapy in Deciduous Molars

This aim of this study was to assess the ability of manual or rotary instrumentation associated with photodynamic therapy (PDT) to reduce Enterococcus faecalis using three combinations of light/photosensitizers: toluidine blue O/laser, fuchsin/halogen light and fuchsin/LED. Twenty deciduous molars were selected and contaminated with Enterococcus faecalis (McFarland 0.5 scale). Working length determination was performed by visual method. The teeth were randomly divided into two groups: G1 (n=10): manual instrumentation (Kerr-type files) and G2 (n=10): rotary instrumentation (ProTaper system). The bacteria were collected three times using sterile paper cones compatible with the anatomic diameter of the root canal for 30 s before and after instrumentation and after PDT. The samples were diluted in peptone water, seeded on blood agar plates and incubated in an oven at 37 °C for colony-forming units counting. The decrease of E. faecalis counts after instrumentation and after PDT was compared using the Wilcoxon test, t-test and Kruskal Wallis test. A significant reduction of E. faecalis occurred after manual and rotary instrumentation and after PDT using the three combinations of light/photosensitizer (p<0.05). It may be concluded that both rotary and manual instrumentation reduced E. faecalis. Fuchsin with halogen light or LED irradiation and toluidine blue O with laser irradiation can be used to reduce E. faecalis in root canals of primary molars. PDT can be used as an adjuvant to conventional endodontic treatment.

Apexification with mineral trioxide aggregate plug in the upper anterior teeth: Presentation of three clinical cases

Introduction: The aim is to describe the treatment of three immature permanent incisors associated to apical periodontitis, based on the placement of an apical mineral trioxide aggregate (MTA) plug for apexification. Case Series: Apexification was carried out by opening the pulp chamber, with debridement of the canal following anesthesia and isolation of the tooth. The canal was filled with pure calcium hydroxide in powder form, dissolved in saline solution for one week, and the aperture was sealed with IRM (Dentsply, Germany). One week later, the calcium hydroxide was removed and an MTA apical plug was positioned, sealing with a humid cotton pellet and IRM (Dentsply, Germany). After setting of the MTA, conventional endodontic treatment was carried out using gutta-percha, with definitive restoration of the tooth. Conclusion: All three cases, treated with MTA showed complete apical repair with rounding of the apex at radiographic control one year later, and the patients remained free of symptoms.

Use of MTA in teeth with incomplete root formation or open foramina: introduction of a protocol and report of clinical cases

Apexification is the endodontic procedure performed in order to induce the formation of a physical barrier of mineralized tissue in teeth with incomplete root formation. It is mainly performed when, for any reason, pulpal necrosis occurs in teeth with incomplete root formation and also in those cases where the foramen is open, due to root resorption. In these situations, conventional endodontic treatment becomes difficult or virtually impossible, because of the large foramen. The apexification procedure, in these cases, is generally performed by means of successive changes of calcium hydroxide dressings, aiming to induce the formation of a physical barrier of mineralized tissue, thus permitting the obturation of root canals. The protocol introduced in this article, as well as the clinical cases reported, illustrate an option for faster treatment, conducted within three sessions, by using a MTA cap or plug, material that offers good biological and physical properties.