The antimicrobial effect of new and conventional endodontic irrigants on intra-orally infected dentin

Objectives. To evaluate if the incorporation of antimicrobial compounds to chelating agents or the use of chelating agents with antimicrobial activity as 7% maleic acid and peracetic acid show similar disinfection ability in comparison to conventional irrigants as sodium hypochlorite or iodine potassium iodide against biofilms developed on dentin. Materials and methods. The total bio-volume of live cells, the ratio of live cells and the substratum coverage of dentin infected intra-orally and treated with the irrigant solutions: MTAD, Qmix, Smear Clear, 7% maleic acid, 2% iodine potassium iodide, 4% peracetic acid, 2.5% and 5.25% sodium hypochlorite was measured by using confocal microscopy and the live/dead technique. Five samples were used for each irrigant solution. Results. Several endodontic irrigants containing antimicrobials as clorhexidine (Qmix), cetrimide (Smear Clear), maleic acid, iodine compounds or antibiotics (MTAD) lacked an effective antibiofilm activity when the dentin was infected intra-orally. The irrigant solutions 4% peracetic acid and 2.5–5.25% sodium hypochlorite decrease significantly the number of live bacteria in biofilms, providing also cleaner dentin surfaces (p < 0.05). Conclusions. Several chelating agents containing antimicrobials could not remove nor kill significantly biofilms developed on intra-orally infected dentin, with the exception of sodium hypochlorite and 4% peracetic acid. Dissolution ability is mandatory for an appropriate eradication of biofilms attached to dentin.

Avaliação clínica e radiográfica do extravasamento da pasta de hidróxido de cálcio em dentes com lesões periapicais

It has been evaluated clinically and radiographically the effect of the extrusion of calcium hydroxide paste in teeth with periapical lesions. Twenty-five patients with teeth showing pulp necrosis and periapical lesions were submitted to endodontic treatment. Dressing calcium hydroxide paste, iodoform and propylene glycol were used. Clinically, the symptoms were evaluated after treatment and, radiographically, the reabsorption of extravasated paste and repair process of the periapical lesion. Only three patients had symptoms severe in the first 24 hours, the paste was completely reabsorbed within 15 days and no interference in the repair process.

Accuracy of five electronic foramen locators with different operating systems: na ex vivo study

Objective: The aim of this study was to evaluate, ex vivo, the precision of five electronic root canal length measurement devices (ERCLMDs) with different operating systems: the Root ZX, Mini Apex Locator, Propex II, iPex, and RomiApex A-15, and the possible influence of the positioning of the instrument tips short of the apical foramen. Material and Methods: Forty-two mandibular bicuspids had their real canal lengths (RL) previously determined. Electronic measurements were performed 1.0 mm short of the apical foramen (-1.0), followed by measurements at the apical foramen (0.0). The data resulting from the comparison of the ERCLMD measurements and the RL were evaluated by the Wilcoxon and Friedman tests at a significance level of 5%. Results: Considering the measurements performed at 0.0 and -1.0, the precision rates for the ERCLMDs were: 73.5% and 47.1% (Root ZX), 73.5% and 55.9% (Mini Apex Locator), 67.6% and 41.1% (Propex II), 61.7% and 44.1% (iPex), and 79.4% and 44.1% (RomiApex A-15), respectively, considering ±0.5 mm of tolerance. Regarding the mean discrepancies, no differences were observed at 0.0; however, in the measurements at -1.0, the iPex, a multi-frequency ERCLMD, had significantly more discrepant readings short of the apical foramen than the other devices, except for the Propex II, which had intermediate results. When the ERCLMDs measurements at -1.0 were compared with those at 0.0, the Propex II, iPex and RomiApex A-15 presented significantly higher discrepancies in their readings. Conclusions: Under the conditions of the present study, all the ERCLMDs provided acceptable measurements at the 0.0 position. However, at the -1.0 position, the ERCLMDs had a lower precision, with statistically significant differences for the Propex II, iPex, and RomiApex A-15.

Comparison of different ultrasonic vibration modes for post removal

This in vitro study compared different ultrasonic vibration modes for intraradicular cast post removal. The crowns of 24 maxillary canines were removed, the roots were embedded in acrylic resin blocks, and the canals were treated endodontically. The post holes were prepared and root canal impressions were taken with self-cured resin acrylic. After casting, the posts were cemented with zinc phosphate cement. The samples were randomly distributed into 3 groups (n=8): G1: no ultrasonic vibration (control); G2: tip of the ultrasonic device positioned perpendicularly to core surface and close to the incisal edge; and G3: tip of the ultrasonic device positioned perpendicularly to core surface at cervical region, close to the line of cementation. An Enac OE-5 ultrasound unit with an ST-09 tip was used. All samples were submitted to the tensile test using an universal testing machine at a crosshead speed of 1 mm/min. Data were subjected to one-way ANOVA and Tukey's post-hoc tests (α=0.05). Mean values of the load to dislodge the posts (MPa) were: G1 = 4.6 (± 1.4) A; G2 = 2.8 (± 0.9) B, and G3= 0.9 (± 0.3) C. Therefore, the ultrasonic vibration applied with the tip of device close to the core's cervical area showed higher ability to reduce the retention of cast post to root canal.

An in vivo radiographic evaluation of the accuracy of Apex and iPex electronic Apex locators

The aim of this study was to evaluate in vivo the clinical applicability of two electronic apex locators (EALs) - Apex (Septodont) and iPex (NSK) - in different groups of human teeth by using radiography. The working lengths (WLs) of 100 root canals were determined electronically. The EAL to be used first was chosen randomly and a K-file was inserted into the root canal until the EAL display indicated the location of the apical constriction (0 mm). The K-file was fixed to the tooth and a periapical radiograph was taken using a radiographic film holder. The K-file was removed and the WL was measured. The same procedure was repeated using the other EAL. Radiographs were examined with the aid of a light-box with lens of ×4 magnification by two blinded experienced endodontists. The distance between the file tip and the root apex was recorded as follows: (A) +1 to 0 mm, (B) -0.1 to 0.5 mm, (C) -0.6 to 1 mm, (D) -1.1 to 1.5 mm, and (E) -1.6 mm or greater. For statistical purposes, these scores were divided into 2 subgroups according to the radiographic apex: acceptable (B, C, and D) and non-acceptable (A and E). Statistically significant differences were not found between the results of Apex and iPex in terms of acceptable and non-acceptable measurements (p>0.05) or in terms of the distance recorded from file tip and the radiographic apex (p>0.05). Apex and iPex EALs provided reliable measurements for WL determination for endodontic therapy.

Time-dependent effects of chitosan on dentin structures

Complete debridement with smear layer removal are essential measures for achieving a successful outcome of root canal treatment. The aim of this study was to evaluate the effects of chitosan at different concentrations on the removal of the smear layer and on dentin structure after 3 and 5 min of application. Twelve recently extracted maxillary canine teeth were instrumented using the crown-down technique and irrigated with 1% sodium hypochlorite. The specimens were distributed according to the time and concentration of the final irrigating solution: G1: 0.1% chitosan for 3 min; G2: 0.2% chitosan for 3 min; G3: 0.37% chitosan for 3 min; G4: 0.1% chitosan for 5 min; G5: 0.2% chitosan for 5 min; G6: 0.37% chitosan for 5 min. All samples were prepared for SEM analysis. G1 exhibited removal of the smear layer, but not the smear plugs. G2 showed visible and open tubules with slight erosion of the peritubular dentin. Cleaning in G3 was similar to that in G2, however, the erosive effect was greater. There was expansion of the diameter of the tubules in G4; and in G5 and G6, there was severe erosion with deterioration of dentin surface. In conclusion, 0.2% chitosan for 3 min appeared to be efficient for removing the smear layer, causing little erosion of dentin.

Healing of a tooth with an overinstrumented apex, extensive transportation and periapical lesion using a 5 mm calcium hydroxide apical plug: an 8-year follow-up report

Besides the risk of filling material extrusion throughout the apex, a satisfactory apical seal can be difficult to achieve in canals with open apices or iatrogenic enlargements of the apical constriction. These situations pose a challenge to root canal filling. This paper describes the root canal filling of a maxillary right canine with an overinstrumented apex, complete loss of the apical stop, extensive canal transportation and apical periodontitis. A 5 mm calcium hydroxide apical plug was placed before root canal filling. The plug was made by soaking paper points with saline, dipping the points in calcium hydroxide powder and then applying it to the apex several times, until a consistent apical plug was obtained. The canal was then irrigated with saline in order to remove any residual calcium hydroxide from the root canal walls, dried with paper points and obturated with an inverted #80 gutta-percha cone and zinc oxide-eugenol based sealer by the lateral condensation technique. An 8-year radiographic follow-up showed formation of mineralized tissue sealing the apical foramen, apical remodeling and no signs of apical periodontitis.

Influence of cervical preflaring on determination of apical file size in the palatal roots of maxillary molars

PURPOSE: The aim of this study was to investigate the influence of cervical preflaring in determining the initial apical file (IAF) in the palatal roots of maxillary molars, and to determine the morphologic shape of the canal 1 mm short of the apex. METHODS: After preparing standard access cavities the group 1 received the IAF without cervical preflaring (WCP). In groups 2 to 5, preflaring was performed with Gates-Glidden (GG), Anatomic Endodontics Technology (AET), GT Rotary Files (GT) and LA Axxes (LA), respectively. Each canal was sized using manual K-files, starting with size 08 files, and making passive movements until the WL was reached. File sizes were increased until a binding sensation was felt at the WL. The IAF area and the area of the root canal were measured to verify the percentage occupied by the IAF inside the canal in each sample by SEM. The morphologic shape of the root canal was classified as circular, oval or flattened. Statistical analysis was performed by ANOVA/Tukey test (P < 0.05). RESULTS: The decreasing percentages occupied by the IAF inside the canal were: LA>GT=AET>GG>WCP. The morphologic shape was predominantly oval. CONCLUSION: The type of cervical preflaring used interferes in the determination of IAF.

Apical surgery of a maxillary molar creating a maxillary sinus window using ultrasonics: a clinical case

AIM: To describe a method of carrying out apical surgery of a maxillary molar using ultrasonics to create a lateral sinus window into the maxillary sinus and an endoscope to enhance visibility during surgery. SUMMARY: A 37-year-old female patient presented with tenderness to percussion of the maxillary second right molar. Root canal treatment had been undertaken, and the tooth restored with a metal-ceramic crown. Radiological examination revealed an apical radiolucency in close proximity to the maxillary sinus. Apical surgery of the molar was performed through the maxillary sinus, using ultrasonics for the osteotomy, creating a window in the lateral wall of the maxillary sinus. During surgery, the lining of the sinus was exposed and elevated without perforation. The root-end was resected using a round tungsten carbide drill, and the root-end cavity was prepared with ultrasonic retrotips. Root-end filling was accomplished with MTA(®) . An endoscope was used to examine the cut root face, the prepared cavity and the root-end filling. No intraoperative or postoperative complications were observed. At the 12-month follow-up, the tooth had no clinical signs or symptoms, and the radiograph demonstrated progressing resolution of the radiolucency. KEY LEARNING POINTS: When conventional root canal retreatment cannot be performed or has failed, apical surgery may be considered, even in maxillary molars with roots in close proximity to the maxillary sinus. Ultrasonic sinus window preparation allows more control and can minimize perforation of the sinus membrane when compared with conventional rotary drilling techniques. The endoscope enhances visibility during endodontic surgery, thus improving the quality of the case.

Endodontic working length measurement with preexisting cone-beam computed tomography scanning: a prospective, controlled clinical study

The determination of root canal length is a significant outcome predictor for endodontic treatments. The aim of this prospective, controlled clinical study was to analyze endodontic working length measurements in preexisting cone-beam computed tomography (CBCT) scans and to compare them with clinical root canal length determination by using an electronic apex locator (EAL).

Cone beam computed tomography in mandibular molars referred for apical surgery

The purpose of the present study was to compare conventional intraoral periapical radiographs (PA) with limited cone beam computed tomography (CBCT) for evaluation of mandibular molars prior to apical surgery. The apical extent and homogeneity of the root canal fillings (RCF) as well as the number of root canals were examined.

Immunodetection of bone-related proteins in microcalcifications of human dental pulp

Objective: Root canal obliterations may pose esthetic and clinical problems or may even be a risk factor for tooth survival. Microcalcifications in the pulp can be so extensive that the entire root canal system becomes obliterated. Since bone sialoprotein (BSP) and osteopontin (OPN) are involved in both physiological and pathological mineralization processes, our hypothesis was that these two bone-related noncollagenous proteins are present in microcalcifications of the pulp. The purpose of this study was, therefore, to characterize the nature of microcalcifications in the pulp of aged human teeth. Methods: From a large collection of human teeth, 10 were found to exhibit pulpal microcalcifications. The teeth were extracted for periodontal reasons from 39-60 year old patients. After fixation in aldehydes and decalcification, teeth were processed for embedding in LR White resin for analysis in the light and transmission electron microscope. For the detection of BSP and OPN, post-embedding high resolution immunocytochemistry was applied. Results: The microcalcifications were round or elongated, occasionally coalescing, and intensely stained with toluidine blue. Collagen fibrils were found in most but not all microcalcifications. All microcalcifications were immunoreactive for both antibodies and showed an identical labeling pattern. Gold particle labeling was extensively found throughout the interfibrillar ground substance of the microcalcifications, whereas the dentin matrix lacked immunolabeling. Conclusion: BSP and OPN appear to be major matrix constituents of pulp microcalcifications and may thus, like in other mineralized tissues, be involved in their mineralization process.

Correlation of bone defect dimensions with healing outcome one year after apical surgery

This clinical study prospectively evaluated the healing outcome 1 year after apical surgery in relation to bony crypt dimensions measured intraoperatively. The study cohort included 183 teeth in an equal number of patients. For statistical analysis, results were dichotomized (healed versus non-healed cases). The overall success rate was 83% (healed cases). Healing outcome was not significantly related to the level and height of the facial bone plate. In contrast, a significant difference was found for the mean size of the bony crypt when healed cases (395 mm(3)) were compared with non-healed cases (554 mm(3)). In addition, healed cases had a significantly shorter mean distance (4.30 mm) from the facial bone surface to the root canal (horizontal access) compared with non-healed cases (5.13 mm). With logistic regression, however, the only parameter found to be significantly related to healing outcome was the length of the access window to the bony crypt.

Intentional replantation for the management of maxillary sinusitis

AIM: To present a case that emphasizes the importance of the use of intentional replantation as a technique to successfully treat a periapical lesion and an odontogenic maxillary sinusitis through the alveolus at the same time. SUMMARY: This case report presents a patient with odontogenic maxillary sinusitis secondary to periapical disease of a maxillary molar that had previously received root canal treatment. The molar was extracted, with drainage and rinsing of the maxillary sinus. The apices were resected extra-orally, the retrograde cavities prepared with ultrasound and retrograde fillings of silver amalgam placed. The tooth was then replanted. After 2 years, the patient was asymptomatic, periapical radiography showed no evidence of root resorption and computed tomography scanning demonstrated the resolution of maxillary sinusitis. Key learning points: *When root canal treatment or periapical surgery cannot be undertaken or has failed, intentional replantation may be considered. *This alternative treatment may be predictable in certain cases.

Loss of pulp sensitivity and pain as the first symptoms of a Ewing's sarcoma in the right maxillary sinus and alveolar process: report of a case

This case report describes the diagnosis and treatment of a Ewing's sarcoma in the right maxillary sinus and alveolar bone of a 19-year-old female patient. The first clinical symptoms were a loss of sensitivity of the premolars and first molar in the right maxilla and acute pain located in the area of these teeth. Initially, the referring dentist had treated these findings as an acute apical periodontitis with root canal medication. Because swellings on the palatal and buccal aspects of the teeth occurred and could not be treated with incision and drainage, the dentist referred the patient. Cone-beam computed tomography revealed a proliferation of soft tissue in the right maxillary sinus, with a radiopaque material at the tip of the mesiobuccal root of the first molar and resorptive signs of the mesiobuccal and distobuccal roots of the first molar. The palatal cortical bone of the right alveolar process seemed to be intact. After explorative surgery with biopsies from the buccal, palatal, and sinus proliferation areas, the pathologist diagnosed the lesion as a Ewing's sarcoma. Treatment of the patient consisted of initial chemotherapy, hemimaxillectomy, and postsurgical chemoradiotherapy.