ENDO, 03/2010

Surgical trephination was commonly used to reduce inflammation and infection in the periapical tissues as an emergency procedure, and the origins of this technique can be traced back to the mid 1800s. Its use has been both advocated and condemned by many of dentistry's pioneers, with similar, mixed feelings expressed by some of today's clinicians. More recent studies have questioned the value of this technique in the reduction of pain and swelling, along with the safety and efficacious nature of the procedure. However, although the technique may have fallen out of favour with many contemporary clinicians who chose to manage endodontic emergencies with antibiotics and powerful analgesics, its goals are still laudable and its clinical value in the hands of a skilled clinician can still be of great benefit to the patient. Keywords: incision and drainage, periapical pain, pulpal and periapical emergencies, surgical trephination

Replantation is widely accepted as an effective treatment option for an avulsed tooth. However, the long-term fate of replanted teeth is unpredictable; it is dependent on various factors such as the time interval between avulsion and replantation, the storage method of teeth during the extra-alveolar period (dry storage or storage media), the vitality status of pulp or periodontal tissues, and the type and period of splinting. The appropriate use of storage media is an important clinical factor affecting the postoperative prognosis of avulsed teeth following replantation. Hanks Balanced Salt Solution (HBSS) or chilled milk are considered to be the most appropriate and clinically recommended storage media for avulsed teeth. The present review discusses the various available storage media for avulsed teeth and their potential maintenance of the vitality of periodontal ligament cells. A brief overview of the effect of clinical factors such as the storage time and temperature, and the osmolarity of storage media on their efficacy is included. Keywords: chilled milk, hanks balanced salt solution, periodontal ligament, propolis, storage media, ViaSpan

Aim: To investigate and compare the prevalence of root canal fillings, apical periodontitis and endodontic treatment needs in a German subpopulation in 1994 and 2004, respectively. Methodology: Two hundred panoramic radiographs taken from 1994 and 2004, respectively, were evaluated using the Periapical Probability Index (PRI). The technical quality of the root canal fillings in terms of length and homogeneity was estimated. Minimum and maximum endodontic treatment needs were calculated. Statistical analysis was performed using the chi-square and Fisher exact test at P 0.05. Results: There was a total of 4660 teeth without root canal fillings for radiographs taken in 1994 and 4244 teeth for those in 2004. In teeth without root canal fillings in 1994, the frequency of PRI 4 was 1.0% and PRI 5 was 1.2%. In 2004, PRI 4 was 1.1% and PRI 5 was 2.4%. The difference was not significant (P > 0.05). A total of 168 teeth (3.4%) in 1994 and 217 (4.8%) in 2004 were root canal filled and the difference was significant (P 0.05). The frequency of PRI scores 4 and 5 for the root canal-filled teeth was 8.5% and 26.1% for 1994, and 6.9% and 31.8% in 2004, respectively. The difference was not significant (P > 0.05). The percentage of short root canal fillings was 52.7% in 1994, and 50.8% in 2004. In 1994, 48.6% of the root canal fillings were scored as inhomogeneous, and in 2004 the percentage was 40.6%. There were no significant differences concerning the radiographic quality of root canal fillings (P > 0.05). Endodontic treatment need was calculated as 3.7% of all teeth in 1994, and 4.6% in 2004. Retreatment need was calculated as 49.7% of root canal-filled teeth for 1994 and 54.5% of root canal-filled teeth for 2004. Conclusion: The prevalence of apical periodontitis in root canal-filled teeth and the need for retreatment increased over the observation period. There were no significant improvements in the technical quality of endodontic treatment from 1994 to 2004. Keywords: apical periodontitis, endodontic epidemiology, root canal treatment, treatment needs

A revised technique for the use of ProTaper Universal nickel titanium instruments is described. This modified technique was based on the crown-down principle, in which the ProTaper instruments were rearranged in such a way that each individual instrument was used only once in the sequence. The instrumentation process was carried out in three phases: i) tracking the 'glide-path', ii) coronal shaping and iii) apical finishing. After endodontic access and establishment of the canal patency and glide path, the shaping set of ProTaper instruments (S2, SX & S1, in that order) were used to shape the coronal portion of the root canal. The finishing set (F1, F2, F3, F4 or F5) was then used to accomplish the apical preparation. This revised sequence is a relatively simple method and can be adopted readily by less-experienced operators. The rationale of the instrumentation sequence was also revisited. Keywords: instrumentation, nickel-titanium instrument, ProTaper, technique

Aim: The objective of this study was to assess, by means of a scanning electron microscope (SEM), the cleanliness of canal dentine surfaces after post space preparation with the aid of two different magnification devices, either dental loupes or an operating microscope. Materials and methods: Twenty extracted single-rooted human teeth (18 canines and 2 premolars) were selected. Root canals were cleaned, shaped using nickel-titanium instruments and filled with gutta-percha. Samples were divided into two groups (n = 10), according to the device used by the operator: A (microscope) and B (loupes). Gutta-percha/sealer fillings were removed using a sequence of low-speed post drills; root canal walls were also cleaned by means of tips for ultrasound and microbrush. SEM images of post spaces were taken, and the presence of both debris and open dentine tubules was evaluated using a three-step scoring system. Mean scores were calculated at three depth levels of post space. Results: Residual debris was observed in all specimens. Statistically significant differences (P 0.05) between groups were found at both coronal and apical levels, and better scores for debris and open tubules were obtained by group A. Conclusions: The use of an operating microscope allowed the authors to achieve superior debridement scores at specific levels (coronal and apical levels) of the post space area, compared with the use of dental loupes. Keywords: debridement, dental microscope, dentinal surface, magnification, post space

The aim of periodontal therapy is resolution of inflammation in the supporting structures of the tooth. Endodontic therapy deals with the disease of the pulp and periapical tissues. Researchers and clinicians have long recognised that an intimate relationship exists between the pulp of a tooth and its surrounding periodontium. The present report describes the use of PRF (platelet-rich fibrin) gel in combination with an intrabony defect and a periapical lesion. The tooth was root canal treated followed by periodontal therapy. A combination of PRF gel, hydroxyapatite graft and guided tissue regeneration (GTR) membrane was used to achieve faster healing of the periapical lesion and intrabony defect. After 1 year, the absence of a periradicular lesion, pain and swelling along with tooth stability and adequate radiographic bone structure indicated a successful outcome. Keywords: guided tissue regeneration, intrabony defect, periodontal-endodontic lesion, periobone-G, platelet-rich fibrin

Aim: To report an uncommon case of an extraoral sinus tract of the submandibular region caused by a molar in the mandible (tooth 47). Case report: Tooth 47 presented with an insufficient coronal restoration and an absence of pain and discomfort to pressure and palpation in the periapical region. Based on oral inspection and radiographic examination, a pulp necrosis of tooth 47 was diagnosed, which had resulted in a cutaneous sinus tract. The persistent purulent drainage of the sinus tract in the submandibular region ceased during the successful root canal treatment of tooth 47. The root canal was irrigated with copious rrigant (3% sodium hypochlorite, 0.9% sodium chloride, 2% chlorhexidine) and several intracanal calcium hydroxide dressings. Conclusion: In the presented case it was observed that it is challenging to diagnose a cutaneous draining sinus tract of endodontic origin. Thus, treatment of skin lesions of the face, and neck odontogenic infections should always be considered. Clinical and radiographic dental examinations can identify the tooth involved and may avoid unnecessary antibiotic or surgical therapies. Proper disinfection of the root canal system by chemo-mechanical instrumentation resulted in resolution of the sinus tract and promoted periapical healing of the tooth involved. This should therefore be considered as the treatment of choice when dealing with an odontogenic extraoral sinus tract. Keywords: apical periodontitis, cutaneous sinus tract, root canal treatment

This article presents two cases of detection and management of four-rooted mandibular first molars. The occurrence of four-rooted mandibular first molars is very rare and the reported incidence is less than 1%. The cases were managed using radiographs taken from different planes (otherwise, the distolingual root of the teeth would have been missed). The contralateral side also showed the same morphological variation. Keywords: anatomical variation, distolingual root, mandibular first molar, radiographic interpretation