The antimicrobial effect of various endodontic sealers.

The antimicrobial activity of an endodontic sealer can be helpful in destroying any remaining root canal microbes. Therefore it was decided to test the antimicrobial activity of several commonly used endodontic sealers. The sealers used were Grossman's sealer, Tubliseal, Calciobiotic, Sealapex, Hypocal, eucapercha, Nogenol, and AH26. Also tested were dry calcium hydroxide powder, calcium hydroxide mixed with saline, and a Teflon formulation. The microbes used were Streptococcus mutans (a gram-positive microaerophile). Staphylococcus aureus (a gram-positive facultative anaerobe), and Bacteroides endodontalis (a gram-negative obligate anaerobe). The freshly mixed sealers were placed into the prepared wells of agar plates inoculated with the test microorganisms. After varying periods of incubation, the zones of inhibition of bacterial growth were observed and measured. Grossman's sealer had the greatest overall antibacterial activity. However, AH26 had the greatest activity against B. endodontalis. The zinc oxide-eugenol-based sealers had more antimicrobial activity than either the calcium hydroxide-based sealers or eucapercha.

A dentist's dilemma: nonsurgical endodontic therapy or periapical surgery for teeth with apparent pulpal pathosis and an associated periapical radiolucent lesion.

First presented is a brief review of nonsurgical versus surgical treatment of radicular cysts. This is followed by a consideration of the use of radiographs for differential diagnosis of periapical radiolucent lesions. Some of the nonendodontic local and systemic lesions that can occur periapically are then presented. Next examined are the fallibilities of pulp vitality testing methods. The need for histopathologic examination of periapical lesions is the subject of the next discussion. The dentist's dilemma is then examined: should teeth with apparent pulpal pathosis and an associated periapical radiolucent lesion have routine surgical treatment including biopsy or should they be treated nonsurgically and have periodic follow-ups? A possible resolution of this dilemma is the final consideration.

A clarification on endodontic flare-ups.

In an article on endodontic flare-ups by Robert J. Matusow, our research and publications are discussed. Since we found what we consider to be distortions and misinterpretations of our work, it was decided to clarify the apparent discrepancies found in Matusow's article.

A comparison of erythromycin and cefadroxil in the prevention of flare-ups from asymptomatic teeth with pulpal necrosis and associated periapical pathosis.

In a previous study by our group with patients having asymptomatic teeth with pulpal necrosis and an associated periapical radiolucent lesion (PN/PL), it was shown that prophylactic administration of penicillin V or erythromycin (high-dose, 1-day regimen) resulted in a low incidence of flare-up (mean = 2.2%) and a low incidence of swelling and pain not associated with flare-up. No hypersensitivity responses occurred, and gastrointestinal side effects were found primarily with the erythromycins. To ascertain whether a single-dose administration of a long-acting 1-gm tablet of the cephalosporin antibiotic cefadroxil would result in a similar outcome, the present study was undertaken with 200 patients having quiescent PN/PL. The patients were randomly given either cefadroxil or erythromycin (base or stearate). Evaluations of flare-up were done 1 day, 1 week, and 2 months after endodontic treatment. A 2.0% flare-up incidence was found, with no statistically significant differences for cefadroxil (1.0%), stearate (2.0%), or base (4.0%). No hypersensitivity responses occurred. Gastrointestinal side effects were found primarily with the erythromycins (19.0%). The results showed that a 1-gm, single-dose regimen of cefadroxil was as effective as erythromycin and penicillin in preventing flare-ups and serious sequelae. A comparative analysis of the data from our first study (no peritreatment antibiotics) and the pooled data from our last three investigations (including the current trial) showed that peritreatment antibiotic coverage significantly reduced flare-ups and serious sequelae after endodontic treatment of asymptomatic PN/PL (p less than 0.001).

A prospective randomized double-blind trial on efficacy of dexamethasone for endodontic interappointment pain in teeth with asymptomatic inflamed pulps.

To determine whether a relatively large dose of oral dexamethasone given for a short period of time would be effective in reducing endodontic interappointment pain, the current double-blind, placebo-controlled study was undertaken. After the visit for instrumentation, 40 patients with asymptomatic teeth having vital-inflamed pulps were randomly given either dexamethasone (3 tablets of 4 mg each) or a dextrose placebo identical in appearance (same dosage schedule). The outcome showed that the oral administration of dexamethasone resulted in a statistically significant reduction in endodontic interappointment pain at all three time periods evaluated, that is, at 8 hours, 24 hours, and 48 hours (p less than 0.01). It appears from the results of this study that this dosage schedule of oral dexamethasone is sufficient to significantly reduce endodontic interappointment pain for teeth with asymptomatic vital-inflamed pulps. Further studies are needed for teeth with other endodontic pulpal-periapical conditions and for symptomatic teeth.

A prospective randomized trial on efficacy of antibiotic prophylaxis in asymptomatic teeth with pulpal necrosis and associated periapical pathosis.

A recent study from a private endodontic practice compared "prophylactic" antibiotic (high-dose, 1-day) regimens of penicillin V and erythromycin (base or stearate) for patients who had asymptomatic teeth with pulpal necrosis and associated periapical radiolucent lesions (PN/PL). A 2.2% flare-up incidence was found, with no statistically significant differences for penicillin (0.0%), base (2.9%), and stearate (3.8%). No hypersensitivity responses occurred, and gastrointestinal side effects were found primarily with the erythromycins (12.4%). To ascertain whether or not similar results would occur with student operators in a dental school clinic population, the current study was undertaken. One-hundred ninety-five patients with quiescent PN/PL were randomly given either penicillin V or erythromycin (base or stearate). A 2.6% flare-up incidence was found, with no statistically significant differences for penicillin (3.1%), base (1.5%), and stearate (3.1%). No hypersensitivity responses occurred, and GI side effects were found primarily with the erythromycins (17.7%). As can be seen, the results were very similar to those of the recent endodontic practice study. Hence, it can be concluded that the results of the previous endodontic practice study were not unique to any one clinician or method. A comparison was also made between the "prophylactic" penicillin group of the current study and the placebo control group of our previous dental school clinic, student operator study (in which the methods, population, and regimen were almost identical to those of the current study). The results showed that the "prophylactic" penicillin group had significant fewer flare-ups and non-flare-up-associated swelling and pain than did the placebo group. In view of these findings and those from studies from the literature in which "prophylactic" antibiotics were not used, it is our opinion that the antibiotic regimens used in the current study should be a component of clinical endodontic therapy for quiescent PN/PL.

A comparative tissue toxicity evaluation of established and newer root canal sealers.

Grossman's sealer, eucapercha, Endo-Fill, CRCS, Sealapex, Hypocal, and sterile saline solution (0.3 ml of each) were injected into specific dorsal subdermal tissue sites of 12 guinea pigs. The animals were killed after 6 days, 15 days, and 80 days (four per time period). Analysis of tissue response showed that, overall, Sealapex and Endo-Fill had less severe inflammatory reactions than any of the other test materials. Grossman's sealer, CRCS, and Hypocal showed principally severe inflammatory responses at both 6 and 15 days, but mild reactions at 80 days. Overall, eucapercha showed less severe inflammatory responses than Grossman's sealer, CRCS, and Hypocal. Diffuse calcification was induced by the three calcium hydroxide preparations (CRCS, Sealapex, and Hypocal). Eucapercha and Endo-Fill had minute local areas of calcification. Both Grossman's sealer and CRCS did not have overall favorable histologic reactions; however, Grossman's sealer and CRCS have been used successfully clinically. Further clinical studies are needed.

Prophylactic penicillin versus penicillin taken at the first sign of swelling in cases of asymptomatic pulpal-periapical lesions: a comparative analysis.

In order to ascertain whether the time of administration of an antibiotic affects the occurrence of flare-ups and non-flare-up-associated swelling and pain, an analysis of components of two prospective endodontic studies on patients having asymptomatic teeth with pulpal necrosis and associated periapical radiolucent lesions (PN/PL) was done. In the first study, prophylactic penicillin was used. In the second study, penicillin (or erythromycin for patients allergic to penicillin) was taken by the patient at the first sign of swelling (patient controlled). For the patient-controlled group, as compared to the prophylactic penicillin group, there was statistically significantly more (1) incidence of flare-ups (p less than 0.05); (2) non-flare-up-associated swelling (p less than 0.001); (3) non-flare-up-associated pain (p less than 0.05); (4) combined moderate and severe pain (p less than 0.05); (5) combined incidence of flare-ups and swelling (p less than 0.001); (6) combined incidence of flare-ups and pain (p less than 0.01); and (7) combined incidence of flare-ups and both swelling and pain (p less than 0.001). There were statistically significantly fewer instances of (1) no patient post-treatment problems (p less than 0.001) and (2) combined mild pain and no patient post-treatment problems (p less than 0.001). Hence, for asymptomatic teeth with PN/PL, it appears that prophylactic antibiotics are preferable to antibiotics taken by the patient at the first sign of swelling.

A prospective randomized trial comparing periapical instrumentation to intracanal instrumentation in cases of asymptomatic pulpal-periapical lesions.

To clarify the divergent viewpoints with respect to method of instrumentation in asymptomatic teeth with pulpal necrosis and associated periapical radiolucent lesions (PN/PL), this prospective study was undertaken. The subjects were 106 patients with quiescent cases of PN/PL. Alternately, 53 had periapical instrumentation and 53 had intracanal instrumentation. Prophylactic antibiotics were not administered but the patients were told to take an antibiotic at the first sign of swelling. Flare-ups, non-flare-up-associated swelling and pain, and cases in which there were no postoperative problems were evaluated at 1-day, at 1 week, and at 2 months. A 6.6% incidence of flare-up was found with no statistically significant difference between periapical instrumentation (7.5%) and intracanal instrumentation (5.7%). A 27.4% incidence of swelling was found with no statistically significant difference between periapical instrumentation (24.5%) and intracanal instrumentation (30.2%). A 43.4% incidence of pain was found, with no statistically significant difference between periapical instrumentation (15.1%) and intracanal instrumentation (47.2%). When moderate pain and severe pain were combined, the incidence was 21.7%, with no statistically significant difference between periapical instrumentation (15.1%) and intracanal instrumentation (28.3%). An incidence of patients having no postoperative problems of 41.5% was found, with no statistically significant difference between periapical instrumentation (47.2%) and intracanal instrumentation (35.8%). When flare-ups were combined with swelling, the incidence was 34.0%, with no statistically significant difference between periapical instrumentation (32.1%) and intracanal instrumentation (35.8%). When flare-ups were combined with pain, the incidence was 50.0%, with no statistically significant difference between periapical instrumentation (47.2%) and intracanal instrumentation (52.8%).(ABSTRACT TRUNCATED AT 250 WORDS)