Effect of Continuous Chelation Irrigation Using DualRinse HEDP+3% NaOCl with or without High-power Sonic Activation on Debris and Smear Layer Removal.

OBJECTIVE: This study aimed to assess the effect of sodium hypochlorite (NaOCl) combined with a novel chelating agent DualRinse HEDP (Medcem GmbH, Weinfelden, Switzerland), a product consisting of 0.9 g of 1-hydroxyethylidene-1,1-diphosphonic acid (HEDP) powder, with or without high-power sonic activation on debris and smear layer removal. METHODS: Seventy-five mandibular premolars were divided into 5 groups (n=15) and treated with different irrigation protocols: group 1 (D3N), DualRinse HEDP+3% NaOCl without activation; group 2 (D3NA), DualRinse HEDP+3% NaOCl with activation (EDDY, VDW, Munich, Germany) during the final irrigation; group 3 (3NE), 3% NaOCl+17% Ethylenediaminetetracetic acid (EDTA)+3% NaOCl without activation; group 4 (3NEA), 3% NaOCl+17% EDTA+3% NaOCl with activation during the final irrigation; group 5 (NC), negative control group, 0.9% saline. Samples were analysed by scanning electron microscopy (SEM) to evaluate residual debris and smear layer at 3 levels of the root canal: coronal, middle, and apical. Statistical analysis was performed with a level of significance set at p<0.05. The normality distribution of scores within each group was assessed using Kolmogorov-Smirnov and Shapiro-Wilk tests. A Kruskal-Wallis test followed by multiple comparison tests was used to compare scores among the 5 groups on the apical, middle, and coronal levels of the root canal. A Friedman test followed by multiple comparison tests was used to compare scores within the apical, middle, and coronal levels for each treatment group. RESULTS: Debris score was significantly the lowest for D3NA, followed by D3N, 3NEA and 3NE at all root levels (p<0.05). The smear layer score was significantly the lowest for D3NA, followed by D3N, 3NEA and 3NE only at the apical level, while no significant difference was found in the middle and coronal levels between the groups (p<0.05). DualRinse HEDP resulted in less debris and smear layer compared to the classic approach of NaOCl without activation. Implementing sonic activation further improved debris and smear layer removal. CONCLUSION: DualRinse HEDP+3% NaOCl improved debris removal at all levels and smear layer elimination at the apical level of the root canal. These results were further enhanced when adding high-power sonic activation. (EEJ-2022-09-116).

Wound Lavage in Studies on Vital Pulp Therapy of Permanent Teeth with Carious Exposures: A Qualitative Systematic Review.

The aim of this study was to systematically review pulp wound lavage in vital pulp therapy (VPT). A search was conducted in six life science databases to identify clinical trials carried out on permanent teeth with a carious pulp exposure and a recall interval of at least six months. Twenty-seven trials of low to moderate risk of bias (RoB-2 and ROBINS-I) were included. Data was extracted and analyzed regarding study characteristics and methods used for pulp wound lavage. The agent used for pulp wound lavage was specified in all included trials. Most of the identified trials (23/27) randomized the pulp capping material. Many (14/27) reported the use of sodium hypochlorite (NaOCl); ten used only saline or water. One trial was identified that compared pulp wound lavage with 2.5% (NaOCl) to saline, another compared 5% glutaraldehyde to water, both in immature molar pulpotomies. Both studies were underpowered. Neither showed a significant difference between treatments. The use of NaOCl was positively correlated to recent year of publication and use of hydraulic calcium silicate cements for pulp capping (p < 0.05). In conclusion, despite a lack of well-designed trials on pulp wound lavage in VPT, a trend towards using NaOCl for this purpose was observed.

Guided apicoectomy using a CAD/CAM drilling template.

AIM: Modern microsurgical techniques have increased the success rate of apicoectomy relative to that of traditional approaches. This case report introduces a novel workaround for guided apicoectomy using a patient-specific computer-aided design/computer-aided manufacturing (CAD/CAM) three-dimensional (3D)-printed template. MATERIALS AND METHODS: Apicoectomy was performed on the mesial root of tooth 36 using template-guided trephine drilling, followed by retrograde filling with mineral trioxide aggregate (MTA). Initially, a cone beam computed tomography (CBCT) scan and an intraoral surface scan were imported into the planning software. After superimposition, virtual planning was performed to determine the exact localization for root resection. Subsequently, a tooth-supported drilling template was designed and 3D printed. Endodontic microsurgical approaches, including root-end cavity preparation and root-end filling, completed the surgical treatment. RESULT: The apical resection was easily feasible. There were no postoperative complications. Radiological assessment after a 6-month period showed signs of reossification. CONCLUSION: Guided apicoectomy allowed precise root resection, suggesting that this technique may be advantageous in complex anatomical situations.

Biological Markers for Pulpal Inflammation: A Systematic Review.

BACKGROUND AND OBJECTIVE: Pulpitis is mainly caused by an opportunistic infection of the pulp space with commensal oral microorganisms. Depending on the state of inflammation, different treatment regimes are currently advocated. Predictable vital pulp therapy depends on accurate determination of the pulpal status that will allow repair to occur. The role of several players of the host response in pulpitis is well documented: cytokines, proteases, inflammatory mediators, growth factors, antimicrobial peptides and others contribute to pulpal defense mechanisms; these factors may serve as biomarkers that indicate the status of the pulp. Therefore, the aim of this systematic review was to evaluate the presence of biomarkers in pulpitis. METHODS: The electronic databases of MEDLINE, EMBASE, Scopus and other sources were searched for English and non-English articles published through February 2015. Two independent reviewers extracted information regarding study design, tissue or analyte used, outcome measures, results and conclusions for each article. The quality of the included studies was assessed using a modification of the Newcastle-Ottawa-Scale. RESULTS AND CONCLUSIONS: From the initial 847 publications evaluated, a total of 57 articles were included in this review. In general, irreversible pulpitis was associated with different expression of various biomarkers compared to normal controls. These biomarkers were significantly expressed not only in pulp tissue, but also in gingival crevicular fluid that can be collected non-invasively, and in dentin fluid that can be analyzed without extirpating the entire pulpal tissue. Such data may then be used to accurately differentiate diseased from healthy pulp tissue. The interplay of pulpal biomarkers and their potential use for a more accurate and biologically based diagnostic tool in endodontics is envisaged.

Pain levels and typical symptoms of acute endodontic infections: a prospective, observational study.

BACKGROUND: This study aimed to identify key symptoms that could be associated with the diagnosis of acute forms of symptomatic apical periodontitis (SAP) and symptomatic irreversible pulpitis (SIP), and to identify a diagnostic algorithm based on these symptoms. METHODS: In this prospective, observational study 173 emergency patients diagnosed with acute pain of endodontic origin and no swelling or fistula were included. Patients were asked 11 specific questions from a checklist with a possible discerning value between acute SAP and acute SIP. Pain levels were recorded using the numeric rating scale (NRS-11). Subsequently, the painful tooth was diagnosed. Logistic regression was used to evaluate the checklist regarding its differentiation between SAP (N = 103) and SIP (N = 70). Moreover, a decision tree was constructed based on recursive partitioning to identify a hierarchy in differentiating symptoms. RESULTS: With identical median NRS-11 scores of 8, the teeth diagnosed with acute SAP and SIP were severely painful. The decision tree analysis resulted in a tree with splits according to pain on cold, perceived tooth extrusion, and pain duration. The overall sensitivity of the tree to detect SAP based on key symptoms was 95 %, its specificity was 31 %. CONCLUSIONS: The best indicator for SAP was a reported absence of pain to cold stimuli. In teeth that did have a history of pain triggered by cold stimuli, the decision tree correctly identified SAP in 72 % of the teeth that felt too high and had hurt for less than one week.

Intracanal Antibiotic Medication for Sustained Root Surface Disinfection-A Laboratory Evaluation.

PURPOSE: To measure the release of an antibiotic mixture of ciprofloxacin, cerfuroxim and metronidazole (TreVitaMix, TVM) through human dentine and to assess the growth inhibition of Fusobacterium nucleatum. MATERIAL AND METHODS: Twenty-four extracted human incisors were scaled and endodontically treated. Root canals were either filled with antibiotic tri-mixture (TVM) or with the carrier material alone (propylene glycol, PG) and were coronally and apically sealed with a flowable composite. Transradicular medicament release was spectrophotometrically measured at 277 nm in simulated body fluid for up to 21 days. In a second part, an agar diffusion assay (F. nucleatum) with representative TVM concentrations as determined in the first part was performed to study the growth inhibition. Samples were anaerobical incubated for 48 h and inhibition zones were measured. RESULTS: TVM was spectrophotometrically detectable in the immersion solution and released in decreasing concentrations up to 21 days (222.5 ± 65.2 mg/ml at day 1 and 35.1 ± 15.6 mg/ml at day 21). In addition, inhibition zones were shown in the agar diffusion assay at representative TVM concentrations. The carrier material showed no antibacterial effect. CONLUSION: TVM showed the potential to penetrate through dentine and to inhibit bacterial growth. Therefore, it might have the potential to disinfect the outer root surface in perio-endo lesions, but further research is needed to confirm these observations.

Identification of Synergistetes in endodontic infections.

The bacterial phylum Synergistetes consists of Gram-negative anaerobes. Oral Synergistetes are divided in two main clusters, namely A and B. Increasing evidence demonstrates their involvement in etiology of oral infections, including apical periodontitis. This condition causes bone loss around the apex of the tooth, subsequent to pulp inflammation (pulpitis). Although the presence of Synergistetes has been confirmed in endodontic infections by molecular methods, these have not been morphologically identified in the affected apical region, and their prevalence among different endodontic infections has not been determined. Therefore, the aim of this study was to evaluate the prevalence, levels and morphology of oral Synergistetes clusters A and B, in apical root canal samples obtained of teeth with irreversible pulpitis, pulp necrosis and apical periodontitis, or previously root-filled teeth with apical periodontitis. For their detection, fluorescence in situ hybridization and epifluorescence microscopy were used. Synergistetes cluster A was not detected in pulpitis, but was found in both apical periodontitis groups, more frequently and at higher ranges in teeth which were previously root-filled. Microscopically, they appeared as straight or slightly curved long rods. Synergistetes cluster B was not detected in any of the cases. Fusobacteria and Actinomyces, which are well-established taxa in endodontic infections, were detected more frequently and at higher ranges than Synergistetes. In conclusion, Synergistetes cluster A constitutes part of the mixed apical microbiota in apical periodontitis, and may be involved in its pathogenesis.

Comparison of vehicles to collect dentinal fluid for molecular analysis.

OBJECTIVES: To test the hypothesis that a material with higher water absorption than polyvinylidene fluoride (PVDF) could increase the yield of target molecules from exposed dentine. METHODS: In a series of standard tests, different cellulose membranes were compared to a PVDF counterpart for their ability to absorb water and release protein. In a subsequent randomized clinical trial, the cellulose material with the most favourable values was compared to PVDF regarding the levels of MMP-2 that could be collected from exposed dentine of healthy human teeth during filling replacement. MMP-2 levels were determined by enzyme-linked immunosorbent assay (ELISA). Data from the laboratory experiments were compared between materials using the appropriate parametric tests. The frequency of cases yielding quantifiable levels of MMP-2 was compared between materials by Fisher's exact test. The level of significance was set at 5%. RESULTS: The cellulose membrane with the largest pore size (12-15µm) absorbed significantly (P<0.05) more water than PVDF. It showed a protein release that was similar to that of PVDF, while the cellulose membranes with smaller pore size retained significantly more protein (P<0.05). Using the large-pore cellulose membrane, MMP-2 could be collected at a quantifiable level from the dentine of healthy teeth in 9 of 13 cases, compared to 1 of 13 with the PVDF membrane (P<0.05). CONCLUSIONS: Under the current conditions, a large-pore cellulose membrane yielded more of a molecule of diagnostic value compared to a standard PVDF membrane. CLINICAL SIGNIFICANCE: Molecular diagnostics of dentinal fluid are hampered by low yields. In the current study, it was shown that cellulose membranes are more useful to collect MMP-2 from dentinal fluid than PVDF membranes.

Reduction of hard-tissue debris accumulation during rotary root canal instrumentation by etidronic acid in a sodium hypochlorite irrigant.

INTRODUCTION: Hard-tissue debris is accumulated during rotary instrumentation. This study investigated to what extent a calcium-complexing agent that has good short-term compatibility with sodium hypochlorite (NaOCl) could reduce debris accumulation when applied in an all-in-one irrigant during root canal instrumentation. METHODS: Sixty extracted mandibular molars with isthmuses in the mesial root canal system were selected based on prescans using a micro-computed tomography system. Thirty teeth each were randomly assigned to be instrumented with a rotary system and irrigated with either 2.5% NaOCl or 2.5% NaOCl containing 9% (wt/vol) etidronic acid (HEBP). Using a side-vented irrigating tip, 2 mL of irrigant was applied by 1 blinded investigator to the mesial canals after each instrument. Five milliliters of irrigant was applied per canal as the final rinse. Mesial root canal systems were scanned at high resolution before and after treatment, and accumulated hard-tissue debris was calculated as vol% of the original canal anatomy. Values between groups were compared using the Student's t test (α < .05). RESULTS: Irrigation with 2.5% NaOCl resulted in 5.5 ± 3.6 vol% accumulated hard-tissue debris compared with 3.8 ± 1.8 vol% when HEBP was contained in the irrigant (P < .05). CONCLUSIONS: A hypochlorite-compatible chelator can reduce but not completely prevent hard-tissue debris accumulation during rotary root canal instrumentation.

Bacterial leakage through temporary fillings in core buildup composite material - an in vitro study.

PURPOSE: To evaluate the ability of the provisional filling material Cavit-W alone or in combination with different restorative materials to prevent bacterial leakage through simulated access cavities in a resin buildup material. MATERIALS AND METHODS: LuxaCore resin cylinders were subdivided into 4 experimental groups (n = 30), plus a positive (n = 5) and a negative (n = 30) control group. One bore hole was drilled through each cylinder, except those in the negative control group (G1). The holes were filled with Cavit-W (G2), Cavit-W and Ketac-Molar (glassionomer cement, G3), Cavit-W and LuxaCore bonded with LuxaBond (G4), Cavit-W and LuxaCore (G5), or left empty (G6). Specimens were mounted in a two-chamber leakage setup. The upper chamber was inoculated with E. faecalis. An enterococci-selective broth was used in the lower chamber. Leakage was assessed for 60 days and compared using Fisher's exact test (α < 0.05) corrected for multiple testing. RESULTS: Bacteria penetrated specimens in the positive control group within 24 h. All specimens in the negative control group resisted bacterial leakage for 60 days. Twenty-seven specimens in G2, 26 in G3, and 16 specimens in G5 showed bacterial leakage by the end of the experiment. G4 prevented bacterial penetration completely. The statistical comparison revealed significant differences between G4 and all other experimental groups. CONCLUSION: Under the current conditions, Cavit-W alone or combined with a glass-ionomer cement did not prevent bacterial leakage through a resin buildup material for two months. In contrast, covering Cavit-W with a bonded resin material resulted in a bacteria-tight seal for two months.

[Chronic orofacial pain (OFP) of different origin. A case report]. / Chronischer Gesichtsschmerz unterschiedlicher Genese. Ein Fallbericht.

INTRODUCTION: Therapy of chronic orofacial pain (OFP) is often a challenge since OFP can be triggered by numerous medical conditions. Pulpitis is frequently related to acute OFP, only in rare cases pulpitis elicits chronic OFP e. g. due to a cracked tooth. Hypertrophy of masticatory muscles can also cause pain. While this pathosis is easily diagnosed, hypertrophy of masticatory muscles is challenging to treat. METHODS: The presented case demonstrates a combination of a cracked tooth and a symtomatic hypertrophy of the masseteric muscle in a 19-year old patient. The patient suffered from diffuse chronic OFP for more than four month. After diagnosis an interdisciplinary step-by-step treatment plan was realized with re-evaluation and adjustment. RESULTS: After physiotherapy and medicamentous pain control intramuscular injection of Botolinum toxin type-A was performed with remission of the muscle hypertrophy but only partial success regarding pain control. After root canal treatment of a cracked tooth the patient was free of symptoms. CONCLUSION: The high degree of specialization in dental medicine requires a multidisciplinary approach for OFP not thoroughly responding to therapy. Stepwise diagnostics and treatments are recommended to clarify the pathology and to address multiple causes of disease.

Influence of different curing approaches on marginal adaptation of ceramic inlays.

PURPOSE: To evaluate the effect of different curing protocols on marginal adaptation of ceramic inlays after thermomechanical loading (TML). MATERIALS AND METHODS: Forty-eight human molars were randomly divided into 6 groups (n = 8). After Class II cavity preparation (mod), ceramic inlays (Cerec) were fabricated. In groups I to IV, the cavities were conditioned with XP Bond mixed with Self Cure Activator (SCA) and the inlays were placed with the luting composite (LC) Calibra Mix (dual curing). The teeth in groups V and VI were conditioned with XP Bond without SCA and the inlays were placed with Calibra base (only light curing). In groups III, IV and V the adhesive was separately light cured prior to, and in groups II, IV, V and VI, after the inlay insertion. Before and after TML, marginal adaptation was measured using scanning electron microscopy (200X). Continuous margins (% of the total) were compared between groups using analysis of variance (ANOVA). A Bonferroni correction was applied to correct for multiple testing (alpha < 0.005). RESULTS: Light curing after inlay insertion improved marginal adaptation on the occlusal interface between LC and enamel significantly, regardless of the LC's curing mode. Separate light polymerization of XP Bond did not result in superior marginal quality. Investigation of the interface between LC and proximal dentin margins showed improved adaptation by dual curing the adhesive and LC, irrespective of light application. CONCLUSION: Light curing after inlay insertion showed improved marginal adaptation. Using dual-curing adhesive and LC, advantages in marginal adaptation between LC and dentin were observed.