What's in this issue?
Cone-beam computed tomography (CBCT) is useful in detecting vertical root fractures (VRF) in vivo even when the fracture line itself could not be visualized on CBCT, according to Russian researchers in an article published online March 12 in International Endodontic Journal.
The researchers defined VRF as a longitudinally oriented fracture of the root that originates from the apex and propagates to the coronal part. “The differential diagnosis of vertical root fractures is challenging because there are no pathognomonic clinical signs and symptoms of VRF and the accuracy of 2-dimensional radiography is low,” researchers wrote.
In their study, the researchers aimed to investigate and assess the in vivo accuracy of CBCT for the detection of fracture lines compared to the accuracy of CBCT for the diagnosis of VRFs, according to the pattern of bone resorption.
They conducted their study with patients who provided informed consent from the department of Therapeutic Dentistry from November 2013 through September 2017. The study included 88 patients with signs and symptoms of suspected VRF.
The criteria for patient inclusion were root-filled treated teeth; single tooth with local swelling of the gingiva, pain or discomfort on biting or without stimuli, sinus tract involvement, or presence of a solitary deep periodontal pocket; conventional radiograph showing bone loss on the mesial or distal aspects of the root; uncertain definitive diagnosis according to clinical findings and 2-dimensional (2D) radiographic image; unsalvageable tooth that was deemed unsalvageable and extracted. Unsalvageable teeth ultimately were excluded from the study. “Only the teeth for which the diagnosis and prognosis was not evident from the clinical examination and 2D radiography were subject to CBCT examination,” researchers wrote.
Exclusion criteria were the presence of fracture was stated clinically or on conventional radiograph (split teeth), cracked teeth (that is, fracture initiating from the crown of the tooth and propagating apically, mainly in the mesiodistal direction), uncontrolled systemic diseases; severe generalized periodontal disease; and immunosuppressed and pregnant patients.
To conduct their study, researchers extracted all the teeth included in the study atraumatically to minimize possible creation of intraoperative fracture. They decorated the molars and separated roots with a diamond bur and high-speed handpiece. They kept each root wet with saline during all manipulations. They confirmed presence or absence of VRFs with staining, transillumination, and examination with a dental operating microscope. Among 88 teeth, 65 had VRFs (fracture group) and 23 had mimicking conditions. Mimicking conditions encompassed 2 teeth with chronic periodontitis, 13 with apical periodontitis, 5 with strip perforations, and 3 with accessory canals. These teeth became the control group.
Researchers recorded fracture location, longitudinal length, characteristic clinical signs, and symptoms in the teeth with VRFs. They stabilized the teeth in plastic cylinders filled with acrylic resin to confirm the presence or absence conformation and for the fracture width measurement. They sectioned teeth into 3 2–millimeter-thick serial slices. Digitized images of the coronal surface of each slice were captured at X 8 magnification.
Blinded observers—3 endodontists, 1 dental surgeon, and 1 periodontist—experienced in VRF diagnosis served as case evaluators but were not aware that VRFs were the subject of the study. Instead, researchers asked them to establish a possible diagnosis from the CBCT scans and clinical signs and symptoms. Still blinded, 2 weeks later, the evaluators reviewed only the series of axial slices of CBCT that researchers asked them specifically to assess for the presence or absence of fracture lines.
“Interestingly, the values of CBCT accuracy during the first session, when the observers were not aware that they were to diagnose VRFs, were still significantly higher compared to the values of CBCT accuracy obtained during the second session, when the observers were directly asked to detect a fracture line,” researchers wrote.
The main results were average (standard deviation) sensitivity of CBCT for diagnosing VRFs, 0.84 (0.2); accuracy and AUC (area under the curve) values, 0.81 (0.08) and 0.84 (0.17), respectively; (significantly lower) sensitivity, accuracy, and AUC values for detecting VRFs, 0.17 (0.24) (P = .042), 0.54 (0.07) (P = .043), and 0.52 (0.09) (P = .043), respectively.
“The present study has shown that experienced observers in real clinical situations rely not only on the detection of a fracture line but also on the size and shape of the bone defect adjacent to the fracture,” the researchers wrote. “Therefore, the use of CBCT in the diagnoses of VRFs should not be limited to the visualization of a fracture line. Unfortunately, the diagnosis of VRF according to indirect radiographic findings is possible when the bone resorption area is large enough to be visualized.”
ACA, hospital emergency departments and periapical abscesses
Americans are increasingly turning to hospital emergency departments (ED) to treat periapical abscesses (PA) as their oral health continues to be overlooked despite increased access to insurance through the Affordable Care Act (ACA), according to a study published in the March issue of Journal of Endodontics.
“Dentists do not always have business hours to accommodate emergencies, and research has shown that 40.5% of dental-related ED visits are associated with uninsured individuals who may not have access to a dentist. Although the Patient Protection and Affordable Care Act … may help with this issue, it has not eliminated the problem,” researchers wrote.
Researchers pointed to a 2006 study showing that US hospital EDs had 400,000 visits with a diagnosis of pulpal and periapical disease with close to 6,000 hospitalizations that averaged 2.95 days. They cited a 2000 through 2008 study of nationwide data that showed 66 deaths of people hospitalized for periapical disease.
In their own study—a nationwide trend analysis—the researchers set out to examine if the proportion of ED visits with PA increased or decreased from 2008 through 2014, a period that included implementation of the ACA. They used the Nationwide Emergency Department Sample (NEDS) for 2008 to 2014, explaining that it was the largest all-payer ED discharge data set in the United States.
The researchers retrospectively analyzed NEDS data by assessing all patients who visited the ED and had a diagnosis of PA from 2008 through 2014. The researchers examined a multitude of patient and hospital-level characteristics, including age, sex, admission date, insurance status, disposition of patient from the ED, disposition of patient after admission, median household income by zip code, hospital teaching status, urban-rural designation, and geographic region. They also studied length of stay, ED charges, and hospitalization charges. They adjusted all charges for inflation to the year 2014.
To examine changes in the number of PA-related ED visits compared with all-cause ED visits, researchers used an extended Mantel-Haenszel x 2 test for linear trend. They computed comorbid burden using Charlson comorbidity severity index.
Over the study period, researchers noted that the proportion of PA-related ED visits tended to increase (from 0.00368 in 2008 to 0.00396 in 2014). They found 3,505,633 patients had a diagnosis of PA during the study time frame. The number of PA-related ED visits increased from 460,260 in 2008 to 545,693 in 2014.
Researchers concluded that populations most affected by the growth in hospital ED visits owing to PA were uninsured or were insured by Medicaid. “Medicaid was the primary payer for 30.3% of all ED visits, followed by private payer (18.4%) and Medicare (8.4%),” researcher wrote. “Approximately 40% of ED visits occurred among the uninsured. Although the percentage of uninsured patients making ED visits for PA remained consistent over the study duration, there was a decrease in numbers after 2013. The percentage of ED visits with PA increased from 2013 for those covered by Medicaid.”
The researchers assessed mean charges for PA-related ED visits and hospitalizations after PA-related ED visits. The mean charge for PA-related ED visits was $1080.50, while mean charges for PA-related hospitalization were $34,245. More broadly, across the United States PA-related ED charges ran to $3.4 billion, while total PA-related hospitalizations after PA-related ED visits ran to $5.7 billion.
Nonsurgical root canal treatment and single tooth implants outcomes
Researchers compared outcomes of nonsurgical root canal treatment (NSRCT) and single tooth implants (STI) in patients who receive both and concluded that the treatments are highly effective but NSRCT is preferable based on a number of measures. The results of this retrospective study were published in the February issue of Journal of Endodontics.
“Several factors were described and compared between NSRCT and STI in the context of identifying important factors in clinical outcomes,” researchers wrote. “In the present study, the overall survival of STI and NSRCT at 7.5 years was even at 95%. This is consistent with the outcome reported previously in systematic review, meta-analyses, and epidemiologic reports.”
The researchers based at Loma Linda University School of Dentistry (LLUSD) in Loma Linda, California, declared that they did not find any other study in the dental literature comparing NSRCT and STI in the same patient. They reviewed medical and dental records of 3,671 patients with at least 1 STI and 1 NSRCT who were treated from January 1, 2001 through December 31, 2016, at LLUSD.
The researchers wanted to determine if there would be a different survival outcome between NSRCT and STIs provided to the same patient. Their null hypothesis was that there is no difference between the outcomes of these 2 procedures. As an alternative hypothesis, they stated that there is a difference between the outcomes of these 2 procedures.
To conduct their study, researchers established the following inclusion criteria: patients needed to be 18 years or older; had at least 1 STI surgery and subsequent restoration at LLUSD; had at least 1 NSRCT and subsequent restoration performed at LLUSD; had residents of oral surgery, periodontics, implant dentistry, endodontics, or prosthodontics surgically place all STIs and residents or dental students restore all STIs at LLUSD; had endodontic residents perform all NSRCTs and residents or dental students restore all NSRCTs at LLUSD; had at least a 5-year follow-up for each treatment; and STI and NSRCT teeth had to be in matching area of the mouth, such as the anterior maxilla, posterior maxilla, anterior mandible, and posterior mandible.
Exclusion criteria included unrestored implants and endodontically treated teeth and implant and NSRCT-treated teeth that retained multiunit restorations.
Researchers ultimately identified 170 patients who met their inclusion criteria, 85 men and 85 women ranging in age from 31 through 97 years old with a mean age of 71.8 years at the last follow-up visit. The mean follow-up for NSRCT was 7.6 years, and the mean follow-up for STIs was 7.5 years.
A table in the study shows that no statistical significance was appreciable for multifactorial considerations that also did not impact the outcome for either of the treatment modalities, including such considerations as age, sex, ethnicity, tooth number, location and position in the jaw, reason for placement of implant, and proximal contact for NSRCT and STI.
“However, the number of adjunct treatments, the number of additional treatments, the number of appointments to get to the final restoration, the elapsed time before the final restoration, the number of prescribed medications, and the cost of the treatment were significantly higher for STI in comparison with NSRCT,” researchers wrote.
For statistical analyses, researchers used statistical calculation at 95% power to determine that at least 146 patients were needed for the study. After collecting data, they used a series of Fisher exact tests to compare categoric outcomes between participant groups. They used Mann-Whitney U test to compare ordinal or continuous measurements and McNemar tests to compare related measurements within each study group. Their hypotheses tests were 2 sided and conducted at an alpha level of 0.05.
Researchers ultimately concluded, “Based on the results of this study, a patient with compromised teeth that could otherwise be saved by NSRCTs and deemed restorable should be offered the option of NSRCT and not routinely be treatment planned for STI.”
Irrigant penetration depths and activation techniques
Apical areas were most limited in achieving thorough irrigation penetration in tests of sonic, ultrasonic, and photoacoustic activation techniques, according to a German study published online March 3 in International Endodontic Journal.
“Traditional irrigation during root canal treatment with a syringe and needle is associated with only limited penetration beyond the main canal into dentinal tubules,” researchers wrote. “In order to increase the efficacy of irrigants, general activation techniques have been developed.”
Canal irrigation is crucial to chemical dissolution of remnant pulp tissue, removal of debris and smear layer, and mechanical detachment of the biofilm. More than one-third of the canal surface remains untouched by endodontic instruments with mechanical preparation alone, researchers wrote. Also, instrumentation of canal walls creates a smear layer and the accumulation of dentine debris in surface irregularities.
Researchers described the apical one-third of the canal system as a particularly difficult area to clean, as it exhibits a complex morphology.
The activation techniques described in the study include passive ultrasonic irrigation (PUI), manual dynamic activation (MDA), sonic activation (EDDY), photon-induced photoacoustic streaming (PIPS), and shockwave enhanced emission photoacoustic streaming (SWEEPS).
The researchers identified SWEEPS as the latest development in laser-activated irrigation in endodontics and declared that, until their study, data from independent research on SWEEPS had not been published. SWEEPS uses erbium:yttrium-aluminum-garnet laser and a fiber tube placed inside the pulp chamber to create a series of bubbles timed to appear so that secondary bubbles lead to the collapse of existing bubbles creating shockwaves and enhanced photoacoustic streaming.
The overarching aim of their study was to assess whether newer methods of activation techniques are more effective than commonly used techniques. They compared several methods of activation for endodontic irrigants, including ultrasonic, sonic, PIPS and SWEEPS for their ability to penetrate dentinal tubules.
To conduct their study, researchers prepared 90 single-rooted teeth (age range, 14-20 years) extracted for orthodontic reasons by transferring them to ultrapure water 24 hours before experimentation. They used a diamond bur to prepare restorations, covered the entrance with a foam pellet, and coated the access cavity with dentin bonding agent. They filled access cavities with bulk-fill composite resin extended coronally to create a 6-millimeter high reservoir. To ensure standardized access cavities, they then prepared a new cone-shaped access cavity with a diamond bur.
To prepare root canals, researchers created a glide path and covered the apical region of each root with a layer of heavy body condensation silicone impression material to avoid extrusion of irrigating solutions. They irrigated canals with 5% sodium hypochlorite. Teeth were stored in ultrapure water before a final irrigation. The researchers used 5% sodium hypochlorite, ultrapure water and ethylenediaminetetraacetic acid for final irrigation.
They used 1% methylene blue activated for 30 seconds with the respective activation method to visualize the penetration depth of the last irrigant. Then, they stored the dried teeth until they randomly divided them into 5 test groups and 1 control group in which activation was performed per activation technique. “Teeth were sectioned horizontally, imaged under a light microscope, and dye penetration depths were measured in six sections per tooth and 24 points on a virtual clock-face per section. Data were analyzed statistically by nonparametric tests for whole teeth and separately for coronal, middle and apical thirds,” wrote the researchers.
At the study’s end, researchers determined that ultrasonic, sonic, and laser-induced activation techniques achieved greater penetration depths in the apical one-third of canals compared with manual dynamic activation (defined in the study as needle irrigation with manual up and down movement of the needle inside the canal). PIPS achieved deeper penetration of irrigants, while SWEEPS did not deepen irrigant penetration.
Irrigate and disinfect with Irritrol
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What's in this issue?
The consulting editor for JADA+ Specialty Scan — Endodontics is Dr. Susan Wood, Diplomate, American Board of Endodontics.