Endo Tribune Middle East & Africa No. 6, 2020
Palliative care successful for endodontic emergencies during lockdown / The importance of irrigation in challenging cases
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DTMEA_No.5. Vol.10_ET.indd
NL
Y
O
LS
NA
IO
SS
FE
O
PR
NT
AL
DE
www.dental-tribune.me
Published in Dubai
November-December 2020 | No. 6, Vol. 10
Palliative care successful for endodontic
emergencies| during lockdown
feature
During the ongoing COVID-19
pandemic, aerosol-generating procedures in dentistry have been restricted in order to comply with a
recommendation by the Centers
for Disease Control and Prevention
(CDC), since dental professionals are
at high risk of infection. But how can
endodontic emergencies be managed without drilling? A study has
investigated the topic and found
that palliative care seems to be the
answer.
The World Health Organization declared SARS-CoV-2 a pandemic on
11 March 2020. Shortly afterwards,
countries began to implement lockdowns, shutting businesses and nonessential services. In the USA, elective
dental procedures were suspended
and, according to the CDC, aerosol-
generating procedures were to be
avoided. This led to challenges in the
management of patients presenting
with emergencies as well as concern
among dentists about all in-process
pending procedures started before
the statewide shutdowns.
To drill or not to drill?
Researchers from the Department
of Endodontics at the University of
Texas (UT) School of Dentistry conducted a two-part study in order to
investigate how endodontists could
work around these extreme conditions while managing their patients’
pain. The results of the first part of
the study showed that 81% of the
21 patients who presented with endodontic emergencies in 25 teeth
during the state-wide shutdown
© Dmitry Galaganov/Shutterstock.com
By Dental Tribune International
ÿPage A2
Although palliative care in endodontic emergencies brings immediate relief to patients, it is not a long-term solution, and aerosolgenerating procedures cannot be avoided forever should treatment restrictions continue.
AD
Although palliative care in endodontic emergencies brings immediate relief to patients, it is not a long-term solution, and aerosol-generating procedures cannot
be avoided forever should treatment restrictions continue.
Palliative care successful
for endodontic emergencies
during lockdown
By Dental Tribune International
During the ongoing COVID-19 pandemic, aerosolgenerating procedures in dentistry have been restricted
in order to comply with a recommendation by the Centers
for Disease Control and Prevention (CDC), since dental
professionals are at high risk of infection. But how can
endodontic emergencies be managed without drilling?
A study has investigated the topic and found that palliative care seems to be the answer.
08
The World Health Organization declared SARS-CoV-2
a pandemic on 11 March 2020. Shortly afterwards,
countries began to implement lockdowns, shutting businesses and nonessential services. In the USA, elective
dental procedures were suspended and, according to
the CDC, aerosol-generating procedures were to be
avoided. This led to challenges in the management of
patients presenting with emergencies as well as concern
RECIPROCATION
REDEFINED
roots
3 2020
THE
RACE
ACE
LEGACY
SAFE. EFFICIENT. SOFT CONTROL.
SAFE. EASY. MINIMALLY INVASIVE.
www.fkg.ch/race-evo
www.fkg.ch/r-motion
[2] =>
DTMEA_No.5. Vol.10_ET.indd
A2
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 6/2020
◊Page A1
required no further treatment or
intervention after palliative care at a
follow-up rate of 96%.
In the second part, 31 teeth had
received partial or full root canal
debridement before the statewide
shutdown. The mean time for completion of treatment was 13 weeks.
At a recall rate of 100%, 77% of the
teeth did not experience any adverse events resulting from delays
in treatment completion. The most
common adverse event was a fractured provisional restoration (13.0%),
followed by a painful and/or infectious flare-up (6.4%). These events
were managed appropriately and
therefore deemed successful. Only
one tooth was fractured and nonrestorable (3%), leading to the failed
outcome of tooth extraction. The remaining four outcome failures (13%)
were due to patient unwillingness
to undergo school-mandated SARSCoV-2 testing or patient unwillingness to continue treatment because
of perceived risk of SARS-CoV-2 infection.
In an interview with Dental Tribune
International, study co-author Dr.
Biraj Patel explained the reasoning behind this study: “The school
decided to defer aerosol-generating
procedures in accordance with the
state guidelines. We managed cases
very differently to what we would
have routinely done and were interested to see how successful we were.
Furthermore, the literature has limited data on the effect of delaying
treatment in endodontics and the
outcomes of the palliative management of endodontic disease. Our
report on the management of endodontic emergencies has important
clinical implications for the dental
community worldwide and aims to
provide an insight into the effect of
conservative management of endodontic emergencies without the use
of aerosol-generating procedures.”
As results have shown, palliative
care proved successful for the UT researchers, but it is important to note
that this level of endodontic emergency management is only a temporary solution and aerosol-generating
procedures cannot be avoided forever. “The state witnessed a lock- down
from 23 March to 20 May 2020,
and palliative care was successful in
managing patient symptoms during
this time. However, if this lockdown
had been longer, we may have had
to reevaluate patients if they became
symptomatic and potentially intervene with aerosol-generating procedures,” said Patel.
What is the long-term solution?
“At present, our school reduces the
risk of transmission by testing all patients for SARS-CoV-2 using reverse
transcription-polymerase chain reaction (RT-PCR) prior to aerosol-generating procedures,” the endodontist
added. “We make sure to follow the
state and CDC guidelines, especially
with regard to social distancing
measures and personal protective
equipment. We hope that a better
understanding of the transmission
of SARS-CoV-2, along with developments in rapid testing, will eventually reduce the risk to healthcare
professionals. This will hopefully
result in a reduced need for clinics to
stay closed. The expectation is that
we will see further lockdowns if cases
of COVID-19 become uncontrolled.
Hopefully, the findings of our study
will help dentists manage patients
without aerosol-generating procedures during periods of lockdown.”
Editorial note: The study, titled “To
drill or not to drill: Management of endodontic emergencies and in-process
patients during the COVID-19 pandemic,” was published on 22 August
2020 in the Journal of Endodontics.
The importance of irrigation
in challenging cases
By Dr Marco Martignoni, Italy
Introduction
Irrigation of root canals is key to
improving the removal of bacteria, pulp tissue, the smear layer and
debris from the root canal system,1
reducing the risk of post-treatment
disease. In fact, it is well known that
mechanical instrumentation leaves
untreated canal areas ranging from
10 to 50% in individual canals.2–6 In
these areas, there is the possibility
for bacteria to replicate, leading to
the failure of the treatment.7 A recent article showed that the bacterial
persistence at the time of filling has a
significant influence on the outcome
of the treatment, regardless of the irrigating solution and the medication
used,8 thus stressing the importance
of eradicating as many microorganisms as possible from the root canal
system. The synergy between mechanical preparation and irrigation
is influenced by several factors, such
as the fluid properties and the volume of the irrigant, the irrigant delivery system and its depth of placement, and the anatomy of the root
canal system.9
Conventional needle irrigation is unable to provide good disinfection10
because of the risk of the vapour
lock effect11 and because needles
can have difficulty penetrating into
narrow spaces;12 as a consequence,
the difficulty in reaching the most
apical region of the canal with large
volumes of fresh irrigant may result in insufficient replacement and
fluid exchange beyond the tip of the
needle.13 In order to increase the efficiency of the irrigation, the literature
suggests the use of preheated solutions14 or activation of irrigants1 by
means of ultrasonic/sonic devices15
or negative pressure devices.16
The closer the needle is to the working length, the greater the irrigation
is. For this reason, using products
that follow the anatomy of the prepared root canal can help in this
clinical step. However, the flux must
not be violent, in order to decrease
the risk of extruding debris into the
periapical tissue.17
Several articles have described the
use of a novel poly-propylene needle (IrriFlex, Produits Dentaires)
characterised by a back-to-back side
vent design that helps the clinician
irrigate the root canal space efficiently and safely. This product, with
its 30-gauge tip, has the advantages
of reaching the working length effortlessly and of bringing a high
volume of irrigant close to the apex.
The product has been shown to be
effective in curved canals, but what
about challenging cases? The following case reports demonstrate the use
of IrriFlex in two different scenarios:
a retreatment and a primary treatment of a calcified canal.
Case 1
A 62-year-old patient was referred
to our clinic for endodontic retreatment. The patient reported swelling
of the maxillary left gingiva. The
radiographic examination revealed
the results of a previous endodontic
therapy and the presence of periapical radiolucencies (Fig. 1). Since the
results of the previous therapy could
be improved, we decided to retreat
the tooth, passing through the existing crown.
After positioning of the dental dam
(Fig. 2), the existing composite filling
in the centre of the crown was removed using a diamond-coated bur
driven by a high-speed handpiece.
In this way, the access cavity was created and refined in order to see the
pulp chamber (Fig. 3). The existing
root canal filling was removed using rotary instruments specifically
designed for retreatment, and then
ultrasonic tips were used to remove
the remnants on the pulp chamber
floor. The chamber was filled with
5% sodium hypochlorite (Fig. 4),
and the second mesiobuccal canal,
which had not been shaped, cleaned
or filled during the initial treatment,
was located and shaped according to
the standard protocol.
Considering the presence of an endodontic lesion and swelling, a great
deal of time was dedicated to decontamination of the root canal system
Fig. 1
(Fig. 5).18 The device chosen to deliver
the irrigating solution to the working length was IrriFlex (Fig. 6 & 7)
because, thanks to its flexibility, it
would be able to deliver the irrigant
to the apical third of each root, without any effort, without stopping in
case of curvatures. The irrigant was
then activated by means of ultrasonic inserts19 according to the indications given by Tonini and Cerutti.12
After ensuring that the root canals
were dry, they were filled according
to the warm gutta-percha compaction technique (Figs. 8–10). After that,
the access cavity was filled by means
of a direct composite restoration
(Fig. 11) and a postoperative radio-
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
graph was taken in order to check the
final result (Fig. 12).
Case 2
A 50-year-old patient came to our office because of an emergency: while
eating, he had broken tooth #22 and
he was not able to find the fragment
(Fig. 13). The fracture had exposed the
pulp and the patient reported spontaneous and acute pain. The preoperative radiograph showed that the
tooth had a very thin canal lumen
(Fig. 14) and sufficient bone support.
It was thus decided to do an endo-
ÿPage A3
[3] =>
DTMEA_No.5. Vol.10_ET.indd
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ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 6/2020
◊Page A2
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 15
Fig. 16
Fig. 17
When the root canal walls looked
sufficiently clean and shiny, obturation with warm gutta-percha was
performed. As a last step of the endodontic treatment, a build-up was
done with composite (Fig. 18) and
a periapical radiograph was taken
(Fig. 19).
Conclusion
Fig. 18
dontic treatment followed by restoration with a prosthetic crown.
As a first step of the therapy, a dental
dam was positioned directly around
the remaining tooth structure and
the root canal therapy was started.
The access cavity was created, and
the root canal opening was located
and enlarged using ultrasonic tips.
Then nickel–titanium rotary instruments were used to complete the
shaping of this narrow root canal
space (Fig. 15). Multiple irrigation
sequences were repeated using Ir-
Fig. 19
riFlex and ultrasonic activation of
the sodium hypochlorite, both in
order to have the endodontic instruments work in the presence of an irrigating solution and to decrease the
bacterial load.20 The great advantage
of using a polypropylene irrigation
cannula was that, once the last shaping instrument had reached the
working length, the cannula reached
the working length smoothly too
(Figs. 16 & 17), allowing the dentist to
bring the irrigant as close as possible
to the apical constriction.1
The same experienced practitioner
performed the two root canal therapies reported in this article. The cases
were extremely different, an initial
treatment of a single-rooted tooth
and a retreatment of a multi-rooted
tooth, but both of them were challenging. The instruments and the
sequences used for shaping the root
canal system differed between the
cases, since the root canal taper was
different and the apical size of the
lateral incisor was discernibly smaller than that of the molar.
The thing that did not change in the
approach to these cases was the attention paid to the irrigation step.
In the retreatment, the eradication
of bacteria was the key to success
in a tooth that had already received
an endodontic treatment that had
failed, whereas in the lateral incisor,
the presence of a narrow canal made
it more difficult to clean the complexity of the root canal system.21
In both cases, the use of a flexible irrigation cannula that follows the path
created by the endodontic instruments precisely made the treatment
easier and reduced operating times,
because it was possible to deliver a
large volume of irrigating solution
where it was needed the most. The
presence of length marks on the cannula helped the clinician establish
the needle penetration inside the
root canal; the yellow stop was put
on the cannula to emphasise the
correspondence between working
length and IrriFlex depth of penetration inside the prepared canal. Obturation with warm gutta-percha was
performed in order to seal the root
canal space in 3D, and the choice to
restore both teeth in the same appointment as that of the root canal
therapy was meant to prevent coroonal leakage often associated with
provisional restorations.
Editorial note:
A list of references is available from
the publisher.
Fig. 14
This article was originally published
in roots-international magazine of
endodontics, Vol. 16, Issue 3/2020.
About the author
Dr Marco Martignoni
He graduated from the Gabriele
d’Annunzio University of Chieti–Pescara
in Italy in 1988. From 1989 through
1991, he completed continuing education
courses at the Boston University Henry M.
Goldman School of Dental Medicine in
the US, presented by Dr Herbert Schilder.
In 1992, he completed a continuing education programme presented by Dr Cliff
Ruddle in Santa Barbara in the US. He
runs a private clinic in Rome in Italy, and
the practice is dedicated mainly to endodontics, pre-prosthetic core build-ups
and prosthodontics. He has conducted
and published research on post-endodontic core build-ups. He is a well-known
speaker and has given numerous lectures and practical workshops in Italy
and worldwide on endodontics, on core
build-ups and on the use of the operating
microscope in dentistry. He is founder of
the Accademia Italiana di Odontoiatria
Microscopica (Italian academy of microscopic dentistry) and an honorary member of the Société Française d’Endodontie
(French society of endodontics).
Turn back time:
Remover facilitates endodontic retreatment
By COLTENE
Where in the past only an implant
offered the last resort, today, thanks
to modern endodontics, many damaged teeth can be preserved. With
the total number of cases, the number of retreatments in endo-practices is also growing, either because
the clinical picture is different from
what the referring dentist thought,
or because the pioneering materials
have proven to be less durable. The
uncomplicated removal of previous
endodontic restorations has thus
become part of the standard pro-
gramme of reliable root canal treatment.
Remover file for safe
preparation
With the special revision files, the internationally leading dental specialist COLTENE is currently expanding
its range of highly flexible nickeltitanium files. The new HyFlex and
MicroMega 30/.07 removers perfectly match the established file systems
and remove insufficient gutta-percha fillings and similar outdated endodontic restorations in an instant.
Thanks to their filigree shape, they
adapt to the natural anatomy of the
canal and efficiently loosen the existing dental material - without the
need for additional solvents. At the
same time, the remover files are gentle on the surrounding tooth structure: their non-cutting tip offers additional safety during preparation.
For a quick and thorough treatment,
the subsequent use of the appropriate NiTi files is recommended for the
optimal shaping of the root canal.
The files with Taper 07 are now available in the lengths 19 and 23 mm in
well-assorted dental depots. They
fit seamlessly into the range of particular designed special files from
the COLTENE Group, such as the HyFlex CM and EDM or the MicroMega
2Shape and One Curve files.
tants. This way, even endo beginners
will be able to achieve competent
and efficient preparation after only
a short time.
Full support for the practice
On www.coltene.com or one of the
innovation leader’s social media
channels, interested dentists can
find out about the latest trends and
ideas from the dental world. In addition, COLTENE also offers a wide
range of training courses and practical workshops to ensure the optimal
use of technical aids and digital assis-
For further information, please contact:
Coltène/Whaledent GmbH + Co. KG
Raiffeisenstrasse 30,
89129 Langenau/Germany
Tel.: +49-(0)7345-805-0
Fax: +49-(0)7345-805-201
[4] =>
DTMEA_No.5. Vol.10_ET.indd
With R2C I have a
workflow I can trust –
in any situation.
R2C™
The Root to Crown Solution – covering every aspect
from the root canal treatment to the final restoration.
dentsplysirona.com
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