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RO0110_01_Titel
issn 2193-4673
roots
international magazine of
Vol. 8 • Issue 1/2012
endodontology
1
2012
| case report
Large periapical lesion management
| special
The antibacterial effects of lasers in endodontics
| research
Ability of four irrigating solutions to remove
debris after root-canal instrumentation
[2] =>
RO0110_01_Titel
[3] =>
RO0110_01_Titel
editorial _ roots
I
Dear Reader,
_Ten years ago, in January 2002, the German Society of Endodontology (DGEndo) was
founded. Full of enthusiasm, the 13 founding members pursued their goal of shaking up the
endodontic world. In no time, a statute had been written, a home page and logo designed and
the first annual meeting planned. Today, there are more than 1,000 registered members and the
enthusiasm is still tangible. In light of this development, the German Society for Conservative
Dentistry (DGZ) and the DGEndo decided to join forces and formed the German Society of
Endodontology and Traumatology (DGET). The first annual meeting was held in Bonn last year—
a great start for a successful merger.
Prof Michael A. Baumann
What began ten years ago with the use of modern technology has rapidly developed in recent years. Literature research on iPads during a presentation, lectures on mobile phones, apps
and videos on YouTube are now available to many. This globalisation is also reflected in the representation of nationalities from all over the world amongst speakers at conferences and in the
instant availability of the latest information and news.
Last year, a child born in Manila was symbolically named the world’s seven billionth baby by
the UN. Never before had that many people simultaneously lived on earth. According to the BBC,
about 77 billion people have lived on our planet since the beginning of human history.1 Thanks
to the Internet, social networks and search engines, we now have virtually unlimited and rapid
access to the knowledge mankind has accumulated thus far. In this context, endodontics has
also experienced an explosion of factual knowledge and technological development in recent
years. Furthermore, medicine, biology, chemistry, physics and engineering have become intermeshed in technology that offers never-before-seen speed and perfection. Today, in addition to
the more technically oriented innovations, such as NiTi, reciprocating one-file systems or the
technologically fascinating self-adjusting file, as well as an immense variety of new irrigation
concepts, more biologically oriented ideas are taking shape.
In the April 2007 issue of the Journal of Endodontics, Kenneth M. Hargreaves called on researchers around the world to combine the available knowledge and to join efforts in the field
of tissue regeneration in endodontics.2 The collected ideas ranged from the revascularisation of
the root canal to stem-cell therapy, pulp implants, 3-D polymer scaffolds, injectable 3-D cell
printing and gene therapy. Today, some of these ideas have already found their way into our practices, such as triple antibiotic paste (metronidazole, ciprofloxacin, minocycline). Teeth with incomplete root growth and necrosis of the pulp treated with this paste show good development
of the dentine–pulp complex in the form of good root development.3
Back in 2005, we succeeded in creating artificial dental and bone tissue in the laboratory.4
Researchers5–8 have been working on creating human teeth in test tubes for many years. Today,
the daily press even reports about such news and, thus, endodontic topics have been made available to the whole world. Even though we only cover one of many sectors, these prospects hold
significant implications for both specialists and patients, and keep us moving forward with
enthusiasm and scientific curiosity.
Yours faithfully,
Prof Michael A. Baumann
University of Cologne, Germany
Editorial note: A complete list of
references is available from the
publisher.
roots
I 03
1
_ 2012
[4] =>
RO0110_01_Titel
I content _ roots
page 6
I editorial
03
page 14
I The Endospot
Dear Reader
30
| Prof Michael A. Baumann, Guest Editor
I case report
06
page 16
The lazy man’s guide to persistent apical periodontitis
| Dr Patrick Caldwell
I industry news
Large periapical lesion management
Decompression combined with root-canal treatment
34
New A-dec LED offers brilliant simplicity
| A-dec
| Dr Nuria Campo
10
Intentional replantation: A viable treatment option for
specific endodontic conditions
35
G-Files—Rotary NiTi instruments for glide path enlargement
| MICRO-MEGA
| Prof Naseem Shah et al.
14
When flexibility and strength are key
I meetings
36
| Dr Philippe Sleiman
The 20th annual SSE conference left nothing to be desired
| Dr Philipp Kujumdshiev
I special
16
The antibacterial effects of lasers in endodontics
| Dr Selma Cristina Cury Camargo
I feature
22
An interview with Dr Maria Emanuel Ryan
40
International Events
I about the publisher
41
42
| submission guidelines
| imprint
I research
26
Ability of four irrigating solutions to remove debris
after root-canal instrumentation
Cover image courtesy of Prof Marco Versiani
and Prof Manoel D. Sousa Neto, Ribeirão Preto
Dental School, University of São Paulo.
| Dr Jorge Paredes-Vieyra et al.
page 34
04 I roots
1_ 2012
page 35
page 36
[5] =>
RO0110_01_Titel
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[6] =>
RO0110_01_Titel
I case report _ periapical lesion management
Large periapical
lesion management
Decompression combined with root-canal treatment
Author_ Dr Nuria Campo, Spain
Periapical lesions often develop slowly and do not
become very large. Patients do not experience pain
unless there is acute inflammatory exacerbation.
These lesions are often diagnosed during routine
radiographic exams. Some periapical lesions become
large and, in cases of large radiolucencies, they may
be diagnosed in the absence of any patient complaint. Sometimes, symptoms such as mild sensitivity, swelling, tooth mobility and displacement may be
observed in these cases.
Fig. 1
Fig. 1_Buccal abscess.
_Most periapical lesions occur as direct sequelae
of chronic apical periodontitis, usually after pulpal
necrosis of a tooth. The affected tooth is non-responsive to thermal and electrical pulp tests.
Large periapical lesions are often associated with
anterior maxillary teeth, probably due to traumatic
injuries. These lesions could be classified as granulomas, pocket cysts (also called bay cysts) and true
cysts. Granulomas are usually composed of solid soft
tissue, while cysts have a semi-solid or liquefied central area usually surrounded by epithelium.1 Pocket
cysts have an epithelial lining that is connected with
the root canal, and true cysts are completely lined
with epithelium and not connected with the root
canal.2
Fig. 2a_Mesio-radial
periapical radiograph.
Fig. 2b_Ortho-radial
periapical radiograph.
Fig. 2c_Disto-radial
periapical radiograph.
Fig. 2a
06 I roots
1_ 2012
Fig. 2b
Fig. 2c
[7] =>
RO0110_01_Titel
case report _ periapical lesion management
I
Fig. 3
According to Nair’s3 research, based on serial
sectioning and strict histopathological criteria, the
prevalence of pocket cysts to be 6%, whereas that
of true cysts is 9%. Previous studies without serial
sectioning that reported ranges from 6 to 55% are
proven to contain a great margin of error.
The differential diagnosis of large periapical lesions
is still a controversial topic. Periapical radiographs,
contrast media, Papanicolaou smears and albumin
tests have proven to be inaccurate in establishing a
preoperative diagnosis. Only once the post-operative
biopsy has been taken, can a diagnosis be established.
There is evidence1 that CBCT scans may provide a more
accurate diagnosis than biopsy.
To obtain an accurate reading, the entire lucency
must be scanned for the most lucent or least dense
areas. If the least dense area of the CBCT scan shows
positive grey-scale values identified as solid tissues,
diagnosis will be consistent with granuloma. If it
shows negative grey-scale values identifying a semisolid or fluid-filled central area, diagnosis will be con-
Fig. 5
Fig. 4
sistent with a pocket or a true cyst. Real-time ultrasound imaging and ultrasound recently demonstrated that they are capable of establishing differential diagnosis as well.4
Fig. 3_Periapical’s composition
showing the full extension of the
lesion.
Fig. 4_Initial panoramic radiograph.
There is widespread agreement that most granulomas heal after non-surgical root-canal treatment
(NSRCT), but there is no consent regarding this in the
case of periapical cysts. In Nair’s opinion, based on
indirect clinical evidence, it appears that pocket cysts
may heal after non-surgical endodontics. He asserts
that a pocket cyst is sustained by the microbes within
the canal system, but that a true cyst is self-sustaining and will remain after the micro-organisms have
been removed from the root-canal system. The new
preoperative diagnostic techniques will be helpful in
the treatment decision process.
The following case report describes the management of a particularly large maxillary periapical lesion
(involving four anterior teeth) by decompression with
tubing, followed by NSRCT using interim long-term
calcium hydroxide (Ca(OH)2).
Fig. 5_Previous root-canal filling
(gutta-percha with a plastic carrier).
Fig. 6_Ca(OH)2 root dressing.
Fig. 7_Remains of buccal
encapsulated tissue.
Fig. 7
Fig. 6
roots
I 07
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[8] =>
RO0110_01_Titel
I case report _ periapical lesion management
_Case report
Fig. 8
Fig. 8_Modified print tip
used as cannula.
A healthy 39-year-old male patient with recurrent
palatal swelling and buccal abscesses was referred
to our practice (Fig. 1). He had had these
symptoms for the last two to three
years owing to trauma sustained
while working with machinery.
An RCT on tooth #9 had been performed following
the incident. One year later, the tooth presented with
apparent brown discolouration according to the
patient.
At the initial examination, tooth #9 was found
to be non-vital (non-responsive to cold or electrical
stimuli), and teeth #7, 8, 10 and 11 had a cold pulpal
response within normal limits. Radiographs revealed
a large cyst-like periapical lesion that appeared to be
centred above the left upper central incisor (Figs. 2 &
3). A panoramic radiograph (Fig. 4) confirmed the full
extent of the lesion, which appeared to involve the
floor of the nasal sinus. The history of repeated palatal
and buccal abscesses suggested a through-andthrough osseous defect. The diagnosis was apical
periodontitis in tooth #9.
ing of the tooth. Persistent purulent content from
the canal was noted. A Ca(OH)2 paste (Ultracal XS,
Ultradent) was placed in the root canal as interim
medication (Fig. 6). Once the buccal encapsulated
tissue was removed (Fig. 7), copious drainage was
also obtained from the buccal abscess.
2. After one month, Ca(OH)2 was replaced because
the canal could not be dried even after shaping and
cleaning with copious amounts of 5.25% sodium
hypochlorite. A vestibular incision was made and
a plastic cannula was inserted into the lesion, obtaining purulent drainage. Thereafter, the cannula
was prepared and sutured to the mucosa (Figs. 8
& 9), and the patient was instructed to irrigate
through the lumen of the cannula with 3ml of
0.12% chlorhexidine on a daily basis for four weeks
(Fig. 10), consistent with the protocol described by
Brøndum and Jensen.5
3. Two months after the last visit, complete drying
of the canal space was achieved but, owing to the
extent of the lesion, it was decided to replace and
maintain the Ca(OH)2 for two months in order to
determine whether this would effect healing as
evidenced in the pattern of the lesion.
The following treatment options were considered:
_decompression combined with RCT; and
_surgical removal of the lesion with RCT on tooth #9
and possibly teeth #8, 10 and even 7 and 11 owing to
the great risk of damaging nervous and vascular
supply during surgery.
The patient preferred the most conservative
approach and treatment was performed in four
appointments over five months.
_Management sequence
4. Two months later, healing appeared to be underway
(Fig. 11a) and the canal was dry. The root-canal filling was performed with gutta-percha and AH Plus
(DENTSPLY DeTrey) and composite were placed to
seal the access (Fig. 11b).
The patient was recalled at eight months and was
asymptomatic and there was no swelling or abscess at
either the palatal or buccal surfaces. Normal pulpal responses have been maintained in teeth #7 to 11 since.
1. During the first visit, the previous root-canal filling
(gutta-percha with a plastic carrier) was removed
(Fig. 5). There was a lot of gutta-percha in the pulpal camera. This and remains of necrotic pulpal tissue could have been the cause of the brown stain-
Healing of the lesion still appeared to be in
progress, owing to the reduction in the size of the
lesion. The trabecular pattern at the borders of the
lesion had been restored (Fig. 11c) and the periodontal
ligament around tooth #9 was almost fully recovered
(Fig. 12). We plan to recall this patient on a yearly
basis until the lesion is fully healed.
Fig. 9
Fig. 10
Fig. 9_Sutured plastic cannula.
Fig. 10_Flat-tipped needle with
Luer-Lok syringe for irrigation.
08 I roots
1_ 2012
[9] =>
RO0110_01_Titel
case report _ periapical lesion management
Fig. 11a
Fig. 11b
_Discussion
The management of large periapical lesions is
the subject of prolonged debate. The treatment
options range from RCT or NSRCT with long-term
Ca(OH)2 therapy to various surgical interventions,
including marsupialisation, decompression with a
tube and surgical removal of the lesion. These treatment options can also be combined.
Long-term drainage is important in the conservative management of these large lesions. One method
is to drain through the canal on a daily basis until the
canal becomes dry. This could last for between 15
days and one month. At each visit, debridement, drying and closing of the access cavity are mandatory.
Another method of drainage is decompression with
a tube from the apical focus. There is no standard
protocol for the length of time for which the tube
should be left in. Some clinical cases, however, have
reported five-week to 14-month-periods, with periodical reshaping if necessary.
Fig. 11c
I
Fig. 12
such time and present less difficulty and less risk of
damage to other teeth or vital structures.
With complete informed consent, the patient
may prefer more immediate therapy and select surgical enucleation without delay in conjunction with
the conventional endodontic therapy of the responsible tooth and usually the adjacent ones involved in
the lesion. It is important to remember that microbes
initially caused the lesion and continue to maintain
the immune response and thus the apical periodontitis. The length of time required for healing in these
cases ranges from eight to 14 months.6 Follow-up on
the process of healing should be done every six
months for four years.
Fig. 11a_After five months
of interim medication, healing
appeared to be underway.
Fig. 11b_Root-canal filling and
coronal sealing.
Fig. 11c_Eight-month recall
periapical radiograph.
Fig. 12_Eight-month recall
panoramic radiograph.
There are also large periapical lesions of nondental origin, such as non-dental cysts (e.g. nasopalatal cyst) and neoplastic entities. If there are
doubts regarding the dental origin of the periapical
lesion, the first choice of treatment is the surgical
approach.
The literature offers evidence that the majority
of these cyst-like lesions heal after conventional
RCT over multiple appointments. Çaliskan6 reported 74 % complete healing and 9.5 % incomplete healing in an in vivo study of anterior teeth
with large periapical lesions ranging from 7 to
18 mm. The treatment combined long-term canal
drainage with Ca(OH)2 dressing and non-surgical
RCT. Several case reports7–9 have demonstrated
that long-term decompression involving a tube
combined with interim Ca(OH)2 dressing and RCT is
also successful.
This case has illustrated the healing of a large
periapical lesion with a minimally invasive approach.
However, every case requires an individual approach
depending on the patient’s cooperation, preferences,
availability and proximity to the surgery, as well as the
dentist’s professional training and technical skills._
Decompression is favoured because fewer visits
are necessary compared with root-canal drainage.
Furthermore, it is much more conservative, especially in comparison with surgical removal of the
lesion with the risk of damaging the nervous and
vascular supply of adjacent teeth and other anatomical structures, such as the nose and maxillary sinus
floor. Even if surgical removal is still necessary later,
the lesion will predictably have shrunk in size by
Dr Nuria Campo received her degree from
the University of Barcelona in 1997. She is a
self-trained endodontist. Dr Campo co-organised
the Roots Summit IX in Barcelona.
Editorial note: A complete list of references is available
from the publisher.
_about the author
roots
ncampob@gmail.com
www.microendodoncia.wordpress.com
es-es.facebook.com/microendodoncia
roots
I 09
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_ 2012
[10] =>
RO0110_01_Titel
I case report _ intentional replantation
Intentional replantation:
A viable treatment option for
specific endodontic conditions
Authors_ Prof Naseem Shah, Dr Ajay Logani & Dr Abhinav Kumar, India
_multi-rooted teeth with diverging roots that make
extraction and reimplantation impossible; and
_teeth with non-restorable caries.
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
Fig. 1a_Tooth #46 with a fractured
Lentulo spiral pushed past the apical
foramen in the mesiolingual canal.
Fig. 1b_Tooth replanted after
removal of the fractured instrument
(apicoectomy and retrograde
MTA obturation).
Fig. 1c_Clinical photograph showing
stabilisation of the replanted tooth
with sling sutures.
Fig. 1d_Six-month follow-up.
_Intentional replantation is defined as the purposeful extraction of a tooth in order to repair a
defect or cause of treatment failure and thereafter
the return of the tooth to its original socket.1 Any
tooth that can be atraumatically removed in one
piece is a potential candidate for intentional replantation. However, specific indications include:1–3
_all other endodontic non-surgical and surgical
treatments have failed or are deemed impossible to
perform;
_limited mouth opening that prevents the performance of non-surgical or peri-radicular surgical
endodontic procedures;
_root-canal obstructions; and
_restorative or perforation root defects that exist in
areas that are not accessible via the usual surgical
approach without excessive loss of root length or
alveolar bone.
Contraindications may include:1–2
_long, curved roots;
_advanced periodontal diseases that have resulted
in poor periodontal support and tooth mobility;
10 I roots
1_ 2012
In order to provide the best long-term prognosis
for a tooth that is to be replanted intentionally,
the tooth must be kept out of the socket for the
shortest period possible, and the extraction of the
tooth should be atraumatic to minimise damage to
the cementum and the periodontal ligament. The
periodontal ligament attached to the root surface
should be kept moist in saline, Hank’s Buffered Salt
Solution (HBSS), Viaspan or Doxycycline solution for
the entire time the tooth is outside the socket.
We have documented three clinical cases to
exemplify the potential of intentional replantation
as a viable treatment option in select endodontic
cases.
_Case I
A 14-year-old male patient presented with a
separated Lentulo spiral extending 4 to 5mm beyond
the apex of the mesiolingual root canal of tooth #46
(Figs. 1a–d). The tooth was badly broken and the
instrument tightly screwed into the root canal. All
efforts to remove the spiral were futile, and we were
concerned that it would fracture at the apex.
Apical surgery was ruled out because accessibility to the mesiolingual root would have been limited.
We decided to replant the tooth intentionally and
discussed this treatment option with the patient,
who agreed to our proposal. Since the tooth was
badly broken, we planned to reinforce its core with a
post in the distal canal prior to extraction.
Once we had obtained adequate anaesthesia, the
tooth was extracted atraumatically with an extraction forceps. We did not use surgical elevators and
[11] =>
RO0110_01_Titel
case report _ intentional replantation
took care that the beaks did not go beyond the cemento-enamel junction (CEJ), as this may have damaged the cementum and the periodontal ligament.
Following extraction, we kept the tooth moist
by immersing it in Viaspan. With the beaks of the
forceps, we held the tooth by its crown and cut the
overextended Lentulo spiral. Thereafter, we performed a 3mm Class I root-end preparation with an
ultrasonic tip, at the apical end of all three canals.
A retrograde filling was done with mineral trioxide
aggregate (MTA). The extraction socket was then
irrigated with normal saline and gently suctioned to
remove blood clots. The socket was filled with tricalcium phosphate in order for the tooth to be 2 to 3mm
higher than before. This helped in planning a good
post-endodontic restoration.
The tooth was carefully reinserted into its socket
and brought into occlusion with digital manipulation and patient bite force. The tooth was stabilised
it its socket with a sling suture. The patient was
re-evaluated after seven days, and the sutures were
removed.
_Case II
A 22-year-old male patient presented with a
history of trauma to his maxillary anterior region.
Clinical examination revealed an Ellis Class III fracture of tooth #12, with the fracture line extending to
the root palatally. Once the mobile fragment had
been extracted, we realised that the fracture line
extended 2 to 3mm sub-crestally. In order to bring
the apical end of the fracture line to a supra-crestal
position, we considered two options: orthodontic
extrusion and intentional replantation. The patient
did not accept orthodontics as an option owing to
the extended treatment time required.
Once the tooth had been atraumatically extracted, it was kept moist in Viaspan. We inserted
tricalcium phosphate in the apical 3 to 4mm of the
socket and reinserted the tooth with a 180° rotation
to bring the deep fracture line into a more accessible
labial side. The tooth was then splinted with fibrereinforced composite for a period of three weeks.
The root-canal treatment was completed at a later
date, and the facial surface was built up with composite. We decided not to proceed with the crown
immediately after stabilisation to prevent loading of
the tooth. The patient was recalled periodically for
follow-up.
_Case III
A 23-year-old female patient presented with
pain in her upper right anterior tooth. There was no
I
history of trauma, and clinical examination revealed
a deep palato-gingival groove (PGG) with respect to
tooth #12 (Figs. 2a–e). The intra-oral peri-apical
radiograph revealed a peri-apical radiolucency. We
decided to extract the tooth, seal the groove and
then replant the tooth. After adequate anaesthesia
had been obtained, the tooth was extracted with
all the necessary precautions and immersed in Viaspan. With help of the forceps, it was then held by its
crown. The PGG was debrided with the tip of the
ultrasonic scaler and sealed with glass-ionomer
cement (GIC). The socket was then gently curetted
and the tooth reinserted. Sutures were placed in the
inter-dental area and endodontic treatment was
completed one week later. The apical 4 to 5mm of the
root were sealed with MTA, and the rest of the root
canal was back-filled with thermo-plasticised guttapercha. The patient was re-evaluated after seven
days.
_Discussion
Intentional replantation in dentistry has been
performed for more than ten centuries and was used
extensively to manage odontalgia.4 In 1561, Pare
recommended its use when a healthy instead of a
diseased tooth was mistakenly extracted!5 In 1712,
Pierre Fauchard6 replanted a tooth and reported it
to be stable on follow-up. Several steps in the replantation were debated, for instance the need for
amputation of root apices, immediate or delayed
replantation, root-canal obturation before or after
replantation, removal or preservation of periodontal
ligament cells and the goal of ultimate healing—
bony ankylosis or ligament repair.
It was in 1881 that Thompson7 presented the treatise on the replantation of teeth and emphasised the
importance of peri-cemental tissues for treatment
success. Later, Fredel8 in 1887 and Scheff 9 in 1890
addressed the role of periodontal ligament cells with
regard to external root resorption after replantation.
As the replantation technique became increasingly
refined, it was used as an easy alternative for failing
root-canal treatment and hence evoked sharp criticism for the technique of replantation per se.
There are many reasons for an adverse outcome
of a replantation: the tooth can fracture during extraction and may be completely lost; peri-cemental
tissues can be damaged, reducing the likelihood of
reattachment; infection; external root resorption;
and ankylosis. Therefore, it is extremely important
to understand that intentional replantation should
be the last choice, selected only when all the other
options of treatment—non-surgical and surgical—
have been exhausted. Replantation can be a treatment of choice in cases in which a surgical approach
roots
I 11
1
_ 2012
[12] =>
RO0110_01_Titel
I case report _ intentional replantation
Fig. 2a_Clinical photograph of
tooth #12 showing the PGG.
Fig. 2b_Intra-oral peri-apical
radiograph showing the
peri-apical lesion.
Fig. 2c_Tooth extracted,
PGG prepared with ultrasonics.
Fig. 2d_PGG sealed with GIC.
Fig. 2e_Intra-oral X-ray showing
obturated canal. The sealed PGG
is superimposed on the
root-canal obturation.
Fig. 2a
Fig. 2b
can be difficult, for example on the lingual root of a
mandibular molar, or in cases in which a surgical approach would be very invasive, such as the removal
of thick bone from the buccal aspect of a second
mandibular molar.
Intentional replantation has a better prognosis
when the extra-oral time is kept as short as possible
and trauma to the periodontal ligament and cementum is minimised.1 It is advisable to perform routine
endodontic treatment intra-orally before the tooth
is extracted to minimise the extra-oral time. It is also
suggested that a team of two dentists work in tandem to prevent prolonged treatment time, thus improving the chances of success. The use of elevators
should be avoided, and the beaks of the extraction
forceps should not go beyond the CEJ. The cortical
bone integrity should be maintained, and the tooth
should be extracted as atraumatically as possible.
_contact
roots
Prof Naseem Shah is
Head of the Department of
Conservative Dentistry and
Endodontics and Chief of
the Centre for Dental Education and Research at the
All India Institute of Medical
Sciences. She can be
contacted at
naseemys@gmail.com.
12 I roots
1_ 2012
The medium in which the tooth is kept moist
plays an important role. Saline, HBSS, milk, Viaspan,
to name a few, are widely used. Viaspan is used for
organ transplantation and preservation. Owing to its
antioxidant activity, the solution keeps the periodontal ligament moist and reduces the likelihood of
surface resorption.2
We generally use ultrasonic tips to prepare the
root-end and the debridement of the PGG. It conserves the tooth structure and produces significantly less smear layer compared with burs.3 Commonly used root-end filling materials are amalgam,
Intermediate Restorative Material (IRM), Super EBA,
GIC, Diaket, composite and MTA. The sealing ability
and marginal adaptation of MTA have been proven
to be superior and not adversely affected by blood
contamination. In addition, MTA promotes deposition of new cementum and stimulates osteoblastic
adherence to the retro-filled surface.
In two of our cases, tricalcium phosphate was
placed in the apical few millimetres of the socket.
This was done in order to bring the defect supragingivally so that the integrity, aesthetics and prognosis of the case were improved. Tricalcium phosphate is an osteo-conductive material that acts as
Fig. 2c
Fig. 2d
Fig. 2e
scaffold for bone growth and is gradually degraded
and replaced by bone.10
A palato-gingival groove is a developmental
anomaly that represents an infolding of enamel
and Hertwig’s epithelial root sheath.11 PGG can vary
in depth, length and complexity, causing varying
degrees of periodontal defects. Mild grooves terminate at the CEJ, whereas moderate grooves continue
apically along the root surface. A treatment option
for a PGG terminating close to CEJ is to expose the
groove surgically and to seal it thereafter. As presented, the groove extended beyond the apex in
Case III. Here, the defect was sealed extra-orally and
the tooth replanted. GIC was used to seal the PGG,
as it chemically adheres to the tooth structure and
has a good sealing ability and antibacterial effect.12
After replantation, the tooth was splinted for ten
days. The splint enabled physiological movement of
the tooth to prevent ankylosis. Endodontic treatment
was completed one week after replantation in order
to prevent inflammatory resorption and ankylosis
and to allow splicing of periodontal fibres, which
limits the seepage of potentially harmful root-filling materials into the traumatised periodontal ligament.13 Final restoration of the tooth was delayed to
avoid loading and to ensure that proper healing of
periodontal ligament took place.
In recent years, several bio-modulators, such as
enamel matrix protein14, hydroxyapatite and plateletrich plasma,15 have been used in intentional replantation cases to improve the success rates. Guided
tissue-regeneration techniques can also be employed
along with these supplements to further improve the
likelihood of success.
We conclude that intentional replantation is a viable
treatment option in carefully selected cases in which
all other treatment options have been exhausted.
We would like to acknowledge the assistance of
Dr Akanksha Gupta and Dr Nikhil Sinha._
Editorial note: A complete list of references is available
from the publisher.
[13] =>
RO0110_01_Titel
Bella Center
Copenhagen
Welcome
W
elcome
elcom to the 45th Scandinavian Dental Fair
The leading annual dental fair in Scandinavia
The 45th SCANDEF
SCANDEFA
ANDEF
FA
A invites you to exquisitely meet the Scandinavian dental market and
sales partners fr
from
om all over the world in springtime in wonderful Copenhagen
SCANDEFA
SCANDEF
FA 2012
20
Exhibit at Scandefa
Is organized by Bella Center
and is being held in conjunction
with the Annual Scientific
Meeting, organized by the
Danish Dental Association
(www
(www.tandlaegeforeningen.dk).
.tandlaegefor
forreningen.dk).
Book online at www
www.scandefa.dk
.scandefa.dk
Sales
ales and Project
Prroject
oject Manager
Manager,
r,, Christian
Ch
Olrik
col@bellacenter.dk,
col@bellacenter
ol@bellacenterr.dk, T +45 32 47 21 25
175 exhibitors and 11.422
visitors participated at
SCANDEFA
SCANDEF
FA 2011 on 14,220 m2
of exhibition space.
Travel
T
r
ravel
information
Bella Center is located just
just aa 10
10
0 minute
minutetaxi
taxidrive
drivefr
from
fr
rom
om Copenhagen
Cop
Airport.
irport.
p
A rregional
egional
g
train runs from
from the airport to Or
Orestad
restad
estad Station,
only 15 minutes drive.
Check in at Bella Center’s
Center’s newly built hotel
Scandinavia’s
Bella Sky Comwell is Scandinavia’
s largest design hotel.
The hotel is an integral part of Bella Center and has dir
direct
re
ect
access to Scandefa. Book your stay on www
www.bellasky.dk
.bellasky.dk
w w w. scandefa.dk
Fotos from
from Bella Center
Center,, W
Wonderful
onderful Copenhagen
2
201
2012
[14] =>
RO0110_01_Titel
I case report _ retreatment
When flexibility and
strength are key
Author_ Dr Philippe Sleiman, Lebanon
Fig. 2
Fig. 3
_Root-canal retreatment is a very common procedure that endodontists and general practitioners
are faced with on almost a daily basis. The biggest
challenge here is to re-establish the initial pathway
of the canal and its original exit or apex. During the
past decade, several techniques required that guttapercha be used to fill the root canals. Sometimes and
for many reasons, such as leakage or short preparation and/or obturation, the gutta-percha needs to be
removed and the canal renegotiated.
Today, thanks to heat treatment that has changed
the world of rotary NiTi files, allowing us to modify the
crystalline structure of the metal, we have been able
to obtain several types of the alloy to give us different
files, from the Twisted File to the latest modification
of the K3 system, the K3XF (SybronEndo; Fig. 1). The
K3 system files are known to be robust yet very safe.
The slight modification in their structure gives these
files much-needed flexibility, while preserving their
very high safety levels.
Generally, NiTi rotary files were used in such cases
The clinical applications are very simple.
in order to facilitate and expedite our task. However,
My favourite sequence of the K3 system is the
the files used to accomplish this task faced additional
G-pack, which allows me to do crown-down
challenges, that is, the debris coming from the preusing the taper of the files and keeping the tip
vious obturation and the density of the obturation
stable at ISO 0.25. This sequence allows for a
material. The first difficulty is piercing the mass of
very nice start, removing the obturation material
the obturation material. Here, our choice of file
from the coronal third with relatively short files,
should focus on a strong tip that can take the pressuch as orifice openers, and doing so in a relatively
sure and engage the mass of the gutta-percha,
short time. The deeper we go, the more we need to debreak it down and push it back into the access
crease the taper, especially when curves are present
cavity. The second challenge is to select an instruinside the canals and smaller taper files are needed.
ment that can enter the root-canal structure and
It is at this particular moment that the flexibility of the
engage the obturation material, pushing it out
heat-treated alloy gives the files the ability to negoticoronally, while offering enough flexibility to
ate the curves without any distortion of the canal or
go around curves and shape the root-canal
macro-damage to the file structure (as has been
Fig. 1 demonstrated in research and clinically).
surface safely.
14 I roots
1_ 2012
[15] =>
RO0110_01_Titel
case report _ retreatment
Fig. 4
I
Fig. 5
_Clinical cases
The first clinical case could be described as a very
bad day in a dental office. Two files had been trapped
and separated in the mesial canals and the patient
was referred to the clinic but had to drive for more
than two hours to get to our clinic. When I first saw
the X-rays (Fig. 2), I remembered a very similar case
from several years ago with practically the same location of file separation. The separated files in the
mesial canals were clearly visible. It was also noticeable that the distal canal had not been treated to full
length. Ultrasonic tips and the use of an operating
microscope allowed me to retrieve the separated files
and it was then time to reshape the canals and retreat
the distal canal (Fig. 3). Owing to the combination of
requirements for the treatment of this case—shaping
and retreatment in one tooth—my instruments of
choice were K3XF files. I started with 25.08, followed
by 26.06 and concluded crown-down with 25.04.
This gave access to the apical part, which was enlarged to 35.04 in the mesial and distal canals in order
to prepare the apical portion of the root-canal system.
The speed of the micromotor for the shaping procedure was 500rpm and a sequence of push-and-pull
movements—four to five strokes per canal—with each
file was used in order to reach full working length. Figure 4 shows the obturation of the canals, which was
performed with RealSeal (SybronEndo) after both
separated files had been removed and the root-canal
system reshaped.
The second case came as another referral. The
patient was suffering from pain in her lower molar
and was sent to the office in order to check the case
and give the necessary treatment. The preoperative
X-ray (Fig. 5) showed an apical lesion with an incomplete
root-canal treatment. Because diagnostics found no
sign of a root-canal crack, retreatment was my choice.
However, we had to overcome two obstacles: the
crown placed on the tooth and the fibre post inside
the distal canal. I decided to go through the crown
without removing it in order not to place any tension
on the distal canal. When analysing the anatomy, it
appeared that the roots were fused. In such cases,
Fig. 6
avoiding any tension is recommended in order to
avoid any cracks.
Under the microscope and through the crown,
I managed to remove the filling surrounding the post.
With the use of the ultrasonic WHAT, I managed to
remove the fibre post itself together with the previous
filling from the access cavity. Using the K3XF after
removal of the fibre post was a great help in reshaping
the root-canal system, which appeared very convergent. The files displayed no sign of metal fatigue and
the 25.06 was taken deeper into the canal compared
with the standard K3 files. The extra flexibility and
strength of the K3XF allowed me to perform crowndown and final apical shaping. Obturation of the rootcanal system was performed with the Elements Obturation Unit (SybronEndo) and RealSeal material. The
post-operative X-ray (Fig. 6) shows that the merging
canals had been cleaned, shaped and filled; and the
same had been done for the fibre-post space.
roots
_Conclusion
_contact
In the two clinical cases presented here—both
rather a challenge for root-canal retreatments—the
final results were an endodontic success. This lends
support to the fact that each challenge needs to be
treated separately without fear or tremor from the
initial preoperative X-rays. Our fear shall control neither our judgment nor our choices!
Dr Philippe Sleiman
Dubai Sky Clinic
Burjuman Business Tower,
Level 21
Trade Center Street,
Bur Dubai
Dubai, UAE
I would like to thank Yulia Vorobyeva, interpreter
and translator, for her help with this article._
phil2sleiman@hotmail.com
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The antibacterial
effects of lasers in
endodontics
Author_ Dr Selma Cristina Cury Camargo, Brazil
Clinically, apical periodontitis is not evident as
long as the necrotic tissue is not infected with microorganisms.4–6 There are up to 40 isolated species of
bacteria present in the root canal. Cocci, rods, filaments,
spirochaetes, anaerobic and facultative anaerobic
are frequently identified in primary infection. Fungus
can also be isolated.2,7 Endodontic microbiota can be
found suspended in the main root canal, attached to
the canal walls and deep in the dentinal tubules at
a depth of up to 300µm (Figs. 2a–c). The absence of
cementum dramatically increases bacterial penetration into dentinal tubules.8–11
_Endodontic infection
It has been shown that bacteria can also been
found outside the root-canal system, located at the
apical cementum and as an external biofilm on the
apex.12–15 Following conventional endodontic treatment, 15 to 20% of non-vital teeth with apical periodontitis fail.16–18 The presence of bacteria after the
decontamination phase or the inability to seal root
canals after treatment are reasons for failure.2 The
remaining contamination in endodontically treated
teeth continues the infectious disease process in the
periapical tissue.
Endodontic treatment can attain success rates of
between 85 and 97%.1 Adequate treatment protocols, knowledge and infection control are essential
to achieving such rates (Figs. 1a–d).2 It is well known
that apical periodontitis is caused by the communication of root-canal micro-organisms and their byproducts to the surrounding periodontal structures.
Exposure of dental pulp directly to the oral cavity or
via accessory canals, open dentinal tubules or periodontal pockets is the most probable route of the
endodontic infection.2,3
Retreatments are the first choice for failed root
canals. The microbiota found in persistent infections
differ from that in primary infection (Figs. 3a–c). Facultative anaerobic Gram-positive (G+) and -negative
(G-) micro-organisms and fungi are common.19–21
Special attention is given to Enterococcus faecalis,
a resistant facultative anaerobic G+ cocci, identified
in a much higher incidence in failed root canals.22–25
The importance of bacterial control plays a significant
role in endodontic success. Adequate and effective
disinfection of the root-canal system is necessary.
Fig. 1
Fig. 1_Success in endodontic
treatment: apical radiolucency repair.
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I
Fig. 2_Primary infection: black
pigmented strains and G- rods.
Fig. 3_Persistent infection.
Fig. 2
_Endodontic therapy
The bacterial flora of the root canal must be actively eliminated through a combination of debridement and antimicrobial chemical treatment. Mechanical instrumentation eliminates more than 90%
of the microbial amount.26 An important point to note
is the adequate shaping of the root canal. Evaluating
the antibacterial efficacy of mechanical preparation
itself, Dalton et al.27 conclude that instrumentation to
an apical size of #25 resulted in 20% of canals free of
cultivable bacteria. When shaped to a size of #35,
60% showed negative results.
Irrigating solution has been used with mechanical
instrumentation to facilitate an instrument’s cutting
efficiency, remove debris and the smear layer, dissolute organic matter, clean inaccessible areas and
act against micro-organisms. Sodium hypochlorite is
the most common irrigant used in endodontics.28 It
has an excellent cleansing ability, dissolves necrotic
tissue, has a potential antibacterial effect and, depending on the concentration, is well tolerated by
biological tissues. When accompanied by mechanical
instrumentation, it reduces the number of infected
canals by 40 to 50%.
Fig. 4a
Fig. 3
Other irrigating solutions are also used during
endodontic preparation. EDTA, a chelating agent used
primarily to remove the smear layer and facilitate the
removal of debris from the canal, has no antibacterial
effect.29 Chlorhexidine gluconate has a strong antibacterial effect on an extensive number of bacterial
species, even the resistant E. faecalis, but it does not
break down proteins and necrotic tissue as sodium
hypochlorite does.30
As mechanical instrumentation and irrigating
solutions are not able to eliminate bacteria from the
canal system totally—a requirement for root-canal
filling—additional substances and medicaments have
been tested in order to address the gap in standard
endodontic protocols. The principal goal of dressing
the root canal between appointments is to ensure
safe antibacterial action with long-lasting effects.31 A
great number of medicaments have been used as
dressing material, such as formocresol, camphorated
parachlorophenol, eugenol, iodine-potassium iodide,
antibiotics, calcium hydroxide and chlorhexidine.
Calcium hydroxide has been used in endodontic
therapy since 1920.31 With a high pH at saturation (pH
above 11), it induces mineralisation, reduces bacteria
Figs. 4a & b_Nd:YAG laser
intra-canal irradiation.
Fig. 5_Nd:YAG laser irradiation,
deep penetration.
Fig. 4b
Fig. 5
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_Lasers in endodontics
Lasers were introduced to endodontics as a complementary therapy to conventional antibacterial
treatment. The antibacterial action of Nd:YAG, diodes,
Er:YAG and photoactivated disinfection (PAD) have
been explored by a number of investigators. In the
following section, each laser is evaluated with the aim
of selecting an adequate protocol with a high probability of success in teeth with apical periodontitis.
Nd:YAG laser
The Nd:YAG laser was one of the first lasers
tested in endodontics. It is a solid-state laser. The
active medium is usually yttrium aluminium garnet
(Y3Al5O12), where some Y 3+ ions are replaced by
Nd3+ions. It is a four-level energy system operating
in a continuous wave or pulsed mode. It emits a
1,064nm infra-red wavelength. Thus, this laser needs
a guide light for clinical application. Flexible fibres
with a diameter between 200 and 400µm are used as
delivery systems. The laser can be used on intra-canal
surfaces, in contact mode (Figs. 4a & b).
Fig. 6a
Figs. 6a & b_Diode 980 nm
intra-canal irradiation.
and dissolves tissue. For extended antibacterial effectiveness, the pH must be kept high in the canal and in
the dentine as well. Sustaining the pH depends on the
diffusion through dentinal tubules.32
Although most micro-organisms are destroyed
at pH of 9.5, a few can survive a pH of 11 or higher, such
as E. faecalis and Candida.21 Because of the resistance
of some micro-organisms to conventional treatment
protocols—and the direct relation between the presence of viable bacteria in the canal system and the
reduced rate of treatment success—additional effort
has to be made to control canal system infection.
The typical morphology of root-canal walls treated
with the Nd:YAG laser shows melted dentine with a
globular and glassy appearance, and few areas are
covered by a smear layer. Some areas show dentinal
tubules sealed by fusion of the dentine and deposits of
mineral components.33,34 This morphological modification reduces dentine permeability significantly.35,36
However, because the emission of the laser beam from
the optical fibre is directed along the root canal, not
laterally, not all root-canal walls are irradiated, which
gives more effective action at the apical areas of the
root.37 Undesirable morphological changes, such as
carbonisation and cracks, are seen only when high
energy parameters are used.
One of the major problems regarding intra-canal
laser irradiation is the temperature increase at the
external surface of the root. Laser light exerts a thermal effect when it reaches tissue. The heat is directly
associated with the energy used, time and irradiation
mode. An increase in temperature levels above 10°C
per minute can cause damage to periodontal tissues,
such as necrosis and anchylosis.
Lan38 evaluated in vitro the temperature increase
on the external surface of the root after irradiation
with a Nd:YAG laser under the following energy
parameters: 50, 80 and 100mJ at 10, 20 and 30 pulses
per second. The increase of temperature was less
than 10°C. The same results were obtained by Bachman et al.39, Kimura et al.40 and Gutknecht et al.41
In contrast to the external surface, the intra-canal
temperature rises dramatically at the apical area,
Fig. 6b
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promoting effective action against bacterial contamination. For the Nd:YAG laser, 1.5W and 15Hz, are
safe energy parameters for temperature and morphological changes.33,41
The primary use of the Nd:YAG laser in endodontics is focused on elimination of micro-organisms
in the root-canal system. Rooney et al.42 evaluated
the antibacterial effect of Nd:YAG lasers in vitro.
Bacterial reduction was obtained considering energy
parameters. The researchers developed different in
vitro models simulating the organisms expected in
non-vital, contaminated teeth. Nd:YAG irradiation
was effective for Bacillus stearothermophilus,43,44
Streptococcus faecalis, Escherichia coli,45 Streptococcus mutans,46 Streptococcus sanguis, Prevotella
intermedia 47 and a specific micro-organism resistant
to conventional endodontic treatment, E. faecalis.48–50
Nd:YAG has an antibacterial effect in dentine at a
depth of 1,000µm (Fig. 5).50
I
The results showed a significant antibacterial effect
in the laser group compared with conventional treatment. When no other bactericidal agent was used, it
was assumed that the Nd:YAG laser played a specific
role in bacterial reduction for endodontic treatment
in patients.
Histological models were also developed in order
to evaluate periapical tissue response after intracanal Nd:YAG laser irradiation. Suda et al.51 demonstrated in dog models that Nd:YAG irradiation at
100mJ/30 pulses per second for 30 seconds was safe
to surrounding root tissues. Maresca et al.,52 using
human teeth indicated for apical surgery, corroborated Suda et al.’s51 and Ianamoto et al.’s53 results. Koba
et al.54 analysed histopathological inflammatory response after Nd:YAG irradiation in dogs at 1 and 2W.
Results showed significant inflammatory reduction
at four and eight weeks compared with the nonirradiated group.
Clinical reports published in the literature confirm
the benefits of intra-canal Nd:YAG irradiation. In
1993, Eduardo et al.55 published a successful clinical
case that combined conventional endodontic treatment with Nd:YAG irradiation for retreatment, apical
periodontitis, acute abscess and perforation. Clinical
and radiographic follow-up showed complete healing after six months.
Similar results were shown by Camargo et al.56
Gutknecht et al.57 reported a significant improvement
in healing of laser-treated infected canals, when
compared with non-irradiated cases.
Camargo et al.58 compared in vivo the antibacterial effects of conventional endodontic treatment
and the conventional protocol associated with the
Nd:YAG laser. Asymptomatic teeth with apical radiolucency and necrotic pulps were selected and divided into two groups: conventional treatment and
laser irradiated. Microbiological samples were taken
before canal instrumentation, after canal preparation
and/or laser irradiation and one week after treatment.
Fig. 7
Fig. 7_Er:YAG laser.
Diodes
The diode laser is a solid-state semiconductor
laser that uses a combination of gallium, arsenide,
aluminium and/or indium as the active medium. The
available wavelength for dental use ranges between
800 and 1,064nm and emits in continuous wave
and gated pulsed mode using an optical fibre as the
delivery system (Figs. 6a & b). Diode lasers have gained
increasing importance in dentistry owing to their
compactness and affordable cost. A combination of
smear layer removal, bacterial reduction and reduced
apical leakage are advantages of this laser and make
it viable for endodontic treatment. The principal laser
action is photo-thermal.
The thermal effect on tissue depends on the irradiation mode and settings. Wang et al.59 irradiated
root canals in vitro and demonstrated a maximum
temperature increase of 8.1°C using 5W for seven
roots
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Fig. 8
Fig. 8_Therapeutic plan.
seconds. Similar results were obtained by Da Costa
Ribeiro.60 Gutknecht et al.61 evaluated intra-canal
diode irradiation with an output of 1.5W and observed a temperature increase of 7°C in the external
surface of the root using a 980nm diode laser at a
power setting of 2.5W at a continuous and chopped
mode, and found that the temperature increase
never exceeded 47°C, which is considered safe for
periodontal structures.41
bacterial contamination by up to 88.38% with a
distal output of 0.6W in continuous wave mode.
A 980nm diode laser has an efficient antibacterial
effect of an average of between 77 to 97% in root
canals contaminated with E. faecalis. Energy outputs
of 1.7, 2.3 and 2.8W were tested. Efficiency was directly related to the amount of energy and dentine
thickness.64
Er:YAG laser
Clean intra-canal dentinal surfaces with sealed
dentinal tubules, indicating melting and recrystallisation, were morphological changes observed at
the apical portion of the root after intra-canal diode
irradiation.62 In general, near infra-red wavelengths,
such as 1,064 and 980nm, promote fusion and recrystallisation on the dentinal surface, sealing dentinal tubules.
Fig. 9_Intra-canal laser irradiation,
molar.
The apparent consensus is that diode laser irradiation has a potential antibacterial effect. In most
cases, the effect is directly related to the amount of
energy delivered. In a comparative study by Gutknecht et al.,63 an 810nm diode was able to reduce
Er:YAG lasers are solid-state lasers with a lasing
medium of erbium-doped yttrium aluminium garnet
(Er:Y3Al5O12). Er:YAG lasers typically emit light with
a wavelength of 2,940nm, which is infra-red light.
Unlike Nd:YAG lasers, the output of an Er:YAG laser
is strongly absorbed by water because of atomic resonances. The Er:YAG wavelength is well absorbed by
hard dental tissue. This laser was approved for dental procedures in 1997. Smear layer removal, canal
preparation and apicoectomy are indications for
endodontic use (Fig. 7).
The morphology of a dentinal surface irradiated
with an Er:YAG laser is characterised by clean areas
showing open dentinal tubules, free of a smear layer,
in a globular surface. Bacterial reduction using the
Er:YAG was observed by Moritz et al.65
Stabholz et al.37 describe a new endodontic tip
that can be used with an Er:YAG laser system. The tip
allows lateral emission of the radiation rather than
direct emission through a single opening at the far
end. It emits through a spiral tip located along the
length of the tip. In examining the efficacy of the
spiral tip in removing the smear layer, Stabholz et al.66
found clean intra-canal dentinal walls free of a
smear layer and debris under SEM evaluation.
Photoactivated disinfection
PAD is another method of disinfection in endodontics and is based on the principle that photoactivated substances, which are activated by light of a
particular wavelength, bind to target cells. Free radicals are formed, producing a toxic effect to bacteria.
Fig. 9
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I
Toluidine blue and methylene blue are examples of
photoactivated substances. Toluidine blue is able to
kill most oral bacteria. In in vitro studies, PAD has an
effective action against photosensitive bacteria such
as E. faecalis, Fusobacterium nucleatum, P. intermedia, Peptostreptococcus micros and Actinomycetemcomitans.67,68 On the other hand, Souza et al.,69 evaluating PAD antibacterial effects as a supplement to
instrumentation/irrigation of canals infected with
E. faecalis, did not prove a significant effect regarding
intra-canal disinfection. Further adjustments to the
PAD protocols and comparative research models may
be required before recommendations can be made regarding clinical usage.
_Discussion and conclusion
There are good reasons to focus the treatment of
non-vital contaminated teeth on the destruction of
bacteria in the root canal. The possibility of a
favourable treatment outcome is significantly higher
if the canal is free from bacteria when it is obturated.
If, on the other hand, bacteria persist at the time of
root filling, there is a higher risk of treatment failure.
Therefore, the prime objective of treatment is to
achieve complete elimination of all bacteria from the
root-canal system.2,31
Today, the potential antibacterial effect of laser
irradiation associated with the bio-stimulation action and accelerated healing process is well known.
Research has supported the improvement of endodontic protocol. Laser therapy in endodontic treatment offers benefits to conventional treatment,
such as minimal apical leakage, effective action
against resistant micro-organisms and external apical biofilm, and an increase in periapical tissue repair.
For this reason, laser procedures have been incorporated into conventional therapeutic concepts to
improve endodontic therapy (Figs. 8a–d).
Clinical studies have proven the benefits of an
endodontic laser protocol in apical periodontitis
treatment. For endodontic treatment, the protocol
entails standard treatment strategies for cleaning
and shaping the root canal to a minimum of #35,
irrigating solutions with antibacterial properties and
intra-canal laser irradiation using controlled energy
parameters. Ideal sealing of the root canal and adequate coronal restoration are needed for an optimal
result.
In practice, little additional time is required for
laser treatment. Irradiation is simple when flexible
optical fibres of 200µm in diameter are used. The
fibre can easily reach the apical third of the root canal,
even in curved molars (Fig. 9). The released laser
energy has an effect in dentine layers and beyond the
Fig. 10
apex in the periapical region. The laser’s effect extends
to inaccessible areas, such as external biofilm at the
root apex.
Fig. 10_Intra-canal laser irradiation,
technique.
The irradiation technique must adhere to the following basic principles. A humid root canal is required
and rotary movements from the coronal portion to
the apex should be carried out, as well as scanning the
root canal walls in contact mode (Figs. 10a–c). The
power settings and irradiation mode depend on one’s
choice of a specific wavelength.
Nd:YAG, diodes of different wavelengths, Er:YAG,
and low-power lasers can be used for different procedures with acceptable results. Laser technology
in dentistry is a reality. The development of specific
delivery systems and the evolution of lasers combined with a better understanding of laser–tissue
interaction increase the opportunities and indications in the endodontic field._
Editorial note: A complete list of references is available
from the publisher.
_contact
roots
Dr Selma Camargo
University of São Paulo
Rua Pinto Gonçalves, 85/54 Perdizes
São Paulo, SP 05005-010
Brazil
selmacris@me.com
roots
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Dental professionals on front
line in fight against diabetes
An interview with Dr Maria Emanuel Ryan, periodontist and Professor of Oral Biology and Pathology at Stony Brook University, USA
_An as-yet unceasing increase in the number of
people with diabetes or prediabetes in the USA and
across the globe makes it not so much a question of
if, but when more dental professionals will need to
become highly skilled in treating such patients. There
are 26 million people with diabetes in the USA, and 95
per cent of them have a form of periodontal disease,
compared with 50 per cent of the general population.
Of those 26 million, more than 7 million are
unaware of their diabetes.
Just as significant, 79 million people are estimated
to have prediabetes, with as many as half unaware
of it. A growing body of research suggests that the
association between oral health and diabetes is bidirectional, placing dental professionals in the position
of not just being able to help patients with diabetes
control the illness, but also perhaps being able to help
those with prediabetes avoid full onset.
In recognition of this link between oral health and
diabetes, Colgate Total is donating US$100,000 and
joining forces with the American Diabetes Associa-
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tion’s campaign to Stop Diabetes by encouraging
people to learn more about oral health care and Raise
Their Hand to Stop Diabetes.
Central to the campaign’s focus is educating
people on the importance of dental visits, as well as
helping dental professionals, who are seeing growing
numbers of patients with diabetes. Colgate’s involvement also stems from its interest in promoting the use
of antibacterial toothpastes such as Colgate Total to
support gum health.
Also helping with the effort is Dr Maria Emanuel
Ryan, a periodontist and Professor of Oral Biology and
Pathology at Stony Brook University, New York. Ryan,
a globally known expert on the link between oral
health and diabetes, recently spoke with roots.
_roots: What size patient base are we talking
about in terms of the need for achieving greater
awareness?
Dr Maria Emanuel Ryan: Some of the talks I have
given have been at the Centers for Disease Control
and Prevention (CDC). They have an interest in this
[23] =>
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FDI World Dental Federation
Leading the World to Optimal Oral Health
2012 Hong Kong
FDI Annual World Dental Congress
29 August - 1 September 2012
Join us in Hong Kong, world capital of oral health 2012
for a
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Design: b’com · +33 (0)6 50 46 60 70
Deadline for abstract submission: 30 March 2012
Early Bird registration until 31 May 2012
Leading the world into a new century of oral health
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[24] =>
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I feature _ interview
area because to them diabetes is an epidemic. Each
year, we have 1.9 million new cases diagnosed in
people 20 years of age and older. If the population of
people with diabetes keeps growing at this rate, in
the very near future it will be about one in three, which
is a very significant number.
_What can dental professionals do to help identify
patients who have diabetes or prediabetes but have
not been diagnosed?
Certainly we can screen for diabetes. And this is
being recommended by the CDC. One way is by risk
assessment: knowing a patient’s family history, looking at obesity as a risk factor, looking to determine
whether the patient is in one of the populations in
which risk factors may be higher (African-Americans,
Pacific Islanders, Native Americans, Latinos and Hispanics), asking about gestational diabetes. Most patients with diabetes are type II patients, who tend to be
older than 45 years of age. Risk factors such as hypertension and dyslipidaemia are also important to consider. Of course, there are the classic signs and symptoms: thirst, frequent urination, infections, numbness
in extremities, leg cramps, vision problems. Unfortunately, with type II diabetes, there are many people
who are unaware they have it. That’s why the CDC is
looking to oral health-care professionals for help. If a
person has any of the risk factors, signs or symptoms,
dental professionals can refer to the physician for additional screening, or obtain a random blood glucose
level or even a fasting blood glucose level and then refer appropriate patients to the physician for diagnosis.
_What do dentists need to be aware of with their
patients who have diabetes or prediabetes?
If patients are poorly controlled, then
you may need to be very cautious
in what procedures you might
be doing because the patients’
wound healing may be affected. You need to know
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whether they have any other long-term complications of diabetes. You need to work closely with the
patients’ physician and other health-care professionals. Many patients with diabetes, especially those who
have a physician working very hard to tightly control
their diabetes and whose blood glucose levels tend to
run low, may have a higher risk for hypoglycaemic
events. Ask patients whether that is common for them
because the more hypoglycaemic events patients
have had, the more likely they are to have more—
and the more likely they are to develop hypoglycaemia unawareness. That’s when they don’t get any
of the classic signs: getting dizzy, feeling like they are
going to pass out or getting confused. Some patients
don’t get those signs and symptoms; they can just
suddenly become unconscious or have seizures.
_What can the dental professional do to confirm
whether patients with diabetes have well-controlled
blood sugar prior to treatment?
You can actively take the blood glucose level by
doing either a random screening for blood glucose or
even a fasting for blood glucose. If the level is greater
than 126, the patient can be referred to a physician
for further treatment. Another way to screen is the
haemoglobin A1C test, a long-term marker of control
that lets you know how well controlled someone with
diabetes has been over the past two to three months.
It used to be that only a centralised laboratory could
do this, but now there are point-of-care tests. The
only way you can help predict a hypoglycaemic event
in your patient is to check blood glucose levels. Patients on insulin are at the highest risk of having a
hypoglycaemic event at the time of peak activity of
the insulin that has been administered, which is not
when you want to be treating them. You also need to
know what oral medications they may be taking
because some may have a higher risk than others of
causing hypoglycaemia.
_Research indicates that serious periodontal disease may affect blood glucose control and contribute
to the progression of diabetes. Why is this?
In fact, the impact of periodontal disease may even
be evident before someone develops diabetes. Recent
research suggests that patients who have untreated
periodontal disease, when followed for over 20 years,
may be twice as likely to develop diabetes. Periodontitis is driven by infection and inflammation; and
infection and inflammation can drive insulin resistance. Insulin resistance can lead to the development
of diabetes and prevent good control of diabetes. By
reducing infection and inflammation, you may actually prevent development of diabetes, and certainly
you can make it easier to control diabetes. Some recent papers have suggested that if you don’t treat the
periodontal disease, not only is it more difficult to
control diabetes, but people with diabetes are then
[25] =>
RO0110_01_Titel
feature _ interview
also at higher risk for long-term complications such
as cardiovascular disease and kidney disease, thereby
increasing the risk for mortality.
_Are people with diabetes and prediabetes at risk
for other dental problems?
If patients are not well controlled, they also tend to
get more cavities or caries. They have a higher risk of
developing oral yeast infections such as candidiasis.
They may have enlarged parotid glands, which can
lead to dry mouth. And because of the yeast infections
in a dry mouth, they could report burning mouth or
dry tongue. Dry mouth due to salivary gland dysfunction will drive periodontal disease and caries formation. Poorly controlled patients are also at greater risk
for abscess formation. Gingival crevicular fluid is a
serum transudate, so if your blood sugar levels are
high, you have more glucose coming out of those
pockets around the teeth. Your mouth has more glucose in it, so your teeth are bathing in glucose, increasing the risk for developing cavities. Working to
improve home care with patients is of great help
because such patients need to keep levels of bacteria
as low as possible in the mouth. They can use antibacterial toothpaste or rinses. One of the toothpastes
that’s very effective at reducing the levels of bacteria
for 12 hours is Colgate Total. I recommend that to
many of my patients with diabetes. And, of course,
we need to provide adequate care in the office. The
treatment of infection and inflammation, providing
periodontal therapy whether it’s surgical or non-surgical, absolutely needs to be provided and should
never be considered an optional or elective procedure.
_Are insurance organisations responding to the
growing evidence of the connection between oral
health and diabetes?
Some dental insurance companies are reimbursing dentists for screening, not only for diabetes but
also for hypertension by checking blood pressure and
for obesity by determining body mass index. Some
dental insurance companies have begun to create
expanded plans that begin to better address the oral
health-care needs of patients with diabetes. This may
help with access. Some patients—especially those
without dental insurance—complain that if they go to
the podiatrist, it’s covered by their medical insurance,
but if they’re going to the dentist, it isn’t covered by
medical in most cases. This may be changing.
_Are there dental professionals specialising in the
treatment of people with diabetes? If so, how does one
develop such a specialty?
When your comfort level goes up, you will see
more and more of these patients (by referral). Patients
say, “You know, Dr Ryan asks me questions that other
dentists never asked me about my diabetes. And she
seems to base her treatment plan around the answer
I
to those questions.” If you’re comfortable talking to
physicians about this, you begin to get more referrals
from physicians who are treating and educating
these patients. I often speak on panels with other
health-care providers at local meetings organised by
the American Diabetes Association, initiators of the
Stop Diabetes campaign. And because the folks from
Colgate recognised the importance of oral health in
this, they have supported this campaign, which I think
is very important. When I speak as part of a diabeteseducation health-care team, patients are already
aware of what the podiatrist has to say, of what the
ophthalmologist may be saying about their eyes and
the cardiologist about cardiovascular disease. But
when I start talking about the dental considerations,
so many of them say to me, “I have never heard this
before. No one’s ever discussed this with me.” It’s
important for all of us in the profession to share this
knowledge not only with our patients but also with
each other.
_Are there established, approved protocols for
dental professionals to follow when treating patients
who have diabetes or prediabetes?
No, but maybe we will be going in that direction.
There has been a substantial effort by the American
Dental Association to improve on continuing education in this area. There are efforts throughout the profession to improve on the transfer of knowledge from
the published research to the practising clinician. In
the future, there may be programmes through which
people may become certified to manage higher-risk
patients, such as those with diabetes or cardiovascular disease. There has been great interest by all members of the profession. Not just dentists, but hygienists and dental assistants are interested in how to
better manage these patients. You’re beginning to see
practices develop protocols that are tailored to the
provision of care to people with diabetes._
Editorial note: This interview was prepared by Robert Selleck,
Dental Tribune America.
_about the interviewee
roots
Dr Maria Emanuel Ryan is a tenured full
professor in the Department of Oral Biology and
Pathology at Stony Brook University’s School of
Dental Medicine and a member of the medical staff
at University Hospital at the Stony Brook University
Medical Center. She has published more than 75
scholarly works and speaks frequently on emerging
therapies, connections between oral and systemic
health and the need for early detection of periodontal disease and oral cancer.
roots
I 25
1
_ 2012
[26] =>
RO0110_01_Titel
I research _ irrigation
Ability of four irrigating
solutions to remove debris after
root-canal instrumentation
Authors_ Dr Jorge Paredes-Vieyra, Dr Francisco Javier Jiménez Enríquez & Dr Carlos Cuevas Lasso, USA & Mexico
_The cleaning and shaping of the root-canal
system are considered key requirements for a successful root-canal treatment (RCT). However, limitations
in the overall quality of preparations obtained by manual and automated root-canal instrumentation have
been reported by numerous researchers.1,2 Many studies have concluded that neither hand instrumentation nor rotary preparation sufficiently clean the root
canal, especially the apical region of curved canals.
Group (n =20)
Irrigating solutions during root-canal preparation
A
17 % EDTA (Roth International)
B
2.5 % NaOCl
C
2.5 % MTAD (BioPure MTAD, DENTSPLY Tulsa)
D
2 % chlorhexidine
Table I_Solutions used during
root-canal preparation.
Cleaning and shaping can be easily accomplished
in straight canals. However, many canals have moderate, severe or abrupt curvatures that make them susceptible to procedural accidents, such all as ledges,
zips, perforations and apical blockages.3–5
The removal of pulp tissue, debris, the smear layer
and bacteria from the root-canal space prior to obturation is one of the primary aims of RCT. The degree
of difficulty experienced during the cleaning and
shaping procedure is affected by the canal curvature,
access to the canal space, canal length and canal
diameter.6,7 There can be no doubt that micro-organisms that either remain in the root-canal space after
treatment or recolonise the filled canal system are the
main cause of endodontic failure.8
While irrigants, such as sodium hypochlorite
(NaOCl), are helpful in dissolving organic debris,9 thorough instrumentation is a necessity. The efficiency
of cleaning the endodontic space depends on both
instrumentation and irrigation. Irrigation plays a main
role in successful debridement and disinfection. The
most widely used irrigant for RCT is NaOCl at concentrations of 0.5 to 5.25%. The tissue-dissolving capac-
26 I roots
1_ 2012
ity and microbicidal activity of NaOCl make it an
excellent irrigating solution.9
Of all the currently used substances, NaOCl appears
to be the most ideal, as it fulfils more of the requirements
for endodontic irrigant than any other known compound. Hypochlorite has the unique capacity to dissolve
necrotic tissue10 and the organic components of the
smear layer. Inactivation of endotoxins by hypochlorite
has been reported;11,12 the effect, however, is minor
compared with that of a calcium hydroxide dressing.13
Acid solutions have been recommended for removing the smear layer, including: EDTA, most active
at a concentration of 15 to 17%, and a pH of 7 to 8;10
citric acid solutions, used at concentrations of 10, 25
and 50%.14,15 In addition, calcification hindering mechanical preparation is frequently encountered in the
canal system.
Demineralising agents such as EDTA show high
efficiency in removing the smear layer.16,17 In addition
to their cleaning ability, chelators may detach biofilms
adhering to root-canal walls. This may explain why
an EDTA irrigant has proven to be highly superior to
saline in reducing intra-canal microbiota,18 despite the
fact that its antiseptic capacity is relatively limited.19
Antiseptics such as quaternary ammonium compounds (EDTAC)20 or tetracycline antibiotics (MTAD)21
have been added to EDTA and citric acid irrigants,
respectively, to increase their antimicrobial capacity.
The clinical value of this, however, is questionable.
EDTAC shows similar efficacy to EDTA regarding
smear layer removal, but it is more caustic.21 As for
MTAD, resistance to tetracycline is not uncommon in
bacteria isolated from root canals.21 Generally speaking, the use of antibiotics instead of biocides such as
hypochlorite or chlorhexidine appears unwarranted,
as the former were developed for systemic use rather
than local wound debridement, and have a far narrower spectrum than the latter.22
[27] =>
RO0110_01_Titel
research _ irrigation
Fig. 1a
MTAD was used to remove the smear layer21 on
coronal leakage of obturated root canals using a dye
leakage test.23
Chlorhexidine is a strong base and is most stable
in the form of its salts. The original salts were chlorhexidine acetate and hydrochloride, both of which are
relatively poorly soluble in water.24 Hence, they were
replaced by chlorhexidine digluconate. Chlorhexidine
is a potent antiseptic widely used for chemical plaque
control in the oral cavity.25,26 Aqueous solutions of 0.1
to 0.2% are recommended for such purpose, and 2%
is the concentration of root-canal irrigating solutions
usually found in the endodontic literature.27
The purpose of the present study was to evaluate
the ability of 17% EDTA, 2.5% NaOCl, MTAD and 2%
chlorhexidine to remove debris when used as a final
irrigant during root-canal instrumentation.
_Material and methods
Tooth selection
Eighty freshly extracted human maxillary central
incisors with a single straight root canal extracted
from 35- to 60-year-old patients with periodontal
disease were randomly selected and radiographed
buccolingually and mesiodistally.
The teeth were devoid of caries and cracks, and had
not undergone endodontic treatment or restoration.
Only teeth with intact and mature root apices were
selected. Teeth were placed in individual containers
with 2% formalin and stored in a refrigerator at 10°C.
The average root length was 12mm. At the time of use,
the teeth were removed from formalin and washed in
tap water for 30 minutes (Table I).
Fig. 1d
Fig. 1b
Root-canal preparation
The teeth were de-coronated to a standard root
length of 12mm and randomly divided into four
groups (n=20). The working lengths were measured
by deducting 1mm from lengths recorded when the
tips of #10 or #15 K-files (DENTSPLY Maillefer) were
visible at the apical foramen and confirmed radiographically.
I
Fig. 1c
Figs. 1a–l_Typical SEM photomicrographs showing the cervical,
middle and apical thirds of the
root-canal dentine surface for
17% EDTA (a–c), MTAD (d–f),
2.5% NaOCl (g–i) and 2%
chlorhexidine (j–l; 1,000–5,000x).
All root canals were then explored and prepared
by rotary instrumentation with a size 25 LightSpeed
LSX instrument (Discus Dental), in establishing the
working length. All working lengths were confirmed
radiographically.
Rotary instrumentation was performed with size
25 to 80 LightSpeed LSX instruments in the apical
third. They were used at a constant speed of 2,000rpm
using an in-and-out movement. LightSpeed LSX instruments were changed every six canals and the instrumentation was performed according to the manufacturer’s instructions. All canals were irrigated with
2 cc of distilled water. Gates Glidden drills (Mani) #1
to #3 were used on the body of the root-canal walls
(cervical and middle thirds) before apical preparation.
Irrigation
After cleaning and shaping, all root canals were
finally flushed with 30-gauge nickel-titanium needles (Stropko NiTi Flexi-Tip, SybronEndo), which penetrated to within 1 to 2mm of the working length. The
canal was irrigated with 2ml of the respective irrigating solution: 17% EDTA (Roth International), 2.5%
NaOCl, MTAD (BioPure MTAD, DENTSPLY Tulsa) or
2.0% chlorhexidine. The same method was used for
all of the 20 teeth in each group, only changing the
Fig. 1e
Fig. 1f
roots
I 27
1
_ 2012
[28] =>
RO0110_01_Titel
I research _ irrigation
Fig. 1g
Fig. 1h
Fig. 1i
irrigating solutions tested. After cleaning and shaping, the canals were dried with absorbent paper points
(DENTSPLY Maillefer).
SEM examination
To prepare the samples for imaging, all teeth were
separated longitudinally and evaluated from the cervical, middle and apical third. Roots were split longitudinally along the buccolingual plane. To facilitate
fracture into two halves, all roots were grooved longitudinally on the external surfaces with a diamond
disk, avoiding penetration of root canals.
The roots were then split into two halves with a
chisel. For each root, the half containing the most
visible part of the apex was conserved and coded. The
coded specimens were placed on metal stubs with
composite, desiccated, sputter coated with gold, and
viewed with a SEM (LEO 1430 VP, Carl Zeiss NTS).
The cleanliness of each canal wall was evaluated
in each of the thirds and photographed at 1,500 magnification at the same height as the groove that
defined each third. The scoring procedure, which did
not identify the specimens’ groups, was carried out by
the authors using the following score system:4
Table II_Results of the debris
removal between irrigating solutions
(x±s; x: arithmetical mean,
s: standard deviation).
Score 1: Clean canal wall; only very few debris particles;
Score 2: Few small conglomerations;
Score 3: Many conglomerations; <50% of canal wall
covered;
Score 4: >50% of canal wall covered;
Score 5: Complete or nearly complete covering of
canal wall by debris.
_Results
The results showed that the increase in the percentage of debris always occurs in the same direction,
that is, from the middle region to the apical, no matter which solution is utilised. Table II displays the debris findings and the comparisons among irrigating
solutions. Group A (EDTA) demonstrated significant
differences to the other groups. EDTA was more
effective in debris removal than the rest of the irrigating solutions (Table II).
Statistical analysis
The experimental data used in this study consisted of the four groups and was tested with a
Q-Cochran test.28 The Q-Cochran test showed statistical significance between the four groups. The
Kolmogorov–Smirnov test was used for checking
the normality of the data distribution. As the data
for each group did not follow a normal distribution,
the variables were analysed using a non-parametric
test. The level of statistical significance was set at
p<0.05.
To determine which of the means of the irrigating
solutions was significantly different from the others,
the complementary Tukey test was used. The Tukey
test showed a statistical difference between the
means of 2% chlorhexidine and EDTA. With the Tukey
test, we found the means of EDTA and BioPure MTAD
to be statistically equal.
Group/Irrigating solution
apical third
middle third
cervical third
Debris was removed mostly at the cervical and
middle thirds, but remained visible in the apical third
in all cases. The apical third of the root canals showed
more debris than the middle third, and none of the
irrigating solutions left the root-canal walls entirely
free of debris (Fig. 1).
EDTA (n=20)
1.22±0.35
0.545
1.15± 033
0.066
1.08±0.10
0.031
_Discussion
NaOCl (n=20)
1.94±0.45
<0.001
1.76± 0.43
0.004
1.76±0.43
<0.001
MTAD (n =20)
1.54±0.35
0.545
1.55± 0.39
0.076
1.69±0.30
0.708
chlorhexidine (n=20)
2.10 ±0.80
0.064
2.15± 0.96
0.330
2.10±0.94
0.082
28 I roots
1_ 2012
The main purpose of this investigation was to
evaluate the ability of 17% EDTA, 2.5% NaOCl, MTAD
and 2% chlorhexidine to remove debris when used
during root-canal instrumentation. Because debridement in the apical third has always been a challenge,
the root canal was analysed and scored by thirds.
[29] =>
RO0110_01_Titel
research _ irrigation
Fig. 1j
Fig. 1k
The combination of chemical and mechanical
preparation forms the key requisite for the success of
root-canal instrumentation. The objective of these
two interdependent factors consists of the cleaning
of the canal and its eventual ramifications removing
the largest possible amount of debris in order to
establish ideal conditions, which allow a functional
recuperation of the dental organ and a regeneration
of tissues.
Tanomaru et al.13 This may be due to the potentiation
of the solvent action when energised by temperature.14 Irrigating solutions used in endodontic
treatment not only have an antimicrobial action but
also clean the pulp chamber.11 None of the irrigating
solutions studied in the present work was capable of
eliminating all of the debris in the root-canal walls,
since none of them left the root canals completely
free of debris.
An NaOCl solution remains the most widely recommended irrigant in endodontics on the basis of
its unique capacity to disinfect and dissolve necrotic
tissue remnants and its excellent antimicrobial potency.4 However, in this study, NaOCl did not remove
the smear layer from the apical third of the canals,
which is consistent with the results previously reported by other authors.29 Numerous studies have
compared the performance of irrigating solutions
in RCT, including different concentrations of NaOCl,
citric acid and EDTA.30
In the present study, no significant differences
in the presence of debris were observed among rootcanal thirds in the manually and rotary instrumented
groups irrigated with NaOCl. Similar results were
found by Tucker,31 who compared rotary instrumentation with the hand technique using 1% NaOCl as
irrigating solution.
EDTA and the different salts from which they are
formulated are effective chelating agents for smear
layer removal. Numerous authors have reported that
alternate applications of NaOCl and EDTA eliminated
both organic and inorganic components.16,19,20
No significant differences were found by Hülsmann et al.6,7 in either debris or smear layer removal
when they used 3% NaOCl as initial and final irrigation and 17% EDTA in the form of a paste after each
file and using two rotary instrumentation techniques.
The results obtained in the present study demonstrate that the EDTA and BioPure MTAD solutions
were the solutions that left the smallest amount of
residue in the interior of the canals, followed by
NaOCl and finally chlorhexidine, which left the greatest amount of debris. With the rotary instrumentation technique, the results for EDTA and the rest of the
irrigants were similar, as had been found in previous
reports,9 and both solutions (EDTA and MTAD) are
recommended.
The finding that the EDTA solution was the
best root-canal cleaner confirms the findings of
I
Fig. 1l
The removal of debris and the smear layer depends
on the irrigation method, as well as on the endodontic instrument, the manner in which the instrument
is used, and the preparation technique. The rootcanal cleaning capacity of manual versus rotary instrumentation techniques with NaOCl is somewhat
controversial.4
_Conclusion
1. The apical third showed a greater amount of debris
than the middle third, regardless of the solution
used.
2. None of the solutions used for irrigation of the root
canals allowed complete removal of the debris
from the interior of the canal.
3. The 17% EDTA and BioPure MTAD irrigating solutions left the root canals with less debris than the
2.5% NaOCl and 2% chlorhexidine solutions.
_Acknowledgement
This research was conducted with the approval of
the institutional review board. We deny any conflicts
of interest and thank Dr Michael Hülsmann and Dr E.
Steve Senia for their valuable assistance in reviewing
this manuscript._
Editorial note: A complete list of references is available
from the publisher.
_contact
roots
Dr Jorge Paredes Vieyra
PMB#1513
710E San Ysidro Blvd.
Suite A
San Ysidro, CA 92173
USA
jorgitoparedesvieyra@
hotmail.com
roots
I 29
1
_ 2012
[30] =>
RO0110_01_Titel
I The Endospot _ apical periodontitis
The lazy man’s guide to
persistent apical periodontitis
Author_ Dr Patrick Caldwell, Australia
_Persistent apical periodontitis (AP) refers to
AP that is associated with a tooth that has had rootcanal therapy (RCT). As with primary AP, bacteria are
the most common cause of the inflammatory response.1 Previously, a large body of evidence indicated
that persistent infections are commonly composed of
a single species; however, recent evidence points to
the presence of a mixed biofilm.2,3 There are also nonmicrobial causes of AP, including foreign-body reactions, cystic formation, endogenous cholesterol crystals and scar formation. These will be discussed later.
The microbes that cause persistent AP are more
commonly located intra-radicularly (inside the root).
Occasionally, these microbes will also be located extra-radicularly. We will discuss the far more common
intra-radicular microbes first.
_Intra-radicular microbes
The key study referenced on the presence of microbes within the root in cases of persistent AP is Nair
et al.4 When considering the cause of the persistent infection, consider that the microbes were either present prior to RCT being initiated (primary infection) or
they entered during or after treatment (secondary
infection).5 In considering those microbes that have
survived from the primary infection, consider how
they might have achieved this. They may have been
resistant to the chemicals used in the disinfection
process (Enterococcus faecalis, for example, has some
mechanisms to survive calcium hydroxide), or they
may have been located in a portion of the canal that
was not instrumented nor cleaned via chemical means.
Regarding secondary infection, these microbes
may have gained access to the canal during treatment
or after treatment. Consider too that they may
have been carried into the canal on a contaminated
instrument or perhaps a leaking rubber dam may
have allowed saliva to contaminate the root canal.
Alternatively, a poorly placed temporary restoration
may have allowed leakage into the root-canal system
in-between visits. If caries has not been completely
removed, or a previous restoration subject to microleakage is left in place, then this can also be a source
of secondary infection. Alternatively, these microbes
may have entered a previously clean root-canal system after the completion of RCT. This could be due to
a leaking restoration, or through caries or a crack in
the tooth. It is important to understand the microbial
nature of AP, and to have this foremost in our minds
when undertaking treatment.
_Which microbes are present in persistent
AP caused by secondary infection?
When we examine the composition of the infection in AP, we find a significantly different microflora
30 I roots
1_ 2012
[31] =>
RO0110_01_Titel
AD
E. faecalis is an opportunist pathogen
implicated in many general surgery postoperative infections. It has been identified
as an opportunistic pathogen in persistent AP in a number of studies.1,7,9 This particular microbe has been studied extensively. It possesses a proton pump on its
cell membrane, which allows it to regulate
its internal pH. This means that it is resistant to calcium hydroxide and this may be
one of the ways that it survives and becomes implicated in persistent infections.
It is also able to survive by itself and without nutrition for long periods. It is rarely
found in untreated canals. C. albicans
(a fungus) is also found more commonly
in persistent infections than in primary
infections.1,4,10
In some cases, AP may not be maintained
by micro-organisms. I say “maintained”, because often the AP is initially caused by microbes, and after endodontic treatment, one
of the following factors takes over, maintaining the immune response and thus AP.
Periapical cysts are an interesting topic.
There are a range of studies that attempt
to measure the incidence of periapical cysts
in examined periapical lesions. In simple
terms, the lesion is biopsied and then examined under a microscope. If an epitheliumlined sack is found, then the lesion is designated a cyst. But … in 1980, Simon published a paper, which included serial sectioning of periapical lesions.15 What he
found was that some lesions that appeared
as cysts on one section, appeared differently on other sections. Thus, it was deemed
that the majority of studies (which did not
use serial sectioning) relating to the prevalence of cysts were subject to error. If one
just takes a random slice, the effect in two
dimensions may be that of a cyst, when in
reality the full 3-D structure of the cyst does
not exist. Nair repeated this study 16 years
later and confirmed Simon’s findings.16
_Extra-radicular infections
Occasionally, we may find a situation
where microbes establish themselves outside the root-canal system. The microbes
may establish themselves on the external
root surface in a biofilm, in association with
infected dentine chips that have been displaced into the periapical region, or within
a periapical cyst.11,12 These microbes must
be able to withstand the body’s attempts to
kill them and it is likely that biofilm formation allows this.13 Similarly in the periapical
cyst situation, it is the cyst itself that protects the microbe from the immune response.
In particular, two microbes have been
implicated in extra-radicular infections.
These are Actinomyces species and Propionibacterium propionicus.14 These microbes are able to form cohesive colonies
within an extra-cellular matrix. This helps
them to avoid phagocytosis and so continue to survive and invoke the immune response.
Nair studied far more lesions than Simon, and found that 15% could be classified as cysts (including both true and pocket
varieties). This is probably the best figure to
quote. Other studies report figures from 5
to 55%, but they failed to use serial sections. It is also important to realise that a
large proportion of abscesses and granulomas will also contain epithelium. In Nair’s
study, 52% of the lesions were epithelialised, but only 15% were cysts. It is likely
that the inflammatory process results in the
proliferation of this epithelium and, over
time, the epithelium develops into a cyst.
Through both of these studies, Simon
and Nair found two distinct types of cysts.
Simon called them true cysts—those with a
complete epithelial lining, and bay cysts—
those whose lining is attached to the root
surface and the contents of the root canal
are contiguous with the contents of the
cyst. Nair referred to these as true cysts and
pocket cysts (equivalent to Simon’s bay
cyst).
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_E. faecalis and Candida albicans
_Non-microbial causes of AP:
Cysts, foreign-body reactions
and cholesterol crystals
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than that found in primary infections.6,7
Generally in persistent AP, there are only
one to five species. These are predominantly Gram-positive and there is an equal
amount of obligate and facultative anaerobes.1,6,8 Owing to the fact that obligate
anaerobes are easier to kill, it may be that
facultative anaerobes are more likely to
persist within the root-canal system after
treatment.
[32] =>
RO0110_01_Titel
I The Endospot _ apical periodontitis
Nair contends that these two types of cysts are
quite different.12 He feels that the true cyst is selfsustaining and will remain independent of efforts to
remove the micro-organisms from the root-canal
system. The pocket cyst, on the other hand, is sustained by the microbes within the canal system. Removal of the microbes, which are maintaining the inflammatory response, may allow the pocket cyst to
heal. In reality, it will be very difficult to prove or disprove this theory, but one could say that it makes
sense.
Foreign-body reactions
When exogenous materials are located in the
periapical region, they can induce and maintain an inflammatory response, which may be asymptomatic,
but will be seen as a radiolucency. Materials may be
gutta-percha, amalgam, sealants, calcium hydroxide or cellulose fibres, such as those contained in paper points.17
In practice, these lesions are rarely seen but have
been reported in the literature, so it is important to
understand that this mechanism for the maintenance of AP does exist. It also reminds us to be careful when using paper points and not to extend them
into the periapical areas, as human cells cannot degrade cellulose and leaving fibres behind may result
in a foreign-body reaction.
Gutta-percha may also induce a foreign-body
reaction, especially in fine particles.18 Overextended
_about the author
roots
Dr Patrick Caldwell is a registered specialist
in Endodontics. He graduated in dentistry with honours from the University of Queensland in 1998
and then went on to work for the Royal Australian
Navy, both ashore and at sea. During this time,
he undertook advanced training in restorative
dentistry and in 2002 sat examinations and was
elected a Fellow of the Royal Australasian College
of Dental Surgeons. In 2003, Dr Caldwell began a
three-year, full-time training programme in root-canal therapy, and graduated with a Master of Dental Science in Endodontics at the end of 2005.
He returned to work with the Royal Australian Navy and was also engaged
as a visiting specialist at the Sydney Dental Hospital. In 2009, he moved
to Shanghai, China, where he was the only endodontist in a city of
21 million people. In late 2010, he returned home to Brisbane and started
Brisbane Microsurgical Endodontics. He is involved in teaching at the
University of Queensland and has conducted courses both nationally and
internationally to help general dentists improve their root-canal skills.
Dr Caldwell runs The Endospot, a blog at www.endospot.com, and can
be contacted at reception@bmendodontics.com.au.
32 I roots
1_ 2012
gutta-percha may, as a result, cause delayed healing
of periapical tissue.
Cholesterol crystals
Cholesterol crystals are also seen in AP, and
are probably released by disintegrating erythrocytes,
lymphocytes, macrophages and plasma cells, as well
as from circulating plasma lipids.19 These collections
of cholesterol are referred to as cholesterol clefts
and induce a reaction similar to a foreign-body
reaction as the macrophages and giant cells are unable to remove the cholesterol. Again, this may result
in a non-healing lesion, despite well-completed endodontic treatment.
_The Endospot easy study guide to persistent AP
A Persistent AP is most commonly caused by microbes remaining within the root-canal system.1
B It appears that a mixed biofilm may be responsible, contrary to the previous belief that usually
only one microbe was responsible.3
C The microbes are either:5
a) primary—remained within the canal from the
initial infection; or
b) secondary—entered during or after treatment.
D Persistent AP shows significantly different flora
to primary AP:7
a) one to five species per canal;
b) predominantly G+;
c) equal number of obligate and facultative
anaerobes.
E E. faecalis—opportunist pathogen that has been
identified more commonly in persistent AP:1
a) possesses a proton pump, which allows it to
survive in high pH (that is it can survive calcium hydroxide);
b) can survive in mono-infection;
c) can survive long periods of low/no nutrition.
F C. albicans also found more commonly in persistent infections than in primary.10
G Extra-radicular infections can occur in biofilm on
the root tip,13 or in the periapical area itself:14
a) P. propionicus and Actinomyces species are
able to form adhesive colonies in an extracellular matrix in the periapical tissue.
H Non-microbial causes of AP are:
a) periapical cysts (15% of lesions)16— serial sectioning indicates two types: true cysts and
pocket cysts;
b) foreign-body reactions; and
c) cholesterol clefts._
Editorial note: A complete list of references is available from
the publisher.
[33] =>
RO0110_01_Titel
You can also subscribe via
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roots 1/12
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[34] =>
RO0110_01_Titel
I industry news _ A-dec
New A-dec LED offers
brilliant simplicity
_Unveiled at the Chicago Dental Society’s 2012
Midwinter Meeting, the new A-dec LED dental operatory light is now available to doctors around the
world. “Designed for optimal visual acuity and treatment-room ergonomics, the A-dec LED is an outstanding solution that outperforms all other industry
options,” says A-dec Product Manager Tom McCleskey.
“By evolving LED technology, we’ve established a new
benchmark for operatory lighting.”
A-dec’s advanced light-emitting diode (LED) technology has been optically engineered specifically for
dentists and the dental operatory. The A-dec LED
stands alone in the market because it reduces eyestrain significantly and provides optimal ergonomics,
while ensuring ample illumination, clarity and depth
during treatment. The new offering features multiple
intensity levels, a cure-safe mode, low cost of ownership—in terms of cost, maintenance and downtime—
and intuitive ergonomics.
Adjustable intensity levels of 15,000, 25,000 and
30,000 lux at 5,000 K are able to flood the oral cavity
with a consistently neutral white light for true-to-life
tones, which help practitioners diagnose clearly. The
34 I roots
1_ 2012
light’s cure-safe mode emits a brilliant yellow light at
25,000 lux, enabling the dental team to work effectively without curing photoinitiated resins.
McCleskey also touts the solution’s ability to reduce eye fatigue because the light’s ‘stadium effect’
mitigates shadows and maintains a uniform light
pattern. Plus, its unencumbered controls, unparalleled
positionability and fluid movement combine to create
outstanding ergonomics. The latest addition sets a
premium standard for A-dec Dental Lights, a family of
lighting solutions that also includes the A-dec 500
Halogen 3-Axis and A-dec 300 Halogen 2-Axis._
_contact
A-dec
2601 Crestview Drive
Newberg, OR 97132
USA
www.a-dec.com
roots
[35] =>
RO0110_01_Titel
industry news _ MICRO-MEGA
I
G-Files—Rotary NiTi instruments
for glide path enlargement
_Regardless of the endodontic instrumentation system used, initial exploration of
the canal system has historically been accomplished by using stainless-steel, pre-curved
hand instruments (files or reamers). Along
with careful examination of radiographs and/
or CBCT scans, this initial phase identifies possible difficulties and obstructions within the
canal system that the clinician may encounter
in preparation for use of rotary NiTi instruments, which will further shape the canal.
.03 taper. The superior cross-section of the
G-File combines efficiency and safety. Along
the length of the instrument, the G-File has
cutting edges on three different radiuses,
creating a large and efficient area for upward
debris removal.
The angular offset of the cutting edges also
creates a different pitch along the length of the
blade, avoiding any screwing or engaging effect into the walls of the canal. The non-working
(safety) tip is asymmetrical, which helps the instrument move forward safely; this is also facilitated by the high degree of flexibility resulting
from the small diameter (Fig. 2).
Initial penetration and glide path creation in
the canal are usually accomplished by using a sequence of narrow-diameter instruments (sizes
06, 08, 10 and 15, with standard ISO .02 taper),
such as MMC files (MICRO-MEGA). The clearing
The G-Files are electropolished, which imand enlargement of the passageway is critical
proves their mechanical properties, particularly
for the safe introduction into the canal of rotary
by releasing internal stresses that develop durNiTi instruments that have larger diameters and
ing machining, thereby increasing the flexibility
Fig. 1
cross-sections. Characteristic of almost all the
of the G-File. The electropolished surface ininstruments currently available, each instrucreases the efficiency in apical progression of
ment has a non-working (safety or rounded) tip that the G-File, while aiding in debris removal. The G-Files
minimises canal distortion and reduces the possibility are available in 21, 25 and 29mm.
of the instrument ledging into the canal wall, which
often precedes either a canal perforation or the sepa- _Operating protocol
ration of an instrument.
Once access has been attained (direct access to
In addition, hand instruments used at this stage the canal opening and removal of overhangs), initial
initially enlarge the canal, facilitating the circulation instrumentation is performed with pre-curved, small
of irrigating solutions, reducing the risk of impacting diameter, stainless-steel instruments (MMC 08 and
dentinal debris, which can lead to the loss of apical 10 files). The working length is determined with the
patency.
MMC 10 file.
In the majority of endodontic procedures, initial
glide path enlargement can be a delicate and timeconsuming task. The innovative design of the G-File
instruments simplifies this delicate step and increases
safety in using canal preparation instruments.
_G-File instrument description
To increase endodontic efficiency in the initial glide
path formation by simplifying the procedure, while
increasing safety, MICRO-MEGA has introduced two
new rotary NiTi instruments, the G-Files (Fig. 1).
The G-File NiTi instruments are machined with
a narrow diameter (n°12 and n°17) and a slight
The canal is now ready for the G1 file. The recommended motor setting for the G-File is 400rpm with
a torque of 1.2N.cm (ENDOAce). The G1 file is placed
into the canal and will advance slowly, without apical
pressure, until the working length has been reached.
After irrigation, the G2 file is then placed into the
canal and used in the same way as the G1 file. The
MMC 10 file is then used again to check apical patency. (It may be advantageous to use the ENDOFLARE
to allow easy direct access of the G-File to the entrance of the canal).
Root-canal treatment can now be completed with
the clinician’s endodontic instrumentation system
of choice (Revo-S, HERO)._
Fig. 1_G-Files.
Fig. 2_SEM view of a G2 file.
Fig. 2
_contact
roots
MICRO-MEGA
5–12, rue du Tunnel
25006 Besançon Cedex
France
www.micro-mega.com
roots
I 35
1
_ 2012
[36] =>
RO0110_01_Titel
I meetings _ SSE
Fig. 1
Fig. 2
Fig. 3
The 20 annual SSE
conference left nothing
to be desired
th
Author_ Dr Philipp Kujumdshiev, Switzerland
Fig. 1_Prof. Pierre Machtou.
Fig. 2_Dr Gilberto Debelian.
Fig. 3_Prof Andrea Mombelli.
36 I roots
1_ 2012
_Dr Ramachandran Nair had the honour of
opening the conference. As one of the founding
members, he touched on the history of the Swiss
Society for Endodontology (SSE). A group of seven
enthusiastic scientists and practitioners evolved
into a well-organised society with over 300 members dedicated to the further development of the
SSE. After his speech, Dr Nair was awarded with the
society’s Guldener Prize. This award honours the late
Dr Peter H.A. Guldener, who had been the spokesperson of endodontics in Switzerland for the last 30
years. He was also an eminent endodontic practitioner, educator, motivating force, founding member and the first SSE President. The award is endowed with 5,000 Swiss francs and is presented
annually at the SSE meetings, provided a worthy recipient is nominated. The award is for achievement
of outstanding quality in the field of endodontic research or of significant contributions in endodontic
education, clinical practice and/or to a professional
organisation.
_Recommendations concerning endodontic
controversies
In his speech, Dr Beat Suter focused on the current
controversies in endodontics. According to Suter,
the use of the dental dam, the features of an ideal
root-canal preparation and the ideal root filling are
undisputed. He referred to the literature for the most
controversial points, but provided his own recommendations too:
_if possible, existing reconstructions should be
retained for the time being;
_electronic determination of working length and
use of patency technique;
_the diameter of the apical canal should be enlarged
such that the irrigating solution can move freely;
_root canals should be prepared to the greatest
possible apical taper;
_use of 2.5% NaOCl as irrigating solution;
_overfilling should be avoided; however, it is better
to overfill than to underfill;
[37] =>
RO0110_01_Titel
meetings _ SSE
_use of Ca(OH)2 as filler;
_single-visit root-canal treatment (RCT) is permitted;
_orthograde treatment is preferred; resection if
orthograde treatment is not successful.
_Apical lesions
In his lecture, Dr Paul Dummer pointed out that correct canal preparation is a prerequisite for the healing
of apical lesions and that the antibacterial effect of
Ca(OH)2 in the canal is rather limited. However, the patient’s individual immune response apparently also
has an influence on the long-term result of RCT. Studies have demonstrated that dentists—that is, their lack
of expertise, lack of practice, impatience, poor risk
management and poor professional conduct—are the
primary reason for persistent lesions.
_SSE Student Prize and mini-workshops
well received
Prior to the lunch break, three students from the
universities of Basel, Bern and Zurich each presented
a case and the panel awarded Noemi Kaderli the SSE
Student Prize. For the first time, visitors were also able
to try out different instruments in mini-workshops
offered by various companies during the lunch break.
I
_New NiTi file systems in focus
Prof Zvi Metzger introduced the self-adjusting file
(SAF) system. The SAF file is hollow and designed as
a thin cylindrical NiTi lattice that adapts to the crosssection of the root canal. The file is moved up and
down in the canal with high frequency and continuous rinsing. In the process, an equal amount of dentine is removed at virtually all canal walls so that a
truly 3-D canal preparation takes place. Owing to the
completely different geometry of the system, Metzger
spoke of a paradigm shift and showed impressive µCT
images that confirmed the system’s efficiency. However, the price for one such file (single use!) is over
€40, in addition to the costs for the system.
Following this lecture, Prof Pierre Machtou introduced the WaveOne system from DENTSPLY Maillefer.
With WaveOne, the canal system is mechanically
prepared with a single NiTi file, which is available in
various sizes. The system’s highlight is the file’s reciprocating motion—it constantly changes its rotational
direction in the canal.
Dr Eric Bonnet talked about MICRO-MEGA’s
Revo-S system. With this system, the canal is prepared
with three mechanically rotating files. The asymmetAD
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2QO\LQVWUXPHQWVIRUPRVWFDVHV
6LQJOHOHQJWKWHFKQLTXH
5
5
5
XSWR:/
XSWR:/
XSWR:/
ZZZL5D&HFK
[38] =>
RO0110_01_Titel
I meetings _ SSE
Fig. 4
Fig. 5
Fig. 4_Dr Ramachandran Nair was
awarded with the SSE’s Guldener
Prize 2012.
Fig. 5_The SSE Executive Board
(from left to right): Dr Denis
Honegger, Dr Bernard Thilo,
Dr Monika Marending Soltermann,
Dr Birgit Lehnert, Dr Klaus Neuhaus,
Prof Serge Bouillaguet, Dr Patrick
Sequeira, Dr Reto Lauper and
Dr Andreas Aebi.
ric cutting-edge geometry of the instrument is the
system’s secret. It ensures good cutting performance
with less stress on the instrument and guarantees
good removal of dentinal debris from the canal.
Finally, Dr Gilberto Debelian discussed the BioRaCe
concept from Swiss manufacturer FKG. He demonstrated that bacterial penetration into the dentine is
greater in the apical region than commonly assumed.
That is the reason that a root canal should be prepared
to at least ISO 35 or 40. He also explained the fracture
characteristics (cyclic and torsional fatigue) of NiTi
instruments comprehensibly. Microcracks always
form during rotary root-canal preparation, but considerably less with BioRaCe. He also briefly touched on
a system still under development for the preparation
of non-rotationally symmetrical canals.
_The search for the best obturation techniques
Prof Roland Weiger had the task of evaluating the
best root-canal filling method. In principle, obturation is an important cornerstone of RCT, but not the
decisive factor. In fact, the success of RCT depends on
the quantity of bacteria remaining in the canal. He
compared the various methods—lateral condensation, cold gutta-percha with central pin, Thermafil
(DENTSPLY), vertical condensation, apical partial pin
and GuttaFlow (Coltène/Whaledent)—with each other
and came to the conclusion that each system is useful for different cases. Adhesive obturation materials
did not prove to be of value. However, a (adhesive)
tight coronal seal is an essential component of RCT.
_Possibilities and limitations
The second day of the conference began with a
review of the last 40 years of endodontics. Prof Gunnar Bergenholtz reviewed what worked and what did
not. For instance, short (but not too short) root fillings
do not necessarily result in failure. Iatrogenic infections of the canal are to be avoided at all times. It has
38 I roots
1_ 2012
been shown that apical lesions are better detected
using digital volume tomography (DVT) than apical
dental film; however, the known disadvantages—
radiation dose, expensive equipment, over-interpretation, etc.—need to be taken into consideration. With
regard to potential risks—obliterated canals, difficult
canal geometry—Bergenholtz advised preparing an
individual treatment plan while considering advantages and disadvantages, preparing canals as far as
possible, avoiding producing artefacts (zipping, steps),
and regularly observing the course of healing.
_Instrument history
In his second lecture, Prof Pierre Machtou gave an
overview of the development of endodontic instruments over the past two decades. Milestones certainly
were the crown-down, step-down and balanced
force concepts, as well as the introduction of NiTi
instruments in sequences of rotary systems. Owing to
their high elasticity, NiTi hand instruments were not
instantly successful. The added rotation made them
effective.
_Regenerative medicine
Prof Antony Smith managed to bring practical
relevance to his lecture on this rather dry and heavily
scientific subject. In comparison with oral surgery, endodontists have already been very successful in regenerative medicine for over 100 years (tertiary dentine
formation in pulp capping with Ca(OH)2). EDTA apparently stimulates tertiary dentine formation similar to
Ca(OH)2. Dentine contains many bioactive substances
necessary for regeneration and science now has to find
and activate these substances. Perhaps we will actually
implant cells for regeneration in the future.
_Biofilm management
Prof Fouad Ashraf discussed a similar topic. He
demonstrated the regenerative potency of the pulp
with impressive images and reported about at-
[39] =>
RO0110_01_Titel
meetings _ SSE
Fig. 6
tempts to eliminate the biofilm developing in open
canal lumen with new combinations of antibiotics
(ciprofloxacin + metronidazole + minocycline). The
well-known Augmentin (amoxicillin + clavulanic
acid) or the newer tigecycline are other, very potent
antibiotics. Irrigating solutions such as NaOCl and
chlorhexidine have an antibacterial effect, but are
potentially lethal for the stem cells important for
regeneration. He resumed by mentioning the wellknown and proven use of 17% EDTA as an alternative.
_Endodontic-periodontal lesions
In his lecture, Prof Andrea Mombelli discussed
the issue of endo-perio lesions and their characteristics. In principle, the same (Gram-positive, usually
anaerobic) bacteria (organised in a biofilm) always
dominate the environment. Differences between extra- and intra-canal environments exist in the availability of oxygen and other crucial substances. The
endodontic problem is to be approached therapeutically in the instance of a combined lesion.
_Vertical root fractures
Prof Claus Löst lectured about vertical root
fractures. Although only slight incidence rates are
described in the literature—between 1 and 5%—his
personal research has revealed a much higher occurrence—up to 37%. The cause of this discrepancy, in his
opinion, is for the most part very small fractures
(mini-fissures) in the root, which are evidently not
detected very often after extraction. He sought to
explain the uncertain aetiology as possibly due to
high loss of substance (owing to root-canal preparation), the actual root-filling method or its material
(lateral condensation?), the materials utilised (sealer
containing glass ionomer cement), irrigating solutions and fillers (NaOCl, Ca(OH)2) or the type of postendodontic care (pin or no pin; crown). It is clear that
such fractures can appear anywhere on the root, not
only apically or cervically. Prior to a planned extraction, a vertical root fracture should always be ruled
I
Fig. 7
out by means of explorative opening. Such fissures
are also not (yet) identifiable by means of DVT.
_Ongoing conflict
In his lecture, Dr Jan Berghmans switched over
to implantology. He questioned the statement of a
well-known, American implantologist, who had said
that, in general, an implant is a better choice for a
prosthetic treatment than an endodontically treated
tooth. Although Berghmans showed several—partially
bizarre—X-ray images of teeth that had obviously not
been treated lege artis, he was able to convince the
audience that correctly treated root canals are less of a
compromise than implants. Whereas implant-related
problems are often merely considered complications,
endodontic problems are immediately stigmatised as
failures or mistakes. Berghmans recommends mounting of the cusp (primarily with premolars) after endodontic treatment. Whether the biological width will
be sufficient for restoration after the treatment must
repeatedly be examined. It must also be considered
whether the existing hard tooth tissue permits a ferrule
(1–2mm high and 1mm thick) and what the crownto-root ratio will be after the restoration. He explained
the higher fracture rate with the high loss of substance
and associated debilitation. Investigations still have to
demonstrate the extent to which poor proprioception
has any relevance. In his opinion, the success rates of
endodontic tooth restorations and single-tooth implants are easily comparable.
Following the final presentation, prizes—equipment and materials worth over 7,000 Swiss francs,
courtesy of the exhibitors—were awarded by the SSE
Executive Committee to members of the audience
who had stayed until the very end.
Overall, it was once again a successful conference.
The only downside was that the national conference
of the Osteology Foundation was held in Zurich at
the same time and many colleagues had to choose
between the two events._
Fig. 8
Figs. 6–8_Various companies (from
left to right: FKG, VDW and DENTSPLY
Maillefer) offered mini-workshops
during the lunch break.
(Photos courtesy of Johannes
Eschmann, DT Switzerland,
and Dr Philipp Kujumdshiev.)
_contact
roots
Swiss Society for
Endodontology
P.O. Box 8225
3001 Bern
Switzerland
info@endodontology.ch
www.endodontology.ch
roots
I 39
1
_ 2012
[40] =>
RO0110_01_Titel
I meetings _ events
International Events
2012
BAET International Dental
Traumatology Symposium
23 March 2012
Brussels, Belgium
www.baet.org
Russian Endodontic Congress
30 March–1 April 2012
Moscow, Russia
www.congress2012.endoforum.ru/e/index.html
AAE Annual Session
18–21 April 2012
Boston, MA, USA
www.aae.org
SCANDEFA
26–28 April 2012
Copenhagen, Denmark
www.scandefa.dk
IADR General Session & Exhibition
20–23 June 2012
Iguaçu Falls, Brazil
www.iadr.org
Trans-Tasman Endodontic Conference
21–23 June 2012
Queensland, Australia
www.tteconference.com
Skand Endo
23–25 August 2012
Oslo, Norway
nina.gerner@c2i.net
FDI Annual World Dental Congress
29 August–1 September 2012
Hong Kong, China
www.fdiworldental.org
ROOTS Summit
18–20 October 2012
Foz do Iguaçu, Brazil
DGET Annual Meeting
1–3 November 2012
Leipzig, Germany
www.dget.de
AMED Annual Meeting
16 & 17 November 2012
San Diego, CA, USA
www.microscopedentistry.com
Greater New York Dental Meeting
23–28 November 2012
New York, NY, USA
www.gnydm.com
40 I roots
1_ 2012
[41] =>
RO0110_01_Titel
about the publisher _ submission guidelines
submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
_the complete article;
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I
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roots
I 41
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_ 2012
[42] =>
RO0110_01_Titel
I about the publisher _ imprint
roots
international magazine of
endodontology
Publisher
Torsten R. Oemus
oemus@oemus-media.de
CEO
Ingolf Döbbecke
doebbecke@oemus-media.de
Published by
Oemus Media AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de
www.oemus.com
Magda Wojtkiewicz, Managing Editor
Printed by
Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
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hiller@oemus-media.de
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m.wojtkiewicz@oemus-media.de
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Editorial Board
Fernando Goldberg, Argentina
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Ken Serota, Canada
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Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
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Gary Cheung, Hong Kong
Unni Endal, Norway
Roman Borczyk, Poland
Bartosz Cerkaski, Poland
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
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Jo Dovgan, USA
Vladimir Gorokhovsky, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA
Jorge Vera, Mexico
Copyright Regulations
_roots international magazine of endodontology is published by Oemus Media AG and will appear in 2012 with one issue every quarter. The magazine
and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable
to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
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Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed
for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty
representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.
42 I roots
1_ 2012
[43] =>
RO0110_01_Titel
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[44] =>
RO0110_01_Titel
Cordless
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wh.com
Endodontics. Cordless!
)
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