[Use of Cone Beam Computed Tomography in endodontics: rational case selection criteria]

AIM

To present rational case selection criteria for the use of CBCT (Cone Beam Computed Tomography) in endodontics.

MATERIALS AND METHODS

This article reviews the literature concerning the benefits of CBCT in endodontics, alongside its radiation risks, and present case selection criteria for referral of endodontic patients to CBCT.

RESULTS

Up to date, the expected ultimate benefit of CBCT to the endodontic patient is yet uncertain, and the current literature is mainly restricted to its technical efficacy. In addition, the potential radiation risks of CBCT scan are stochastic in nature and uncertain, and are worrying especially in pediatric patients.

CONCLUSIONS

Both the efficacy of CBCT in supporting the endodontic practitioner decision making and in affecting treatment outcomes, and its long term potential radiation risks are yet uncertain. Therefore, a cautious rational decision making is essential when a CBCT scan is considered in endodontics. Risk-benefit considerations are presented.

Evaluation of Root Canal Cleaning and Shaping Efficacy of Three Engine-driven Instruments: SafeSider, ProTaper Universal and Lightspeed LSX

AIM

To compare the cleaning effectiveness and shaping ability of SafeSider, ProTaper Universal and Lightspeed rotary instruments during the preparation of curved root canals in extracted human teeth.

MATERIALS AND METHODS

A total of 63 roots with curved root canals were divided into three groups. Canals were prepared using SafeSider, ProTaper Universal or Lightspeed LSX. Using pre- and post-instrumentation radiographs, straightening of the canal curvatures and loss of working length were determined with a computer image analysis program. The amounts of debris at the apical 5 mm were quantified on the basis of a numerical evaluation scale. The data were analyzed statistically using the two-way analysis of variance (ANOVA).

RESULTS

There was significantly more transportation among the Lightspeed LSX group compared to the SafeSider and ProTaper Universal groups only at the 4 mm level (p < 0.05). The ProTaper Universal instruments performed significantly faster than other groups. No significant differences were observed between the three engine-driven instruments with regards to debris removal.

CONCLUSION

SafeSider, ProTaper Universal and Lightspeed LSX rotary instruments maintained the original canal curvature well at the apical 3 mm and were safe to use. No difference was found in cleaning efficacy and none rendered the apical part of the canal free of debris.

CLINICAL SIGNIFICANCE

SafeSider, ProTaper Universal and Lightspeed LSX rotary instruments are safe to use in curved root canals.

[U.S. Food and Drug Administration (FDA) strengthens warning that non-aspirin non steroidal anti-inflammatory drugs (NSAIDs) can cause myocardial infarctions or strokes: the dentist's perspective]

This short communication is aimed to update dental practitioners regarding the recently published warning of the U.S. Food and Drug Administration (FDA) regarding the risk for severe cardiovascular complications such as myocardial infarction or stroke following the use of non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs).

[Medicolegal aspects of iatrogenic root perforations]

AIM

To retrospectively analyze the medico-legal aspects of iatrogenic root perforations (IRP) that occurred during endodontic treatments.

METHODOLOGY

A comprehensive search in a professional liability insurance database was conducted to retrospectively identify cases of IRP following root canal treatments (RCTs). The complaints were categorized as either financial risk bearing or financial nonrisk bearing, and related demographic and endodontic variables were analyzed.

RESULTS

One hundred and twenty cases of patients with IRP were identified. Twenty six cases (22%) were elective RCTs, and 94 cases (78%) were endodontic treatments performed due to pathologic processes (p < 0.05). Sixty cases (50%) were identified in mandibular molars, significantly more than other tooth locations (P < 0.05). In 102 cases (85%) the outcome was extraction, and in 18 cases (15%) the outcome was an additional treatment (p < 0.05). For both the cases with outcome of extraction and for the cases with an additional treatment, the complaints were judged as financial risk bearing in 95% of the cases.

CONCLUSIONS

latrogenic root perforation is a complication of root canal treatment and may result in tooth extraction and in legal actions against the treating practitioner. Mandibular molars are more prone to medico-legal claims related to root perforations. The patient should be informed of the risks during RCT and should get information on alternative treatments and their risks and prognosis

Postextraction implant in sites with endodontic infection as an alternative to endodontic retreatment: a review of literature

The aim of this literature review is to evaluate the outcomes of implants placed after extraction of teeth with infections of endodontic origin. An electronic search was performed through electronic databases (Medline and Embase) using the terms "immediate implant," "post-extractive implants," "endodontic infection," "infected site," and "extraction socket" combined with the use of Boolean operators ("AND" and "OR"). Only articles on human subjects were considered. At least 12 month of mean follow-up was required for inclusion. No restriction was placed regarding study design. Ten studies were included in this review. Survival rates ranged from 92% to 100%. A total of 497 implants were placed in sites with endodontic infection. In nine studies the use of bone substitutes was associated with immediate implant placement. Because of the low number of included studies and the heterogeneity of study design, more well-designed studies are required to assess the relevance of this treatment alternative.

Implant treatment choice after extraction of a vertically fractured tooth. A proposal for a clinical classification of bony defects based on a systematic review of literature

OBJECTIVES

The objectives of this study were to propose a classification for the bone defects resulting after extraction of a vertically fractured tooth and to review the existing literature about the treatment of such kind of defects by means of dental implants in combination with regenerative procedures.

MATERIALS AND METHODS

An electronic search was performed on biomedical databases using a combination of appropriated search terms combined through the use of Boolean operators. All articles concerning the treatment of peri-implant bone dehiscences and fenestrations through guided bone regeneration (GBR) with at least 6 months follow-up were eligible. Outcomes data extracted from the selected articles were summarized using descriptive tables. A classification of the bone defects associated with vertical root fracture (VRF) was also proposed.

RESULTS

A total of 33 articles were included in the review. Twenty-three articles (814 implants) were about bone dehiscence treatment, ten articles presented the treatment of fenestrations, and ten (429 implants) adopted vertical bone augmentation. The percentage of bone filling was variable among different procedures and defect classification. The use of resorbable membrane was associated with better outcomes than the use of non-resorbable ones.

CONCLUSIONS

Guided bone regeneration for the management of bone defects in the presence of a VRF of the extracted tooth is a viable treatment option. The assessment of bone defect geometry prior to a tooth extraction could be clinically relevant for evaluating the feasibility and the success of immediate implant placement as well as the need of GBR.

Impact of the use of plasma rich in growth factors (PRGF) on the quality of life of patients treated with endodontic surgery when a perforation of sinus membrane occurred. A comparative study

INTRODUCTION

The aim of this retrospective investigation was to evaluate the postoperative quality of life after endodontic surgery in maxillary molars when a sinus membrane perforation occurred and platelet concentrates were used.

MATERIALS AND METHODS

Included patients were treated by microsurgical endodontic treatment in molar and premolar maxillary regions between 2007 and 2010. Patients who fulfilled the inclusion criteria were screened. Data from the quality of life questionnaire were analyzed. The use of plasma rich in growth factors (PRGF) (test group) was compared with a control group when a Schneiderian membrane perforation occurred during endodontic surgery performed with a modern technique in maxillary molars and premolars.

RESULTS

A total of 20 patients (12 in the control group and eight in the test group) fulfilled the inclusion criteria. No differences were evaluated at baseline for clinical parameters. Significantly improved patients' quality of life was observed in the test group considering symptoms as swelling, bad breath or taste, and pain. Functional activities were less impaired in the test group and swelling was significantly higher in the control group. In the test group, pain was significantly lower than the control group during the first 6 days after surgery and also, the consumption of painkillers was lower for patients belonging to the test group even if it was not statistically significant.

DISCUSSION

In general, a small sinus membrane perforation (less than 6 mm) during endodontic surgery did not cause severe complications. The use of platelet concentrates could be effective in reducing the impact on patients' quality of life, decreasing pain and surgery side effects as well as swelling.

Osteotome-Mediated Sinus Lift without Grafting Material: A Review of Literature and a Technique Proposal

Implant rehabilitation of the edentulous posterior maxilla may be a challenging procedure in the presence of insufficient bone volume for implant placement. Maxillary sinus augmentation with or without using grafting materials aims to provide adequate bone volume. The aim of the present study was to systematically review the existing literature on transalveolar maxillary sinus augmentation without grafting materials and to propose and describe an osteotome-mediated approach in postextraction sites in combination with platelet derivative. The systematic review showed that high implant survival rate (more than 96% after 5 years) can be achieved even without grafting the site, with a low rate of complications. Available alveolar bone height before surgery was not correlated to survival rate. In the described case report, three implants were placed in posterior maxilla after extraction of two teeth. An osteotome-mediated sinus lifting technique was performed with the use of platelet derivative (PRGF); a synthetic bone substitute was used to fill the gaps between implant and socket walls. No complications occurred, and implants were successfully in site after 1 year from prosthetic loading. The presented technique might represent a viable alternative for the treatment of edentulous posterior maxilla with atrophy of the alveolar bone though it needs to be validated by studies with a large sample size.

Endoscopic minimally invasive management of a periradicular lesion invading the maxillary sinus

A referred patient presented with a lesion of endodontic origin located at the apex of tooth #27. The tooth had been endodontically treated and re-treated. A periapical radiograph revealed a close relationship between the lesion and the maxillary sinus. A cone-beam computed tomography scan confirmed that the lesion had invaded the sinus cavity. The treatment plan consisted of periapical surgery using an endoscope as a magnification device. Due to a sinus membrane perforation, a new sinus membrane repair technique was performed. Twelve months after surgery, a cone-beam computed tomography scan revealed successful healing of the lesion. The continuous preservation of the sinus physiology was also observed. The use of an endoscope as a magnification device and a tailored technique for sinus membrane management allowed us to achieve a successful treatment outcome in the case of an endodontic lesion invading the maxillary sinus.

[Immediate implant placement in endodontically infected sites: an alternative treatment for compromised teeth]

In certain clinical conditions when endodontic treatment is either impractical or unlikely to improve the previous results, tooth extraction and replacement with a dental implant becomes a viable alternative. Although the presence of active infection has long been considered a major contraindication to the insertion of implants immediately following tooth extraction, several articles assessing this treatment modality reported excellent and promising results. The aim of this literature review is to evaluate and discuss the clinical outcome of implants placed immediately following extraction in endodontically infected sockets. A Medline and EMBASE search was performed to identify articles published from 1966 to 2010 using the keywords "dental implants", "immediate implant", "extraction socket", "infected teeth", "infected site", "infected socket". No restrictions were placed regarding the study design. Only clinical articles with at least 6 months of follow-up were included. The available relevant literature concerning this topic was limited, and based on relatively low level of evidence study designs with limited follow-up periods. However, the data analysis of the selected articles showed that an immediate implant insertion in endodontically infected sites following tooth extraction and careful debridement of the socket, could be a predictable viable technique. Additional large scaled, well-designed studies are required in order to further assess the clinical applications of this treatment alternative.

Medico-legal aspects of altered sensation following endodontic treatment: a retrospective case series

OBJECTIVE

The objective of this study was to analyze cases of liability claims related to persistent altered sensation following endodontic treatments so as to characterize the medico-legal aspects of this complication.

STUDY DESIGN

A comprehensive search of an Israeli professional liability insurance database was conducted to retrospectively identify and analyze cases of persistent altered sensation following endodontic treatment.

RESULTS

Sixteen claims of persistent altered sensation following endodontic treatments were identified and analyzed. The typical profile of a claim was a female patient who underwent an endodontic treatment at a second mandibular molar, which was associated with overfilling. A significant correlation between the tooth location and the suggested cause of nerve injury was found. None of the claims were reported by the practitioners, and all cases were identified as a result of the patient's demand for financial compensation, either directly or by legal actions.

CONCLUSIONS

When a nerve injury is diagnosed, the treating practitioner should be encouraged to seek medical and legal assistance so as to prevent permanent damage and to enable a better medico-legal response.

[Clinical dilemmas concerning immediate implants in the esthetic zone]

Teeth replacement in the esthetic zone is a considerable challenge. Dental implants are usually the preferred treatment alternative for tooth replacement. The present review discusses several clinical issues concerning implant placement in the esthetic area. It is still unclear whether raising a flap at the time of implant placement enhances alveolar crest remodeling. However, a flapless surgical procedure could avoid changes in the free gingival margin and maintain the the attached gingiva width. A submarginal approach not involving the free gingival margin can be applied to treat bone defects with the GBR technique. Implants should be placed as palatal as possible while maintaining optimal restoration emergence profile and the horizontal bone defect filled with a non resorbable material such as bovine bone mineral. Thick periodontal biotype and coronally positioned free gingival margin usually lead to better results. Immediate implant placement in presence of a periapical lesion may be performed, however, sites should be thoroughly debrided prior to implant placement.

Magnification in modern endodontic practice

The use of magnification devices in endodontics is becoming more and more common, with the aim of improving the quality of treatment. The common magnification systems used in modern endodontics are the surgical operation microscope, fiber-optic endoscope, and surgical loupes. The benefits of using magnification devices for conventional endodontic treatment include the increased visualization of the treatment field, enhanced possibilities in locating canals, aid in the removal of separated instruments, diagnosis of root and tooth fractures, perforation repair, and case documentation. In endodontic surgery, the use of magnification improves the ability to locate, clean, and fill the root canal system, thus achieving a predictable outcome. Further evidence-based research might better clarify the advantages and limitations of using magnification in endodontic practice.