Accidental perforations during root canal treatment: an 8-year nationwide perspective on healthcare malpractice claims

Assessment of the diagnostic accuracy of strip and furcal perforations in different sizes by cone beam computed tomography

OBJECTIVE

Root perforation is an adverse event that may accidentally occur during root canal treatment and can adversely affect the treatment plan and tooth prognosis. This study aimed to assess the accuracy of cone beam computed tomography (CBCT) for detecting the strip and furcal perforations with different sizes.

METHODS

The mesiolingual canals of 155 extracted human mandibular first molars were instrumented and randomly divided into four experimental groups and one control group (n = 31). Furcal (in the pulp chamber floor) and strip perforations with 0.5, 1, 1.5, and 2 mm in diameter were manually created. The teeth were randomly mounted in bovine ribs and scanned using CBCT. Two radiologists unaware of the study groups observed the images and reported the greatest perforation diameter. The inter-observer agreements were calculated. The diagnostic accuracy was compared for furcal and strip perforations with different sizes.

RESULTS

The inter-observer agreement for detecting furcal and strip perforations with different sizes were good. The diagnostic accuracy was 100% for the absence of perforation in each group.

CONCLUSIONS

CBCT can detect the absence of perforation with high accuracy. The diagnostic accuracy of CBCT in the presence of strip and furcal perforation with different sizes was not significant.

Outcomes of furcal perforation management using Mineral Trioxide Aggregate and Biodentine: a systematic review

Furcal perforation is an iatrogenic or pathologic communication between the pulp chamber floor and the alveolar bone. The outcome of perforation sealing depends greatly on the tissue compatibility and bioactivity and sealing properties of the repair materials. Mineral trioxide aggregate (MTA) and Biodentine are currently the most used materials to treat this condition. The present systematic review aimed to report the treatment outcome of repaired furcal perforation using MTA and Biodentine and identify which material would yield a better outcome.

METHODOLOGY

A comprehensive search was conducted using the PubMed database to identify experimental studies and case reports that describe treatment of furcal perforation. Studies and case reports that evaluated the outcome of repaired furcal perforations using MTA and Biodentine, published in English from 2018 to April 2022, were identified. Unavailable full texts were excluded.

RESULTS

Initial screening of 724 articles (670 studies and 54 case reports). After discarding the duplicated studies, we reviewed 50 studies, selecting 13 for abstract analysis. We retrieved and evaluated full texts of eight studies and five case reports. Both materials had an equivalent success rate in the first three months but by 12 months Biodentine performed better than MTA clinically and radiographically.

CONCLUSIONS

Repair of furcal perforation with Biodentine yields a better outcome compared to MTA.

Guided Endodontics as a Personalized Tool for Complicated Clinical Cases

The aim of this paper is to present a technique to individualize root canal localization in teeth with calcified root canals using a digitally planned, 3D-printed endodontic guide. Root canal calcification is characterized by the apposition of tertiary dentin along the canal wall. The endodontic treatment of teeth with calcified canals is often challenging. However, digital dentistry meets these challenges. Merging CBCT images with an intraoral scan allows a clinician to prepare an endodontic guide. This article describes the clinical and digital workflow of the guided endodontic access approach in teeth with difficulties in terms of root canal localization due to post-traumatic pulp canal obliteration (PCO) and canal calcification in elderly patients. The path of entry into the root canal system was planned using cone-beam computed tomography (CBCT). The template was printed on a 3D printer using transparent resin. During root canal treatment (RCT), the endodontic tool was inserted through the sleeve until the desired location was reached. The use of an endodontic guide allowed for minimally invasive RCT, avoiding the excessive loss of tooth structures. Navigated endodontics enables clinicians to perform RCT in a more predictable manner and allows clinicians to avoid iatrogenic complications, which improves the treatment prognosis.

Guided endodontic treatment in a region of limited mouth opening: a case report of mandibular molar mesial root canals with dystrophic calcification

BACKGROUND

The endodontic treatment of calcified root canals in molars is a challenging and time-consuming procedure. Even with the aid of a surgical microscope, the risk of root perforation is high, especially in the furcation area. The purpose of this study is to report the Computer-Aided-Design and Manufacturing (CAD-CAM) workflow, the innovative strategies for the template ideation, and the guided endodontic treatment of a mandibular molar with dystrophic calcification in the mesial root canals.

CASE PRESENTATION

A 58-year-old female patient, ASA I, was referred to endodontic treatment in the right first mandibular molar for prosthetic reasons. The mesiobuccal and mesiolingual canals appeared obliterated in the radiographic images. The absence of dental crown, tooth inclination, and the limited mouth opening of the region contributed to a poor visual reference of the tooth in the dental arch and the direction of the remaining lumens of the canals. Despite using surgical microscopy, the conventional technique led to the deviation of the mesiobuccal canal towards the furcation area. The obliteration of both mesial root canals was confirmed using the Cone Beam Computer Tomography. The clinical history associated with the tomography diagnosis was compatible with dystrophic calcifications in the pulp canals. The patient was submitted to an intra-oral scanning as well. The Digital Imaging and Communications in Medicine data (DICOM) were segmented. The Standard Tessellation Language (STL) files were processed following the CAD-CAM workflow, aiming to create two different endodontic templates with a new open design concept. The templates with open design allowed direct visualization of the operative field, irrigation, and dentin debris removal. The strategy of the guidance sleeves niche as half-cylinders allowed the drill insertion in a limited mouth opening region.

CONCLUSIONS

The digital planning and guided access permitted to overcome the case limitations and then re-establish the glide path following the original anatomy of the root canals. The guided endodontic represents a personalized technique that provides security, reduced risks of root perforation, and a significant decrease of the working time to access obliterated root canals even in the mesial root canal of mandibular molars, a region of limited mouth opening.

Does MTA provide a more favourable histological response than other materials in the repair of furcal perforations? A systematic review

BACKGROUND

There is no consensus on which furcal perforation repair material induces a more favourable histological response. This systematic review of laboratory studies provides an overview of the studies comparing repair materials in animal models.

OBJECTIVES

To evaluate whether mineral trioxide aggregate (MTA) yields a more favourable histological response than other materials when used to repair furcal perforations in animal experimental models.

METHODS

This review followed the PRISMA checklist. The studies included various materials used to repair furcal perforations and compared the histological responses with MTA. An electronic search was conducted in EMBASE, PubMed, Scopus and Web of Science up to 2 September 2020, with no language or publication date restrictions. Studies whose full text was unavailable were excluded. The ARRIVE and SYRCLE tools were used to assess the methodological quality and risk of bias (RoB) of the studies.

RESULTS

The studies included in the qualitative synthesis were conducted in rat (n = 3) and dog (n = 17) models. They were classified as having a low quality, high methodological heterogeneity and high RoB. MTA and Biodentine, the materials most often compared, reduced the inflammatory reaction to mild over time. In addition, a mineralized tissue was formed in all studies. The response yielded by MTA was better than or equivalent to that of the other tested materials.

DISCUSSION

This review confirmed that MTA is the reference standard material for furcal perforation repair. However, research using animal models has inherent limitations, and the substantial methodological heterogeneity across the studies included should be considered. Therefore, the knowledge generated by this systematic review should be translated into clinical practice cautiously.

CONCLUSIONS

Features described in the report and quality assessment guidelines, such as PRIASE, ARRIVE and SYRCLE, should guide researchers. Despite the high RoB and the low methodological quality of the studies included, findings indicated that MTA yields a more favourable histological response than other materials in the repair of furcal perforations.

REGISTRATION

PROSPERO (CRD42020181297).

Benchmarking health-care supply chain by implementing Industry 4.0: a fuzzy-AHP-DEMATEL approach

Purpose

With the rising needs of health-care (HC) services during the health outbreaks, it is essential to upgrade the existing HC delivery infrastructure. The study aims to prioritize and highlight the interrelationships among the key factors of the smart health-care supply chain (HCSC) by implementing the concept of Industry 4.0.

Design/methodology/approach

The key factors of implementing Industry 4.0 in HCSC have been identified through extensive literature review and stakeholders' opinions. To achieve the abovementioned objectives, the present study proposed hybrid multi-criteria decision-making (MCDM) tools, namely, the fuzzy-analytic hierarchy process (AHP) and fuzzy- decision-making trial and evaluation laboratory (DEMATEL). The Fuzzy-AHP prioritized the factors of implementing Industry 4.0 in HCSC, while the cause–effect relationships among the factors have been explored using fuzzy-DEMATEL.

Findings

The results of the study indicated that HC logistics management (HCLM) is the most prioritized factor of implementing Industry 4.0 in HCSC, followed by the integrated HCSC, then sustainable HCSC practices, HCSC innovation and technological aspects, HCSC institutional perspectives, HCSC competitiveness, social aspects and economic factors of HCSC. The cause–effect analysis has highlighted integrated HCSC, HCLM, HCSC competitiveness and social aspects as the cause group factors and they are the critical success parameters for implementing Industry 4.0 in the HCSC.

Practical implications

The results of the study can be useful for policymakers, humanitarian organizations, health administrators and other decision makers considering the smartening of HCSC to enhance the operational performance of health facilities.

Originality/value

This is one of the few studies to have been conducted so far in which the subfactors of HCSC implementing Industry 4.0 have been identified and analyzed using the fuzzy-AHP and fuzzy-DEMATEL hybrid approach.