A Review of Factors Influencing Treatment Planning Decisions of Single-tooth Implants versus Preserving Natural Teeth with Nonsurgical Endodontic Therapy

Healing and long-term prognosis of root-fractured permanent teeth: a retrospective longitudinal study

AIM

The purpose of the present study was to evaluate permanent teeth with post-traumatic transversal root fractures, for their initial healing modality, the effect of candidate predictors and their long-term prognosis.

METHODOLOGY

A retrospective longitudinal clinical study was conducted to evaluate records from patients bearing transversal root fractures in permanent teeth in order to radiographically assess short-term healing and non-healing events in the fracture line, their prognostic factors and their relationship with long term outcomes. The inter-fragmentary tissues were classified as healing: hard tissue (HT), connective tissue (CT) or connective tissue and bone (CT + B) and non-healing: interposition of granulation tissue (GT). A competing risk survival analysis was conducted to estimate the hazards of healing and non-healing events in the short-term and the effect of demographic, clinical, and treatment variables was assessed using the subdistribution regression model (Fine & Gray).

RESULTS

Radiographic findings showed 61.4% of healing in the short-term being strongly influenced by the presence and type of concomitant injuries to the coronal fragment. Teeth with concomitant crown fractures (sHR 24.38, 95% CI [3.16-188.3], p = 0.0022), luxations with dislocations (sHR 10.58, 95% CI [1.37-81.9], p = 0.0240) and subluxations (HR 9.66, 95% CI [1.14-81.7], p = 0.0370) were more likely to present non-healing of root fractures in the short-term. The healing rate in the long-term was of 75.9%, most of them with interposition of bone and connective tissue. Kappa statistics demonstrated an overall agreement of 67.1% between short and long-term healing patterns, in special HT and CT + Bone modalities.

CONCLUSION

Healing at the fracture site was the most frequent outcome, both in the short-term and in the long-term. Short-term healing modality was strongly influenced by the presence and type of concomitant injuries to the crown fragment, being the worst prognosis observed in root-fractured teeth with concomitant crown fractures, followed by concomitant luxations with dislocation.

CLINICAL RELEVANCE

Post-traumatic transversal root fractures have a positive prognosis supporting therefore, a more conservative approach for these teeth before considering more radical treatments.

Cost-effectiveness analysis: nonsurgical root canal treatment versus single-tooth implant

BACKGROUND

Economic evaluation of nonsurgical root canal treatment (NSRCT) and single-tooth implant (STI) provides useful information for medical decision. This retrospective study aimed to evaluate the cost-effectiveness of NSRCT versus single-tooth implant (STI) after 5-year treatment in a university affiliated hospital in Beijing, China.

METHODS

211 patients who underwent NSRCT and 142 patients who had STI were included and recalled after 5-year treatment. The propensity scores were used to match the cases of two treatment modalities. At recall, outcomes were determined based on clinical and radiographical examinations. For endodontically treated cases, absence or reduction of radiolucency were defined as success. Marginal bone loss (MBL) ≤ 4 mm were determined as success for implant cases. Direct and indirect costs were calculated in China Yuan (CNY). Patients' willingness to pay (WTP) for each treatment modality was evaluated by questionnaires. A cost-effectiveness analysis was performed from the societal perspective.

RESULTS

170 patients with 120 NSRCT teeth and 96 STI were available at recall. Based on propensity score matching, 76 endodontically treated teeth were matched to 76 implants. Absence of the radiolucency was observed in 58 of 76 endodontically treated teeth (76%) and reduction of the radiolucency in 9 of 76 teeth (12%) and altogether the success rate was 88%. 100% implants were detected with marginal bone loss (MBL) ≤ 4 mm. The cost advantage of NSRCT (4,751 CNY) over STI (20,298 CNY) was more pronounced. Incremental cost effectiveness ratio (ICER) was 129,563 CNY (STI-NSRCT) per success rate gained. It exceeded the patients' willingness to pay value 7,533 CNY.

CONCLUSIONS

Clinical outcomes of NSRCT and STI could be predictable after 5-year treatment. NSRCT may be more cost-effective than STI for managing endodontically diseased teeth.

Comparing the Long-Term Success Rates of Tooth Preservation and Dental Implants: A Critical Review

Implant therapy is considered a predictable, safe, and reliable rehabilitation method for edentulous patients in most clinical scenarios. Thus, there is a growing trend in the indications for implants, which seems attributable not only to their clinical success but also to arguments such as a more “simplified approach” based on convenience or the belief that dental implants are as good as natural teeth. Therefore, the objective of this critical literature review of observational studies was to discuss the evidence concerning the long-term survival rates and treatment outcomes, comparing endodontically or periodontally treated teeth with dental implants. Altogether, the evidence suggests that the decision between keeping a tooth or replacing it with an implant should carefully consider the condition of the tooth (e.g., amount of remaining tooth and degree of attachment loss and mobility), systemic disorders, and patient preference. Although observational studies revealed high success rates and long-term survival of dental implants, failures and complications are common. For this reason, attempts should be made to first save maintainable teeth over the long-term, instead of immediately replacing teeth with dental implants.

The impact of endodontic workload and allocated treatment time of dentists in turkey on perceived stress and complication frequency and suggested solutions

Background

Procedural complications and workload have been reported as sources of stress in dentistry.

Aim

To investigate the impact of endodontic workload and allocated treatment time of dentists on perceived stress and frequency of complications.

Material and Methods

The online survey included questions to evaluate the average number of root canal treatments per week, stress levels during root canal treatment, frequency of single-visit root canal treatments, time spent on single-visit treatments, frequency of endodontic complications per week, preference for management of complication, and proposed solutions.

Results

A negative correlation was found between endodontic workload and perceived stress, which was statistically significant at slight and moderate stress levels (P < 0.05). Amongst the clinicians who feel "very stressful" during the treatment, the clinicians who allocate only 20 minutes or less per treatment had the highest frequency, and their numbers were significantly higher than clinicians who spent 20-40 minutes per treatment (P < 0.05). Amongst the clinicians who experience instrument separation 4-6 times/week, the number of clinicians who spent 40-60 minutes or more than 60 minutes per root canal treatment was significantly lower in comparison to the number of clinicians who spent 20-40 minutes (P < 0.05).

Conclusion

Increasing the quality of dental equipment and reducing the time pressure on dentists might result in lesser stress levels of clinicians and fewer endodontic complications.

Post-Fatigue Fracture Resistance of Lithium Disilicate and Polymer-Infiltrated Ceramic Network Indirect Restorations over Endodontically-Treated Molars with Different Preparation Designs: An In-Vitro Study

The aim of the present study was to evaluate the fatigue to cyclic and static resistance of indirect restorations with different preparation designs made either of lithium disilicate (LS) or polymer-infiltrated ceramic network (PICN). Eighty-four (n = 84) molars were chosen, endodontically treated, and prepared with standardized MOD cavities. The molars were randomly divided into 6 study groups (n = 14) taking into account the "preparation design'' (occlusal veneer with 1.2 mm occlusal thickness; overlay with 1.6 mm occlusal thickness; adhesive crown with 2 mm occlusal thickness) and the "CAD/CAM material'' (E-max CAD, Ivoclar vivadent; Vita Enamic, Vita). A fatigue test was conducted with a chewing simulator set at 50 N for 1,500,000 cycles. Fracture resistance was assessed using a universal testing machine with a 6 mm diameter steel sphere applied to the specimens at a constant speed of 1 mm/min. A SEM analysis before the fracture test was performed to visually analyze the tooth-restoration margins. A statistical analysis was performed with a two-way ANOVA and a post-hoc pairwise comparison was performed using the Tukey test. The two-way ANOVA test showed that both the preparation design factor (p = 0.0429) and the CAD/CAM material factor (p = 0.0002) had a significant influence on the fracture resistance of the adhesive indirect restorations. The interaction between the two variables did not show any significance (p = 0.8218). The occlusal veneer had a lower fracture resistance than the adhesive crown (p = 0.042) but not lower than the overlay preparation (p = 0.095). LS was more resistant than PICN (p = 0.002). In conclusion, in the case of endodontically treated teeth, overlay preparation seems to be a valid alternative to the traditional full crown preparation, while occlusal veneers should be avoided in restoring non-vital molars with a high loss of residual tooth structure. LS material is more resistant compared to PICN.

Restorative difficulty evaluation system of endodontically treated teeth

OBJECTIVE

This article provides an updated overview of restorative procedures of endodontically treated teeth.

CLINICAL CONSIDERATIONS

The different techniques and procedures to restore an endodontic treated tooth were considered in the last decades. While they are generally performed using bonding procedures in combination with or without the placement of a post into the root to build up the abutment, there has been a lack of interest in restorative difficulties that can be faced. Failures are represented such as debonding of the post, fracture of the root, decementation, and/or fracture of the restoration, microleakage of the margins. Essentially, the presence of a sufficient failure is considered a key point of a long prognosis. Different clinical factors can directly influence the type of restoration and the longevity of the treatment. The restorative difficulty evaluation system (RDES) is proposed in this article. This new system is composed of eight different clinical factors that are divided into six levels of difficulties. The RDES is composed of 1. Endodontic complexity and outcome, 2. Vertical amount of coronal residual structure and dimension of the pulp chamber, 3. Horizontal amount of coronal residual structure, 4. Restoration marginal seal, 5. Local interdisciplinary conditions, 6. the complexity of the treatment planning, 7. Functional need, 8. Dental wear and esthetic need.

CONCLUSION

This article reviews the RDES and outlines critical steps and tips for clinical success.

CLINICAL SIGNIFICANCE

The RDES allows to any clinician to evaluate restorative difficulties when an endodontic treated tooth must be restored, combines clinical aspects that can involve from the single tooth to a full mouth rehabilitation.

Patient-reported outcome measures comparing static computer-aided implant surgery and conventional implant surgery for single-tooth replacement: A randomized controlled trial

OBJECTIVE

To compare static computer-aided implant surgery (s-CAIS) and conventional implant surgery (CIS) for single-tooth replacement in posterior sites in terms of patient-reported outcome measures (PROMs).

METHODS

Forty patients were divided into two groups for treatment with s-CAIS (Test) and CIS (Control). Patients' anxiety level was measured using the modified dental anxiety score before implant surgery. After surgery, patients completed two questionnaires for 7 days. The first questionnaire assessed pain level using a visual analog scale (VAS) and the incident rate of pain using a 5-point Likert scale; analgesic intake was also recorded. The second questionnaire investigated patients' oral health-related quality of life (OHRQoL) including postoperative symptoms, oral function, and daily activity. The difference between data was compared at significance level (α = 0.05).

RESULTS

There was no statistically significant difference in pretreatment dental anxiety level, postoperative pain scores, and OHRQoL between treatment groups. Overall, mild or moderate dental anxiety was reported by 70% and 20% of patients, respectively. Pain score was significantly reduced by postoperative Day 3 in the test group and Day 4 in the control group, compared with baseline. Both groups significant reduced analgesic intake by postoperative Day 5. Most OHRQoL-related complaints subsided approximately 3 days after surgery.

CONCLUSIONS

Overall, PROMs between s-CAIS and CIS were not significantly different for the single-tooth implant surgery in the posterior area. Postoperative symptoms after implant surgery still inevitably occurred, reflecting the normal process of oral wound healing.

The effect of retrograde material type and surgical techniques on the success rate of surgical endodontic retreatment: systematic review of prospective randomized clinical trials

Background

Endodontic surgical procedures, when performed, require retrograde filling materials that are biocompatible, non-toxic, non-irritant, dimensionally stable, and ideally promote bone formation. Precise evaluation of retrograde filling materials in clinical trials is necessary to give holistic view for properties of material and potential outcome from its use. The purpose of this review is to evaluate the effect of retrograde material type and surgical techniques on the success rate of surgical endodontic retreatment.

Methods

An electronic search was performed in the time frame between 1st of January 2000 to 1st of September 2020 using database.

Sources

Web of Science, PubMed and redundant hand searches through their references. Seven inclusion–exclusion criteria were set for the selection and identification of relevant articles. Risk of bias was conducted for the included studies.

Results

Nine randomized clinical trials (RCTs) fulfilled the inclusion criteria for this systematic review. The outcome of this review revealed that none of the reviewed trials totally-fulfilled CONSORT 2010 criteria.

Conclusions

In light of the outcome of this review, there is no enough evidence to support the superiority of certain retrograde filling material or surgical technique over another in the success rate of surgical endodontics retreatment. The variety of methodologies and strategies, such as patient selection, the method of treatment and study analysis, led to doubtful credibility of the obtained clinical evidence. Further prospective randomized controlled clinical trials evaluating the specific effect of the various used materials are needed.

Single-Tooth Rehabilitation Combining Root Displacement and Crown Lengthening Two-Year Follow-Up: A Case Report

CLINICAL RELEVANCE

Combined techniques to expose circumferential tooth structure associated with subsequent restoration may represent a valid option in many situations. This case provides an example of the successful management of the anterior tooth rehabilitation combining root displacement and crown lengthening.

SUMMARY

Rehabilitation of an extensively compromised single anterior tooth represents an intriguing challenge for dentists, particularly when the rehabilitation involves esthetic, psychosocial, and functional requirements. The success in rehabilitating a patient with a conservative approach depends on a critical evaluation of the remaining structures, precise treatment plan, systematic treatment strategies, and patient compliance. In this case, the patient's chief complaint was the undesirable appearance of the maxillary right lateral, caused by the displacement of the post and crown. Clinical examination revealed a remaining tooth with coronal fracture, severe loss of tissue due to caries, and absence of ferrule effect. Radiographic examination revealed that the fracture margin was located subgingival. This case report describes a single-tooth rehabilitation involving a combination of root displacement via orthodontic extrusion and crown lengthening. The rehabilitation was followed by post-and-core restoration using a prefabricated glass fiber post associated with a disilicate lithium crown. The clinical decision making and combined effect of both treatment strategies are explained in this report. The treatment required three months, including recovery times after surgery and the placement of the provisional crown. The patient was esthetically and functionally satisfied with the restoration. Patient follow-up examination was performed 24 months after the treatment. This clinical report contributes to the clinical practice and exemplifies the possibility of rehabilitating the natural tooth using combined techniques, which may offer particular advantages regarding prognosis and invested efforts.

Influence of Dental Pulp Harvesting Method on the Viability and Differentiation Capacity of Adult Dental Pulp-Derived Mesenchymal Stem Cells

Objective

To compare two pulp harvesting methods for stem cell expansion, namely, conservative pulpotomy and pulpectomy from exodontia.

Method

Ten freshly extracted sound third molars from five patients were selected. Five were used in the control group, where pulp harvesting was performed by exodontia and the remaining teeth were used in the test group, where the pulp was harvested by conservative pulpotomy (preserving the tooth). This was a split-mouth design study, where a third molar from one side was randomly allocated into the test group and the contralateral tooth in the control group. After pulp harvesting, the following evaluations were performed: cell morphology, sterility test, immunophenotyping, differentiation assays, first pass live cell counts, time to cryopreservation, and total number of expanded cells at the end of the fourth pass.

Results

Regarding morphology, the cells from both groups presented a fibroblastic phenotype. All samples were sterile. Immunophenotyping demonstrated a positive expression for CD105, CD90, and CD73 and negative expression for CD45 in both groups. Differentiation assays were positive for osteogenic and chondrogenic differentiation in both groups. Regarding live cell counts in the first passage, the control group had 95.8% live cells in the total count and the test group 91.2% (p < 0.05). The time required for cryopreservation was equivalent in both groups 51.6 days and 52.6 days, respectively (p > 0.05). The total number of cells at the end of the fourth passage was 5,286,782 and 5,736,862, respectively (p > 0.05).

Conclusion

These results suggest that adult stem cell harvesting from conservative pulpotomy is as effective as the traditional exodontia-based method.

Factors Associated with Extraction following Root Canal Filling in Adults

Essentially, root fillings are performed to preserve natural teeth. Over time, however, some root-filled teeth will inevitably be extracted. The aim of this historical prospective cohort study in the adult Swedish population was to identify factors associated with extractions within 5 y of registration of a root filling. The cohort consisted of all those whose root fillings had been reported to the tax-funded Swedish Social Insurance Agency (SSIA) in 2009. Demographic data on the individuals registered with a root filling (sex, age, country of birth, disposable income, educational level, and marital status) were received from Statistics Sweden or the SSIA. Dental care setting, tooth type, and any registration of subsequent restorations within 6 mo were received from the SSIA. Multivariable regression analysis was used, and P < 0.05 was considered statistically significant. In total, 216,764 individuals had been registered with at least 1 root filling. Individuals (n = 824) without complete data were excluded from the analyses. After 5 y, 9.3% of the root-filled teeth had been registered as extracted. Logistic regression analysis found significant associations for all variables except country of birth, disposable income, and educational level. The highest odds ratios for extractions were associated with the type of restoration: teeth with no registration of any restoration and teeth with a direct restoration combined with a post were 3 times more likely to undergo extraction than teeth restored with an indirect restoration combined with a post and core. Overall, high odds ratios for extractions were associated with any type of composite restoration, including composite fillings and crowns combined with or without any post. In summary, after root filling in the Swedish adult population, several individual- and tooth-specific variables were associated with extraction. The reasons for the extractions remain to be studied further.

Influence of Photon-Induced Photoacoustic Streaming (PIPS) on Root Canal Disinfection and Post-Operative Pain: A Randomized Clinical Trial

The aim of this study was to evaluate the ability of a PIPS (photon-induced photoacoustic streaming) Er:YAG laser to reduce the root canal system bacterial count in vivo in comparison to the traditional irrigation technique. The post-operative patients’ quality of life (QoL) after endodontic therapy was evaluated through a questionnaire. Fifty-four patients affected by pulp necrosis with or without apical periodontitis biofilm disease were selected for endodontic treatment and randomly assigned to Group A (n = 27) with traditional irrigation and Group B (n = 27), with PIPS irrigation applied according to the protocol. Shaping was performed with ProGlider and ProTaper Next, and irrigation was performed with 5% NaOCl and 10% EDTA. Intracanal samples for culture tests were collected before and after irrigation. The microbiological analysis was evaluated by the Kolmogorov–Smirnov normality and Mann–Whitney tests (p < 0.05). A self-assessment questionnaire was used to evaluate the QoL during the 7 days after treatment; differences were analysed with Student’s t-test. Irrigation with the PIPS device was significantly effective in reducing bacterial counts, which were higher for facultative than obligate anaerobic strains, particularly for Gram-negative bacteria, without statistical significance (p > 0.05). There were no significant differences among the QoL indicators, except for the maximum pain (p = 0.02), eating difficulty (p = 0.03) and difficulty performing daily functions (p = 0.02) in the first few days post-treatment. PIPS may represent an aid to root canal disinfection not affecting the patients’ QoL, particularly for the first day after treatment.

Surgical extrusion of a maxillary premolar after orthodontic extrusion: a retrospective study

Objectives

Crown-root fracture and cervical caries in maxillary premolars constitute a challenge in cases of subgingival placement of restoration margins. Surgical extrusion has been practiced successfully in permanent anterior teeth. The aim of the present retrospective study was to assess the clinical outcome of surgical extrusion after orthodontic extrusion in maxillary premolars.

Materials and Methods

Twenty-one single, tapered root maxillary premolars with subgingival crown-root fracture or caries were included. Presurgical orthodontic extrusion was performed on all teeth to prevent root resorption. Extent of extrusion and rotation was determined based on crown/root ratio. The postoperative splinting period was 7 to 14 days. Clinical and radiographic examination was performed at an interval of 1, 2, and 3 months.

Results

After the mean follow-up of 41.9±15.2 months, failure was observed as increased mobility in 3 of 21 cases. No significant difference was observed in the outcome of surgical extrusion based on tooth type, age, sex, 180° rotation, or time for extraction. Furthermore, marginal bone loss was not observed.

Conclusion

Surgical extrusion of maxillary premolars can be a possible therapeutic option in cases of subgingival crown-root fracture.

Complicated Crown-root Fracture Management Using the 180-degree Rotation Method

Aim

The aim of this article is to report a successful treatment of a complicated crown-root fracture.

Background

The management of complicated crown-root fracture in young patients is challenging as the fracture line is below the bone crest and the pulp is exposed. Treatment options include crown lengthening, orthodontic extrusion, and intentional replantation.

Case description

Here, a case of complicated crown-root fracture of tooth number 11 in a ten-year-old boy is presented. Intentional replantation with 180° rotation and slight extrusion and fixation was performed. In addition, root canal therapy was done and tooth was restored with a composite resin after four weeks. The patient was asymptomatic clinically and radiographically after three-year follow-up.

Conclusion

Intentional replantation with 180° rotation is a valuable treatment for crown root fractures.

Clinical significance

The management of complicated crown-root fracture using intentional replantation with 180° rotation can help to maintain natural dentition and interdental papilla.

How to cite this article

Mokhtari S, Hajian S, et al. Complicated Crown-root Fracture Management Using the 180-degree Rotation Method. Int J Clin Pediatr Dent 2019;12(3):247-250.

Long-term survival of structurally compromised tooth preserved with crown lengthening procedure and restorative treatment: A pilot retrospective analysis

AIM

Since there is limited study to assist in an evidenced-based decision whether to extract or preserve a structurally compromised tooth, the aim of this retrospective study was to investigate the long-term survival rate of tooth preservation after crown lengthening procedure (CLP) and restorative treatments.

METHODS

Electronic and paper chart of patients received CLP in our graduate clinic from 1990 to 2015 were reviewed. Statistical analysis was done using Cox regression analysis and Kaplan-Meier estimator.

RESULTS

A total of 766 coded charts were initially collected. Four hundred and fourteen cases were included in the final analysis. The Kaplan-Meier estimate shows a cumulative survival rate of 88.3% in 5 years, 78.4% in 10 years and 68.1% in 15 years. In terms of reasons for failure, restorative problem such as recurrent decays was the main issue (35.2%), followed by fracture (29.6%), endodontic complications (23.9%) and periodontal breakdown (11.3%).

CONCLUSIONS

Within the limitation of this study, structurally compromised teeth have a reasonable long-term survival rate close to 80% after 10 years in a teaching institute. Patients with high fracture or caries risk may pose a higher chance of failure. Objective information should be presented to the patient to arrive at an evidence-based decision.

Evaluation of Related Factors in the Failure of Endodontically Treated Teeth: A Cross-sectional Study

INTRODUCTION

The aim of this study was to review the factors related to the failure and extraction of unsuccessful endodontically treated teeth.

METHODS

A total of 1000 teeth treated with nonsurgical root canal therapy were analyzed, and the following information was recorded for each patient: reasons for failure and extraction, type of tooth, presence and type of coronal restoration, smoking status, age, gender, and level of education. One main reason was recorded for each failed tooth. The associations between reasons for failure, patient, and tooth were tested by using χ² analysis.

RESULTS

Of the 1000 endodontically failed teeth analyzed in this study, 28.1% (n = 281) were extracted, 66% (n = 660) were re-treated, and 5.9% (n = 59) were treated with apical surgery. Among the reasons for failure, restorative and endodontic reasons were seen most frequently (43.9%, n = 439), whereas orthodontic reasons were seldom seen (0.1%, n = 1). The most common reason for extraction was for prosthetic reasons (40.8%), and perforation/stripping was the least common (2.9%). The mandibular first molars were the most frequently extracted teeth (27.4%, n = 77).

CONCLUSIONS

The most common reason for the extraction of endodontically treated teeth was for prosthetic reasons. Among the reasons for failure, restorative and endodontic reasons were the most frequently seen, and orthodontic reasons were the most seldom. The teeth that failed most frequently were mandibular first molars, and the teeth that failed least frequently were maxillary third molars. The most common reason for the extraction of failed endodontically treated teeth was for prosthetic reasons.

No clinical quantifiable benefits between non-surgical and surgical endodontic treatment

Data sourcesThe authors searched the following electronic databases: the Cochrane Oral Health Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline Ovid and Embase Ovid. The US National Registry of Clinical Trials (ClinicalTrials.gov) and the World Health Organisation (WHO) International Clinical Trials Registry Platform were searched for ongoing trials. There were no restrictions regarding language and publication date. The authors hand-searched the reference lists of the studies retrieved and key journals in the field of endodontics.Study selectionRandomised controlled trials (RCTs) involving people with periapical pathosis including comparison of surgical versus non-surgical treatment or different types of surgery. Outcome measures were healing of the periapical lesion assessed after one-year follow-up or longer, postoperative pain and discomfort and adverse effects such as tooth loss, mobility, soft tissue recession, abscess, infection, neurological damage or loss of root sealing material evaluated through radiographs.Data extraction and synthesisTwo review authors independently extracted data from the included studies and assessed their risk of bias. Study authors were contacted to obtain missing information. The authors combined results of trials assessing comparable outcomes using the fixed-effect model, with risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, and 95% confidence intervals (CIs) and they used generic inverse variance for split-mouth studies.ResultsThe review included 20 RCTs. Two trials at high risk of bias assessed surgery versus a non-surgical approach: root-end resection with root-end filling versus root canal retreatment. The other 18 trials evaluated different surgical protocols.There was no clear evidence of superiority in the surgical or non-surgical approach for healing at one-year follow-up (RR 1.15, 95% CI 0.97 to 1.35; two RCTs, 126 participants) or at four- or ten-year follow-up (one RCT, 82 to 95 participants), although the evidence is very low quality. More participants in the surgically treated group reported pain in the first week after treatment (RR 3.34, 95% CI 2.05 to 5.43; one RCT, 87 participants; low quality evidence).In terms of surgical protocols, there was some inconclusive evidence that ultrasonic devices for root-end preparation may improve healing one year after retreatment, when compared with the traditional bur (RR 1.14, 95%CI 1.00 to 1.30; one RCT, 290 participants; low quality evidence). There was evidence of better healing when root-ends were filled with MTA than when they were treated by smoothing of orthograde GP root filling, after one-year follow-up (RR 1.60, 95% CI 1.14 to 2.24; one RCT, 46 participants; low quality evidence).There was no evidence that using CBCT rather than radiography for preoperative evaluation was advantageous for healing (RR 1.02, 95% CI 0.70 to 1.47; one RCT, 39 participants; very low quality evidence), nor that any magnification device affected healing more than any other (loupes versus endoscope at one year: RR 1.05, 95% CI 0.92 to 1.20; microscope versus endoscope at two years: RR 1.01, 95% CI 0.89 to 1.15; one RCT, 70 participants, low quality evidence). There was no evidence that antibiotic prophylaxis reduced incidence of postoperative infection (RR 0.49, 95% CI 0.09 to 2.64; one RCT, 250 participants; low quality evidence).There was some evidence that using a papilla base incision (PBI) may be beneficial for preservation of the interdental papilla compared with complete papilla mobilisation (one RCT (split-mouth), 12 participants/24 sites; very low quality evidence). There was no evidence of less pain in the PBI group at day one post surgery (one RCT, 38 participants; very low quality evidence).There was evidence that adjunctive use of a gel of plasma rich in growth factors reduced postoperative pain compared with no grafting (measured on visual analogue scale: one day postoperative MD -51.60 mm, 95% CI -63.43 to -39.77; one RCT, 36 participants; low quality evidence). There was no evidence that use of low energy level laser therapy (LLLT) prevented postoperative pain (very low quality evidence).ConclusionsAvailable evidence does not provide clinicians with reliable guidelines for treating periapical lesions. Further research is necessary to understand the effects of surgical versus non-surgical approaches, as well as to determine which surgical procedures provide the best results for periapical lesion healing and postoperative quality of life. Future studies should use standardised techniques and success criteria, with precisely-defined outcomes and the participant as the unit of analysis.

Treatment of Necrotic Teeth Using Two Engine-Driven Systems and Patient's Postoperative Pain: A Double-Blind Clinical Trial

INTRODUCTION

One of the most important reasons for postoperative pain is the extrusion of debris from the apical foramen during preparation and shaping of root canals. The aim of this clinical trial was to evaluate the severity of postoperative pain with the use of two different engine-driven NiTi systems.

METHODS AND MATERIALS

Ninety mandibular molars were randomly divided into two groups (n=45), and root canal cleaning and shaping was done using either RaCe or Reciproc instruments. The severity of postoperative pain was determined with visual analogue scale (VAS) at 4-, 12-, 24-, 48- and 72 h and 1-week intervals and postoperative pain was compared between the two groups. The chi-squared test and repeated-measures analysis were used to compare the data between the two groups.

RESULTS

Based on the results of the statistical analyses, the two groups were matched regarding the age and gender, with no significant differences. In addition, except for 4- and 24-h and 1-week intervals, postoperative pain was significantly less in the RaCe group compared to the Reciproc group (P<0.001).

CONCLUSION

Based on the results of the present study, use of RaCe files for cleaning and shaping of root canals in necrotic mandibular molars resulted in less severe postoperative pain compared to Reciproc files.

Root Canal Treatment versus Single-Tooth Implant: A Systematic Review of Internet Content

INTRODUCTION

There is an absence of professional consensus regarding when a tooth should be retained with root canal treatment and when to extract and replace it with an implant. Considering that patients often seek health-related information on the Internet, completeness and accuracy of online content are highly desirable. Websites should also fulfill several technical characteristics to be accessible to all.

METHODS

The search term root canal treatment implant was entered into 4 search engines. The first 100 webpages per engine search were evaluated. After removal of duplicates, those webpages comparing root canal treatment against single-tooth implant by using the AAE Implant Statement criteria as a benchmark were included. Completeness of information was evaluated against the AAE Statement by using a binary scale assessment tool. The related content was synthesized by using a protocol for systematic review of textual, non-research evidence. The webpages/sites were assessed for accessibility, usability, reliability, and quality of information by using the DISCERN and LIDA tools.

RESULTS

Twenty-six relevant webpages were found. Information completeness scores ranged from 1 to 6; however, nearly one third scored 1. Nine syntheses were derived relating to survival rates, tooth restorability, bone quality, esthetic demands, and systemic factors. The median overall scores for LIDA and DISCERN were 72% and 61%, respectively.

CONCLUSIONS

There is scarcity of information available on the Internet for the lay public with respect to the specific clinical question, although the webpages' content was consistent with available scientific literature. The accessibility, usability, reliability, and quality of information were largely moderate or low.

Resurrecting an unsalvageable lower incisor with a mono-block approach

Contemporary techniques, as well as the availability of bioactive and adhesive materials in endodontics, have helped revivifying teeth that were deemed hopeless. These newer materials and techniques would enable the clinician: (a) to predictably stop microbial activity (b) to achieve a total corono-apical fluid tight seal and (c) to strengthen mutilated teeth by obtaining intra-radicular reinforcement through mono-block effect. This case report demonstrates the successful treatment of a mutilated anterior tooth with the use of bioactive and adhesive materials to obtain a total seal and mono-block effect. This article also shows the use of a simple method in the placement of root filling cement into the root canal.

Incidence of post-obturation pain after single-visit versus multiple-visit non-surgical endodontic treatments

BACKGROUND

Post-obturation pain is frustrating to both patients and dentists. Its incidence may change with the use of contemporary endodontic techniques. This randomised clinical trial aims to compare the incidence of post-obturation pain at one and seven days after single-visit and multiple-visit non-surgical endodontic treatments.

METHODS

Patients who required primary endodontic treatment in the two clinical trial centres in Hong Kong (HK) and in Beijing (PK) were recruited. Three HK dentists and three PK dentists performed endodontic treatments on 567 teeth using the same procedures and materials, either in a single visit or over multiple visits, using either core carrier or cold lateral condensation for obturation.

RESULTS

The attrition rate was 5.1%, and a total of 538 teeth were evaluated. Among these teeth, 232 (43%) were operated in HK, 275 (51%) were treated in a single visit, and 234 (43%) were treated using core carrier obturation. Logistic regression analysis showed that teeth with apical periodontitis (OR = 0.35, 95% CI = 0.21-0.57, p < 0.01) and less pre-operative pain (OR = 1.10, 95% CI = 1.03-1.18, p < 0.01) had lower incidences of post-obturation pain after one day. The incidences of post-obturation pain after one day for single-visit and multiple-visit treatments were 24.7% (68 of 275) and 33.5% (88 of 263), respectively (p = 0.50). The incidences of post-obturation pain after seven days for single-visit and multiple-visit treatments were 4.0% (11 of 275) and 5.3% (14 of 263), respectively (p = 0.47).

CONCLUSIONS

There was no significant difference in the incidences of post-obturation pain after one day and seven days with single-visit or multiple-visit endodontic treatments.

TRIAL REGISTRATION

ChiCTR-IOR-15005989.

Early Cytokine Response to Infection with Pathogenic vs Non-Pathogenic Organisms in a Mouse Model of Endodontic Infection

Using the subcutaneous chamber model of infection, we showed previously that a mixture of four endodontic pathogens (EP: P. intermedia, F. nucleatum, S. intermedius and P. micra) are able to persist without clearance for up to seven days, while a non-pathogenic oral species, S. mitis, was substantially cleared in this time. Here we have compared the cytokine response inside the chambers against these microorganisms. A majority of cytokines tested (17/24) showed different patterns of expression. Several cytokines had a peak of expression at 2 h after infection in response to the EP, while none showed this pattern in S. mitis infections. Chemokines were uniformly present at similar or higher levels in response to S. mitis, with redundant expression of CXCR2 ligands, while several growth/survival factors were present at higher levels in EP infections. Protease activity expressed by EP may be responsible for the lower levels of some chemokines. T-cell associated cytokines were in general expressed at extremely low levels, and did not differ between the two infections. The inflammatory markers IL-6, IL-1α and IL1-β were expressed at similar levels in both infections at early times, while TNFα was preferentially present in S. mitis infections. In EP infected chambers, reciprocal changes in levels of IL-6 and IL-1α were observed at later times suggesting a switch in the inflammatory response. Analysis of the cytokine response to infection with the individual species from the EP mix suggests that P. intermedia drives this inflammatory switch. Together these results show a surprising level of divergence of the host response to pathogenic and non-pathogenic organisms associated with oral infections, and supports a dominant effect of P. intermedia in polymicrobial endodontic infections.

Choice of Treatment Plan Based on Root Canal Therapy versus Extraction and Implant Placement: A Mini Review

Case selection and treatment plan are important aspects of endodontic treatment. Dentists should organize the treatment plan based on their knowledge, abilities, skills and more importantly the patients’ preference and dentition. Indubitably, the treatment plan for each patient is exclusive and “tailor-made” and cannot be used for all patients. Dentists’ selfestimation of their abilities opens up treatment options; however, in difficult or complicated cases it is advisable to refer to a specialist. Currently, one of the most challenging aspects in dentistry is the choice between extraction and placement of implant (EPI) instead of a complicated root canal treatment (RCT). Overemphasis on one treatment plan while neglecting other options, not only mislead the dentist but also impose unnecessary charges to the patients. This mini-review compares RCT to EPI from various aspects to help practitioners in routine decision making.

A study of osseointegrated dental implants following cremation

BACKGROUND

The comparison of dental morphology and restorative work for human identification has been well documented. This case study involved documentation of osseointegrated and clinically restored dental implants following cremation.

METHODS

The mandible and the maxilla were excised from a head containing implants and cremated. The remains were retrieved, digital and radiographic images were taken and elemental analysis undertaken. The brand of implants was identified utilizing web based search engines. A prosthodontist, known to commonly use this implant system, was approached to ascertain possibilities that matched the data given.

RESULTS

Following cremation the implants were identified and a prosthodontist was able to identify the deceased. Two implants in the maxilla had dehiscences on their buccal surfaces, which could not be detected by periapical radiographs.

CONCLUSIONS

Dental implants osseointegrated and restored with a prosthetic superstructure were recognizable following severe incineration. It was possible to trace back the identity of the unknown victim to a prosthodontist. Bone dehiscences discovered in this study highlighted how two-dimensional radiographs may not reveal lack of bone support.

Treatment planning the endodontic-implant interface

One of the most challenging treatment planning decisions in restorative dentistry is the retention of a root filled tooth or its extraction and replacement with an implant. Making an informed judgement relies upon not only clinical experience and expertise but also interpretation of the published clinical evidence. In the last few years, more robust data and closer scrutiny of the evidence has helped to understand the advantages and disadvantages of each of these treatment modalities. The purpose of this paper is to provide a narrative review of some of the factors that may influence treatment planning for root canal treated teeth and indications for whether these teeth would be better replaced by an implant. From the evidence presented it is clear that both treatments have a place in contemporary restorative dental treatment and that survival for both root filled teeth and implants are similar. Unsurprisingly, both these treatment choices require high standards of clinical expertise and careful planning to ensure the best outcome.

Long-term survival rate of teeth receiving multidisciplinary endodontic, periodontal and prosthodontic treatments

Deciding whether to replace or preserve a compromised tooth, even with emerging trends in implant dentistry, is still a common dilemma for practitioners. This study sought to determine the 3- to more than 10-year survival rate of teeth that had undergone endodontic, periodontal and prosthodontic treatments. A total of 245 teeth in 87 patients were clinically and radiographically evaluated. All the teeth had received crown lengthening surgery by a single periodontist. Root canal therapy and prosthodontic procedures were rendered either by specialists or by experienced general dentists. Numbers of lost teeth were recorded and the criteria for hopeless teeth were defined. Survival rate was determined using the Kaplan-Meier estimator. Clinical indices including pocket depth (PD), bleeding index (BI), C/R ratio, position of the restoration margin relative to the gingival margin (RM-GM) and the presence of intra-canal post were compared between different survival groups (<3, 3-5, 5-10 and >10 years) using one-way analysis of variance (anova). Potential predictors of failure were determined using the Cox regression model. The mean ± s.d. of 3-, 5-, 10- and 13-year survival rates was 98 ± 1%, 96 ± 1·6%, 83·1 ± 4·5% and 51·9 ± 14·5%, respectively. The mean PD (P < 0·013), as well as C/R ratio in the mesial (P = 0·003) and distal (P = 0·007) surfaces, was significantly higher in the >10-year-survived teeth. Bleeding index and RM-GM showed no significant differences between the groups. C/R ratio and RM-GM position appeared to be the major determinants of tooth loss. The long-term survival rate of multidisciplinary-treated teeth was 83-98% in this specific sample.

Oral diagnosis and treatment planning: part 7. Treatment planning for missing teeth

Although more people are retaining increasing numbers of their natural teeth into older ages, approximately 30-40% of persons over the age of 75 years in Western countries are edentulous. The causes and significance of tooth loss vary widely among individuals and cultures, and missing teeth may be replaced by a variety of means for functional, social and psychological reasons, rather than for significant physical health benefits. Therefore, it is essential to determine what the loss of teeth means to patients and what their expectations are for the outcomes following tooth replacement by various methods.

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.