Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma of permanent incisors

Radiographic evaluation of teeth with pulp stones and pulp canal obliteration: characteristics, and associations with dental parameters

The study aimed to radiographically assess the characteristics of pulp stones (PS) and pulp canal obliteration (PCO) in teeth and examined their associations with various dental parameters such as caries, restorations, periodontal status, and age. This cross-sectional observational study was conducted at the Faculty of Dentistry, King Abdulaziz University between September 2022, and May 2023, involved 101 patients exhibiting 402 teeth with PS or PCO. Data were collected from periapical and bitewing radiographs, and analyzed by two calibrated dentists. Multiple dental parameters were assessed, including caries level, presence and level of restorations, periodontal condition, and age of the patient. The study population consisted of 62 females and 39 males, with an age range of 18-65 years. Inter- and intra-examiner reliability were high (Kappa = 0.88 and 0.98 respectively). PS were more commonly found in molars (81.2%), while PCO were presented in only 115 teeth (23%). Age significantly affected the type of calcification (p < 0.001), with PS more common in the 20-30 age group and PCO more common in individuals over 40. Presence of caries was significantly associated with the type of calcification (p = 0.013), but restoration was not. The majority of teeth with PS (76%) or PCO (93%) had healthy periodontium. Around 40% of teeth with PCO showed signs of periapical changes, a finding significantly different from those with PS (p < 0.001). Pulp calcifications were significantly associated with various dental parameters, including caries presence, age, and periodontal status. The findings provide crucial insights into the epidemiology and aetiology of pulp calcifications.

Negotiation of Calcified Canals

The gradual formation of hard tissue along the root canal walls is a natural process associated with aging, typically progressing slowly over time. In reaction to tooth wear, operative procedures, vital pulp treatments, or regenerative endodontic procedures, hard tissue may also accumulate within the pulp canal space at a slow rate. In certain cases, such as dental trauma, autotransplantation, or orthodontic treatment, this deposition of hard tissue can accelerate unexpectedly, resulting in rapid narrowing or complete closure of the root canal space. This situation is called calcific metamorphosis (CM), root canal calcification, or pulp canal obliteration (PCO). Performing conventional endodontic therapy on severely calcified canals presents significant challenges and increases the risk of procedural accidents. Calcified canals introduce such complexity that dedicated negotiation concepts and specially designed instruments have been developed to deal with the challenge. This article seeks to review the existing methods for effectively navigating calcified canals and to introduce the buckling resistance activation test (BRAT) technique.

Special considerations in paediatric dental trauma

Traumatic dental injuries (TDIs) in the paediatric population are common and frequently seen in general dental practice. The management of TDIs can be challenging and, in most cases, the General Dental Practitioner is tasked with the initial assessment and emergency treatment. Patients and their families typically attend with elevated levels of distress, which is complicated by the limited dental experience of some children. Behaviour management is essential and helps prepare patients for dental care at both their emergency and follow-up appointments. Early and accurate diagnosis in combination with appropriate treatment contributes to favourable outcomes for traumatised teeth. Early discussions with or referral to paediatric dental teams for management of complex TDIs is encouraged, however shared follow-up care is beneficial over the long-term. In specific cases, initial dental treatment can be delayed by a few days to a subsequent appointment, allowing the dental team to book sufficient time for the treatment and for the patient and their families to prepare. Education of the patients and adults with parental responsibility is essential to manage expectations, explain likely complications and encourage attendance for long-term follow-up visits. This paper discusses the management of paediatric patients to aid the primary care practitioner in providing effective immediate and long-term care.

Do orthodontic movements of traumatized teeth induce dental pulp necrosis? A systematic review

INTRODUCTION

Usually, orthodontic movements encompass children and young adult patients, which are more susceptible to the occurrence of traumatic dental injuries. It is necessary to understand whether the effects of orthodontic movements on traumatized teeth could induce pulp necrosis. The aim of this study was to answer the following question: "Do orthodontic movements of traumatized teeth induce dental pulp necrosis?".

MATERIAL AND METHODS

Searches were performed for studies published up to May 11, 2023, in the MEDLINE/PubMed, Cochrane Library, Scopus, SciELO Citation Index, Web of Science, EMBASE, and Grey Literature Report databases, without restriction for language or year of publication. The revised Cochrane risk of bias tools for nonrandomized interventions (ROBINS-I) was used to assess the quality of the included studies. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Of 2671 potentially relevant studies, five were included. Four were classified as having a moderate risk of bias and one as a serious risk of bias. It was reported a higher susceptibility to pulp necrosis in teeth subjected to orthodontic movements with history of trauma involving periodontal tissues. Additionally, orthodontic movements of traumatized teeth with total pulp obliteration had an increased risk of pulp necrosis. GRADE analysis presented a moderate certainty of evidence.

CONCLUSIONS

An increased risk for pulp necrosis when traumatized teeth are subjected to orthodontic movements was verified. However, this is based on evaluations performed with subjective tests. Further well-designed studies are necessary to confirm this trend.

CLINICAL RELEVANCE

Clinicians must be aware of the possibility of pulp necrosis. However, endodontic treatment is recommended when verified signs and symptoms of pulp necrosis.

Prevalence of pulp canal obliteration and periapical pathology in human anterior teeth: A three-dimensional analysis based on CBCT scans

This study aimed to determine the prevalence of pulp canal obliteration (PCO) and its association with periapical pathology (Hypodense areas) in cone-beam computed tomography (CBCT) scans of anterior teeth. A total of 2161 CBCT scans from patients 18 years or older taken between 2000 and 2020 were selected. Patient-, tooth- and scan-related data were registered. Two calibrated evaluators recorded the number of teeth with PCO ≥4 mm in the cervical third of the roots and the presence or absence of periapical hypodensities (PH). The length of the root canal that was calcified was also determined. Logistic regression analysis was used to determine whether any of the recorded factors influenced the presence of PCO and the presence of periapical pathology in teeth presenting with PCO. The only factor significantly related to the presence of PCO was patient age. The prevalence of PH in teeth exhibiting PCO was 10%.

Access Cavity Preparation and Localization of Root Canals Using Guides in 3D-Printed Teeth with Calcified Root Canals: An In Vitro CBCT Study

Pulp canal obliteration (PCO) is a significant complication in endodontics that can occur due to various factors. Cone beam computed tomography (CBCT) is a useful diagnostic tool for identifying root canal anatomy and variations, and guided endodontics is emerging as an alternative treatment solution for teeth with partially or entirely obliterated pulpal canals. However, the accuracy of CBCT-guided 3D-printed guides on different materials and layer thicknesses is not well understood. Therefore, this study aimed to evaluate the accuracy of guides prepared using CBCT images on 3D-printed teeth with stereolithography (SLA) using three different materials and two different layer thicknesses. This study found that 3D-printed guides were accurate and reliable for accessing 3D-manufactured obliterated teeth and reaching the apical area. No significant differences in distance or angle measurements were found when different guide materials were used, suggesting that materials can be selected based on availability and cost. These findings contribute to the knowledge base regarding the effectiveness of 3D printing technology in guided endodontics and can help to identify the most suitable materials and techniques for this application.

Intracoronal tooth bleaching - A review and treatment guidelines

Intracoronal bleaching is a minimally invasive procedure that was introduced into dentistry in the 19th century. The role of that procedure in enhancing the colour of teeth subjected to internal discolouration while being conservative made it extremely popular amongst dental professionals. Different materials and techniques have been utilized over the years attempting to obtain predictable long-term results while minimizing any associated risks. Contemporarily, bleaching agents are mainly based on peroxide-releasing compounds in different formulations and delivery systems. Different theories have been formulated on the bleaching mechanism of such agents, but the exact mechanism is yet to be proven. The effect of hydrogen peroxide-based bleaching agents on the organic structure of enamel and dentine has been extensively investigated to address the effects of bonding of resin-based restorative materials to hard tooth structure. Multiple case reports raised a concern about the contribution of intracoronal bleaching in developing invasive root resorption. Modification of intracoronal bleaching techniques was thus necessary to address such concerns. This review will provide a summary of the important aspects of intracoronal bleaching, focusing on how it applies to the contemporary clinical setting. © 2023 Australian Dental Association.

Endodontic-orthodontic interactions: a review and treatment recommendations

The literature is replete with articles describing the many and varied interactions between endodontic treatment and orthodontic tooth movement (OTM), often reporting conflicting views and findings, which creates confusion for clinicians. Original research and review articles have described aspects such as apical root resorption and potential pulpal complications of teeth related to OTM. Some interactions are of relatively minor clinical significance, whilst others may have adverse consequences. A history of dental trauma before or during OTM further complicates the interactions. This review re-assesses the historical literature on endodontic-orthodontic interactions in light of more recent research and presents guidelines for managing clinical situations involving both disciplines. © 2023 Australian Dental Association.

Ex-vivo and in-vivo validation of a novel measuring protocol for guided endodontics

OBJECTIVES

To (1) validate the use of a post-operative intraoral scan (IOS) versus Cone Beam Computed Tomography (CBCT), gold standard, on its ability to measure the accuracy of guided endodontics, and (2) present clinical data on the accuracy of guided endodontics.

METHODS

Four models, including 10 extracted teeth each, were created. Forty guided access cavities were planned on dentin to simulate pulp canal obliteration (PCO). Two operators performed guided access cavities. A post-operative CBCT and IOS were acquired. The deviation coronally, apically, and angular deviation was measured with CBCT and IOS. Clinical accuracy was measured using an IOS acquired immediately after drilling the access cavity with the aid of a guide. Data analysis was performed using multiway Anova and corrected for simultaneous hypothesis testing according to Tukey. P ≤ 0.05 was considered statistically significant. Descriptive statistics on the clinical accuracy of guided endodontics were performed.

RESULTS

Thirty-eight cavities were assessed with a mean length of 13.8 mm. No statistical difference between operators and methods was found for all parameters (P > 0.05). Thirty-three patients were treated with guided endodontics and measured using an IOS. Results show an average coronal, apical, and angular deviation of 0.2 mm, 0.45 mm, and 1.91^° respectively. The average length of the access cavities was 12.5 mm.

CONCLUSIONS

An IOS can be used to measure the accuracy of guided endodontics. Clinical data showed high accuracy of guided endodontics with a mean apical deviation smaller than 0.5 mm and a mean angular deviation of less than 2^°.

CLINICAL SIGNIFICANCE

The use of an IOS does not involve additional radiation exposure. A safety margin of at least 1 mm around the planned trajectory should be respected when planning the case to minimize the possibility of root perforation.

Impact of Dental Trauma on Orthodontic Parameters-A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Investigation into the impact of dental trauma on the results of orthodontic treatment is crucial because it can have a major influence on patient care. However, there has not yet been a thorough review or meta-analysis of the available data, which is inconsistent and scant. Therefore, the goal of this systematic review and meta-analysis is to investigate the impact of dental trauma on orthodontic parameters. Search methods and criterion of selection: Major online databases were searched (beginning from the year 2011) for relevant articles using a properly defined search strategy. Analysis protocol: Risk of bias (RoB) and the Cochrane risk of bias tool were utilized for the purposes of bias evaluation within the individual studies and within the review, respectively.

RESULTS

Out of the six clinical trials selected, a significant impact of trauma was observed in individuals in all but one paper. Gender predilection varied across studies and could not be conclusively determined. The follow-up period ranged from two months to two years in the trials. The odds ratio (OR) 0.38 [0.19, 0.77] and the risk ratio (RR) 0.52 [0.32, 0.85] indicated that both the odds as well as the relative risk of experiencing dental trauma were lower in the group with negligible impact compared to the group with noticeable impact. Conclusion and further implications: The findings show that dental trauma significantly affects orthodontic parameters, with lower risk and likelihood of suffering dental trauma in the group with negligible impact than in the group with noticeable impact. However, given the substantial heterogeneity among the studies, it is advised to exercise caution when extrapolating the findings to all populations. Registration and protocol: Registration in the PROSPERO database was carried out before initiating the investigation [CRD42023407218].

Management of Discolored Anterior Teeth with Pulp Canal Obliteration

The purpose of this article is to present the effect and follow-up results of combined single-tooth vital bleaching when discoloration is due to pulp canal obliteration. In these cases, discoloration was managed successfully via home bleaching with a customized single-tooth tray and in-office bleaching without root canal treatment.

Guided Endodontics: A Literature Review

The main objective of this paper is to perform an updated literature review of guided endodontics based on the available up-to-date scientific literature to identify and describe the technique, its benefits, and its limitations. Four electronic databases (PubMed, Scopus, Science Direct, and Web of Science) were used to perform a literature search from 1 January 2017 to 13 May 2022. After discarding duplicates, out of 1047 results, a total of 29 articles were eligible for review. Guided endodontics is a novel technique that is currently evolving. It is applied in multiple treatments, especially in accessing and locating root canals in teeth with pulp canal obliteration, microsurgical endodontics, and removing glass fiber posts in endodontic retreatments. In addition, it is independent of an operator's experience, requires less treatment time for the patient, and is more accurate and safer than conventional endodontics.

Generalized pulp canal obliteration in a patient on long-term glucocorticoids: a case report and literature review

BACKGROUND

The calcification of the tooth pulp is a pathological condition that occurs in response to various factors. A uncommon haematological condition known as paroxysmal nocturnal haemoglobinuria (PNH) is characterized by bouts of haemolysis, and it requires long-term use of glucocorticoids (GCs).

CASE PRESENTATION

A female patient who was diagnosed with PNH and had a history of long-term use of GCs came to our department for root canal therapy (RCT) for teeth 25, 26, and 27. The radiographs showed generalized pulp canal obliteration (PCO) in most of the patients. None of these teeth (25, 26, or 27) were sensitive to percussion, and they did not respond to thermal or electrical sensitivity tests. A diagnose of pulp necrosis was made for these teeth. RCT was carried out with the help of an oral microscope, and then a prosthodontic procedure was created for the teeth.

CONCLUSIONS

Based on the patient's long history use of GCs and a series of related studies, we conclude that the long-term usage of GCs contributes significantly to the onset of PCO.

10-Year Follow-up of Previously-Traumatized Immature Permanent Incisors Sustaining Second and Third Traumatic Injuries After Revascularization Treatment: Case reports

The long-term prognosis of previously traumatized immature permanent teeth treated with guided endodontic repair is well documented, but little is known about how these teeth respond to further traumatic injury after treatment. This case report presents the 10-year clinical and radiographic findings of two patients with traumatized maxillary incisors who underwent guided endodontic repair treatment and sustained two further traumatic injuries. Three crown-fractured maxillary central incisors with pulp necrosis were treated with a protocol that used 2.5% NaOCl irrigation, 3-4 week medication with calcium hydroxide or ciprofloxacin-metronidazole paste, induction of apical bleeding, and coronal sealing with mineral trioxide aggregate. One tooth sustained subluxation and a crown fracture after 20 months and 7 years, respectively. Two other teeth had a luxation injury at 9 months and subluxation 6.5 years after the regenerative treatment. One subluxated and one luxated tooth remained free of symptoms for 10 years with radiographic evidence of progressive root canal calcification, while the other luxated incisor required root canal treatment after 7.5 years. Although teeth treated with the so-called "regenerative" endodontic techniques do not possess true pulp tissue, the reparative tissue may respond to traumatic injuries in a similar manner to teeth with normal pulps.

Biomaterial scaffolds for clinical procedures in endodontic regeneration

Regenerative endodontic procedures have been rapidly evolving over the past two decades and are employed extensively in clinical endodontics. These procedures have been perceived as valuable adjuvants to conventional strategies in the treatment of necrotic immature permanent teeth that were deemed to have poor prognosis. As a component biological triad of tissue engineering (i.e., stem cells, growth factors and scaffolds), biomaterial scaffolds have demonstrated clinical potential as an armamentarium in regenerative endodontic procedures and achieved remarkable advancements. The aim of the present review is to provide a broad overview of biomaterials employed for scaffolding in regenerative endodontics. The favorable properties and limitations of biomaterials organized in naturally derived, host-derived and synthetic material categories were discussed. Preclinical and clinical studies published over the past five years on the performance of biomaterial scaffolds, as well as current challenges and future perspectives for the application of biomaterials for scaffolding and clinical evaluation of biomaterial scaffolds in regenerative endodontic procedures were addressed in depth.

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Overview of biomaterials for scaffolding in regenerative endodontics are presented.

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Findings of preclinical and clinical studies on the performance of biomaterial scaffolds are summarized.

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Challenges and future prospects in biomaterial scaffolds are discussed.

A Prospective Study of Long-Term Regenerative Endodontics Outcomes of Necrotic Immature Permanent Teeth: An 8-Year Follow-Up

For the management of necrotic immature teeth, regenerative endodontics offers the advantage of further root lengthening, thickening of dentin wall, and apical closure. This prospective study aimed to evaluate the long-term outcome of regenerative endodontics in immature necrotic permanent teeth. A total of 23 immature roots were medicated by triple antibiotic paste. After 21 days, bleeding was induced by over-instrumentation, and then mineral trioxide aggregate and coronal restoration were applied. Patients were scheduled for clinical and radiographic follow-up for 8 years. The radiographic changes of root dimensions were assessed using the ImageJ Plugin and statistically analyzed by Kruskal-Wallis test at a 95% confidence level. For qualitative evaluation, images were overlapped and analyzed using Photoshop software. All teeth were asymptomatic one month after the treatment. All teeth (n = 18) with preoperative periapical radiolucency showed complete resolution within 6-9 months. Recall rate at two, three, and eight years was 69.6%, 56.5%, and 34.8%, respectively. Continuous root development with a significant increase in root length and thickening of dentin wall accompanied by a significant decrease in apical canal diameter was seen at the end of the observation period (p < 0.001). In conclusion, the long-term outcome of regenerative endodontics revealed successful clinical and radiographic results with appropriate case selection.

Management of Pulp Canal Obliteration-Systematic Review of Case Reports

Background and Objectives: This systematic review aimed to assess the literature focusing on the clinical management of traumatized teeth with Pulp Canal Obliteration (PCO) and propose an updated clinical decision-making algorithm. The present review follows the PRISMA guidelines and was registered on PROSPERO database (CRD42020200656). Materials and Methods: An electronic search strategy was performed in Pubmed, EBSCOhost and LILACS from inception to March 2021. Only anterior permanent teeth with PCO due to dental trauma were included. Regarding clinical approaches, only teeth managed with a “watchful waiting” approach, tooth bleaching or root canal treatment (RCT) were included. Quality assessment was performed using the JBI Critical Appraisal Tool for Case Reports. Results: Twenty case reports were selected, resulting in a total of 27 patients. The number of traumatized teeth diagnosed with PCO was 33. The “watchful waiting” approach was the most implemented clinical strategy. Discolored non-symptomatic PCO teeth were mostly managed with external bleaching. The prevalence of pulp necrosis (PN) was 36.4%. For teeth diagnosed with PN, non-surgical RCT was performed in 10 teeth and surgical RCT in one tooth. Guided endodontic technique was performed in six of those teeth. Conclusions: For discolored non-symptomatic PCO teeth, external bleaching is advocated and the RCT approach should not be implemented as a preventive intervention strategy. Symptomatic PCO teeth should follow regular endodontic treatment pathways. Clinical approach of teeth with PCO should follow a decision-making algorithm incorporating clinical and radiographic signs and patient-reported symptoms.

Preserving the vitality of teeth adjacent to a large radicular cyst in periapical microsurgery: a case report with 4-year follow-up

Background

Radicular cysts may enlarge considerably, cause extensive bone destruction, and jeopardize the integrity of the associated vital teeth. The different treatment approaches are aimed mainly at eliminating the cystic epithelial membrane while reducing the risk of injury to vital structures. Contrary to other treatment modalities, preapical surgery offers an unequivocal single occasion resolution for the patient. However, it has been associated with higher risk of collateral damages.

Case presentation

A patient presented with a large radicular cyst originating from a maxillary lateral incisor. The adjacent central and canine teeth initially failed to exhibit responses to sensibility tests but showed signs of vitality. Microsurgical management was aimed at enucleating the cystic membrane while maintaining adjacent teeth vitality. Upon careful and controlled cyst enucleation under the dental operating microscope, the neurovascular bundle of one of the involved teeth was visualized and its integrity was maintained throughout the procedure.

Results

The procedure was successful and follow up recalls revealed recovery of normal sensibility of tooth 11 and 13 with complete bone regeneration around their apices.

Conclusion

Within the limitation of the present case report, we demonstrated that complete excision of large periapical cyst can be performed without sacrificing the vitality of the adjacent teeth, by preserving the integrity of their neurovascular supply through controlled microsurgical enucleation, and by a potential apical vascular repair ensuing unintended injury. Diagnosing the pulp vitality of non-offending teeth whose apices protrude into the cystic lumen is a complex process and can be misleading. Pressure from the growing cyst can inhibit vital teeth responses to neural-based sensibility tests leading to false negative results. Thus, in such cases, the use of blood perfusion-based vitality testing is recommended for correct initial diagnosis.

European Society of Endodontology position statement: endodontic management of traumatized permanent teeth

This position statement represents a consensus of an expert committee convened by the European Society of Endodontology (ESE) on the endodontic management of traumatized permanent teeth. A recent comprehensive review with detailed background information provides the basis for this position statement (Krastl et al. 2021, International Endodontic Journal, https://doi.org/10.1111/iej.13508). The statement is based on current scientific evidence as well as the expertise of the committee. Complementing the recently revised guidelines of the International Association of Dental Traumatology, this position statement aims to provide clinical guidance for the choice of the appropriate endodontic approach for traumatized permanent teeth. Given the dynamic nature of research in this area, this position statement will be updated at appropriate intervals.

Dynamic navigation: a laboratory study on the accuracy and potential use of guided root canal treatment

AIM

To evaluate 3D accuracy and outcome of a dynamic navigation method for guided root canal treatment of severe pulp canal obliteration (PCO) in 3D printed jaws.

METHODOLOGY

Three operators with different levels of experience in Endodontics performed navigated access cavities, using the Navident system (ClaroNav), in two sets (maxillary and mandibular) of 3D-printed jaw models with teeth presenting severe PCO. Models were mounted on a phantom to mimic a real clinical situation. After treatment, a postoperative high resolution Cone-Beam Computer Tomography (CBCT) scan (NewTom) was taken for each model and registered to the preoperative model. All access cavities were then segmented using 3-Matic Medical software 15.0 (Materialise). Length and volume of each access cavity were measured, and a comparison was done by measuring the distance deviation in mm at the coronal entry point, apical point, vertical deviation, total deviation and angular deviation of the access cavity in comparison with the virtual planning. Additionally, all access cavities were scouted with a size 10 K-file and inspected on the CBCT to confirm that the canal was located. Descriptive statistics for each parameter were performed. Normality of the data was assessed; data were transformed if needed to make it normally distributed. One-way analysis of variance (anova) was applied to assess differences between parameters for tooth type, jaw, and operators and corrected for simultaneous hypothesis testing according to Tukey. Significance level was set at .05.

RESULTS

After training with the system (28 cavities per operator), a total of 132 teeth and 168 access cavities (56 per operator) were prepared. All operators located a total of 156 canals, obtaining an overall success of 93% without a difference between operator experience (p > .05). The mean deviation at the apical point was 0.63 mm (SD 0.35) and was significantly lower in anterior teeth in comparison with molars (p < .05). The mean angular deviation from the planning was 2.81° (SD 1.53).

CONCLUSION

Dynamic navigation was an accurate approach for root canal treatment in teeth with severely calcified canals. However, the technique has a learning curve and requires extensive training prior to its use clinically.

Endodontic management of traumatized permanent teeth: a comprehensive review

The pulp plays a key role in the treatment of traumatic dental injuries (TDIs) and is strongly associated with the outcome, particularly in severe cases. A correct pulp diagnosis is essential as it forms the basis for developing the appropriate management strategy. However, many TDIs are complex, and their treatment requires a profound knowledge of the physiological and pathological responses of the affected tissues. This comprehensive review will look at the dentine-pulp complex and its interaction with the surrounding tissues following TDIs. The literature up to 2020 was reviewed based on several searches on PubMed and the Cochrane Library using relevant terms. In addition to the recently revised guidelines of the International Association of Dental Traumatology, this article aims to provide background information with a focus on endodontic aspects and to gather evidence on which a clinician can make decisions on the choice of the appropriate endodontic approach for traumatized permanent teeth.

Guided Endodontics for Managing Severely Calcified Canals

Endodontic treatment of teeth with pulp canal obliteration presents a challenge given the high likelihood of procedural errors and complications during treatment. These drawbacks can be avoided by using a personalized 3-dimensional (3D) guide designed by overlaying a cone-beam computed tomographic scan with an intraoral scan of the patient. This 3D guide enables the clinician to obtain a straight access to the obliterated root canal.This article described guided endodontics in managing 7 severely obliterated teeth using both virtually designed 3D guides and a customized 1-mm-diameter cylindrical bur. This treatment approach was demonstrated to be safe and fast and can be considered as a predictable technique for the location of calcified canals, thus minimizing complications.

A Contemporary Treatment of an Iatrogenic Root Perforation: A Case Report

Pulp canal calcification is 1 of the possible outcomes after certain types of dental trauma. This can make endodontic treatment more challenging should it become necessary. Because of the increased degree of difficulty, sometimes procedural incidents do occur during root canal treatment. This case report demonstrates an unusual clinical presentation of a root perforation and missed canal, which had undergone calcification as a result of trauma some years earlier. A contemporary approach to treatment involved a combination of treating the biological complication of the calcified canal combined with surgical repair of the iatrogenic complication of a perforation using modern imaging techniques and materials.

Guided Endodontics: Use of a Sleeveless Guide System on an Upper Premolar with Pulp Canal Obliteration and Apical Periodontitis

Guided endodontics has been used for the treatment of anterior teeth with a successful outcome. This approach is not only limited to anterior teeth because it can also be used for the treatment of premolars and molars. However, in such cases, space may be a limitation because a long bur has to be used in addition to the guide being placed on top of the teeth. The aim of this case report was to present a novel guided endodontics technique using a sleeveless 3-dimensional-printed guide. This design can reduce vertical space, allowing an open view of the tooth and irrigation during drilling. A 46-year-old female patient consulted the endodontic department with intermittent pain around tooth #5. Tooth #5 presented pain upon percussion and responded negative to a cold test. The initial periapical radiograph revealed an apical radiolucency with pulp canal obliteration. Clinically, there was no sinus tract. The tooth was diagnosed with pulp necrosis and symptomatic apical periodontitis. Guided endodontic treatment was performed with a sleeveless 3-dimensional-printed guide and long neck carbide bur with a head diameter of 1 mm to drill a minimally invasive access cavity up to the root canal. A completely healed apical area of tooth #5 was visible after 1 year on periapical radiographs. This technique seems to be a promising alternative in comparison with the conventional guided endodontic guide design for the negotiation of pulp canal obliteration in cases in which vertical space is limited.

Orthodontic treatment recommendation and expected adverse reactions in patients with a history of dental trauma: A survey among general dentists, paediatric dentists, and orthodontic specialists

BACKGROUND

Trauma-induced adverse reactions may trigger complications when moving teeth orthodontically.

AIM

The purpose of this study was to evaluate the knowledge of dental practitioners about this topic.

DESIGN

A questionnaire survey was organized among general dentists, paediatric dentists, and orthodontists in Flanders (Belgium). Three clinical cases describing trauma-induced tooth damage (tooth ankylosis, apical root resorption, and pulp/root canal obliteration) were presented, followed by a set of questions.

RESULTS

The questionnaire was completed by 121 general dentists (GD), 47 paediatric dentists (PD), and 99 orthodontic specialists (OS). In the case with ankylosis, impossibility to move the tooth orthodontically was reported as most frequent adverse reaction (82.8% of GD, 95.7% of PD, and 100.0% of OS) (P < .001). In the situation of apical root resorption, the most frequently reported adverse event was progressive apical root resorption (78.9%, 85.7%, and 88.8% respectively; P = .265). Most frequently mentioned adverse reaction in the case with pulp and root canal obliteration was tooth discoloration (64.1%, 57.1%, and 78.3%; P = .055), followed by apical root resorption (57.4%, 56.8%, and 68.7%; P = .283). Orthodontic treatment recommendation differed among specific clinical situations but also among groups of dental practitioners.

CONCLUSIONS

Important knowledge gaps exist regarding the orthodontic managment of traumatized teeth. This topic requires more attention in undergraduate training, specialist training, and continuing education.

Comparison of iRoot BP Plus and Calcium Hydroxide as Pulpotomy Materials in Permanent Incisors with Complicated Crown Fractures: A Retrospective Study

INTRODUCTION

Calcium hydroxide has been used as a traditional pulpotomy agent for a long time but has some disadvantages. iRoot BP Plus (Innovative Bioceramix Inc, Vancouver, Canada) is a newly developed, ready-to-use calcium silicate-based bioactive ceramic with excellent bioactivity and sealing ability. However, whether iRoot BP Plus shows superiority over calcium hydroxide as a pulpotomy material on permanent incisors with complicated crown fractures remains unknown.

METHODS

This research included 205 permanent incisors with complicated crown fractures. These teeth were treated with pulpotomy and divided into 2 groups according to the pulpotomy material (105 treated with iRoot BP Plus and 100 with calcium hydroxide). Clinical and radiographic information was collected during the 12- to 24-month follow-up period. The formation of reparative dentin bridges and pulp canal obliteration were analyzed using radiographs in both groups.

RESULTS

The success rates for recall in the average follow-up period of 17.5 ± 4.4 months (12-24 months) after pulpotomy treatment were significantly different between the 2 groups, with 99% for the iRoot BP Plus group and 93% for the calcium hydroxide group. Reparative dentin bridges were observed in 92.4% of the iRoot BP Plus group and 90% of the calcium hydroxide group, but the difference was not significant. Pulp canal obliteration was observed in 2 teeth (2%) in each group.

CONCLUSIONS

The success rates obtained in our study indicate that iRoot BP Plus as a pulpotomy agent can be a suitable alternative to calcium hydroxide to manage complicated crown fractures.

Effects of endodontic irrigants on blood and blood-stained dentin

Objectives

This study aimed to investigate bleaching effects of common endodontic irrigants on human whole blood and blood-stained dentin. Specifically, it was assessed whether sodium hypochlorite at a clinically recommended concentration (2.5% NaOCl) would bleach with similar efficacy as a peroxide-based irrigant at higher molarity (5% H₂O₂). Furthermore, the effects of a NaOCl-compatible chelator with a high affinity to iron (Dual Rinse HEDP) were investigated.

Methods

Human whole blood was mixed at a 1:20 ratio with either phosphate-buffered saline, 9% HEDP, 2.5% NaOCl, 2.5% NaOCl containing 9% HEDP, or 5% H₂O₂. Effects were assessed spectrometrically and photographically. Human dentin specimens were prepared with a methacrylate reservoir for liquids and a polished assessment side over 1 mm dentin thickness. Dentin was stained using human whole blood for 3 weeks and subsequently exposed to the irrigants for 60 min. Measurements were performed in the CIELAB color space. Results were compared using parametric tests with the alpha-type error set to 5%.

Results

When directly exposed, the solutions containing NaOCl completely discolored the blood, while the 5% H₂O₂ exerted a bleaching effect without complete dissolution of dissolved matter, and the pure 9% HEDP had no effect at all. The NaOCl solutions bleached blood-stained dentin more efficiently than H₂O₂ (p < 0.05).

Conclusions

Under the current conditions, the 2.5% NaOCl solution had a stronger bleaching effect on blood and blood-stained dentin than 5% H₂O₂. HEDP did not have any direct impact on blood color or NaOCl-derived bleaching.

Pulp canal obliteration after traumatic injuries in permanent teeth - scientific fact or fiction?

Pulp canal obliteration (PCO) is a frequent finding associated with pulpal revascularization after luxation injuries of young permanent teeth. The underlying mechanisms of PCO are still unclear, and no experimental scientific evidence is available, except the results of a single histopathological study. The lack of sound knowledge concerning this process gives rise to controversies, including the most suitable denomination. More than a mere semantic question, the denomination is an important issue, because it reflects the nature of this process, and directly impacts the treatment plan decision. The hypothesis that accelerated dentin deposition is related to the loss of neural control over odontoblastic secretory activity is well accepted, but demands further supportive studies. PCO is seen radiographically as a rapid narrowing of pulp canal space, whereas common clinical features are yellow crown discoloration and a lower or non-response to sensibility tests. Late development of pulp necrosis and periapical disease are rare complications after PCO, rendering prophylactic endodontic intervention useless. Indeed, yellowish or gray crown discoloration may pose a challenge to clinicians, and may demand endodontic intervention to help restore aesthetics. This literature review was conducted to discuss currently available information concerning PCO after traumatic dental injuries (TDI), and was gathered according to three topics: I) physiopathology of PCO after TDI; II) frequency and predictors of pulpal healing induced by PCO; and III) clinical findings related to PCO. Review articles, original studies and case reports were included aiming to support clinical decisions during the follow-up of teeth with PCO, and highlight future research strategies.

Therapeutic Approach to Pulp Canal Calcification as Sequelae of Dental Avulsion

Tooth avulsion represents the most complicated dental injury, and the classic treatment is tooth replantation. The most common sequelae are pulp canal calcification (PCC) and pulp necrosis. The presence of pulp necrosis after PCC is reported in up to 30% of the cases and is a challenge due to the difficulty of endodontic treatment. This case report describes the surgical treatment of a replanted tooth presenting PCC and periapical pathology eight years after the trauma. An endodontic surgery was performed to remove the apical granuloma, to prepare the apical root, and to seal the apical region with an endodontic cement. In a three-year follow-up, there was an absence of inflammatory signs and symptoms or apical lesion. This report shows the importance of close follow-up after dentoalveolar injuries. After the initial dental trauma and its consequences to pulpal tissues, the executed procedures allowed a favourable outcome.

Cvek pulpotomy - revisited

BACKGROUND/AIM

While some studies support the notion that the time elapsed from coronal fracture and treatment with Cvek pulpotomy in permanent teeth plays an important role in minimizing the possibility of pain and discomfort, microbial pulp invasion, and ensuring pulp and periodontal healing, others consider that neither time between the accident and treatment nor size of exposure is critical if the inflamed superficial pulp tissue is amputated to the level of a healthy pulp. This study compares published data in an attempt to assess whether the outcome of Cvek pulpotomies is affected by these factors.

RESULTS AND CONCLUSIONS

Evidence in the literature suggests to treat a permanent tooth with a complicated crown fracture as soon as possible to diminish the possibility of pain and prevent necrosis and infection of the pulp. Delay of treatment by 9 days or less may have minimal effect on the outcome of Cvek pulpotomies. While the literature indicates that pulp exposures of 4 mm or less may have a good prognosis after a Cvek pulpotomy, the prognosis in teeth with pulp exposures of more than 4 mm has not yet been clarified. Although the literature is not conclusive regarding a difference in the outcomes of Cvek pulpotomies in teeth with open or closed apices, it appears that teeth with open apices have a better prognosis. The outcome of a Cvek pulpotomy may be compromised by a luxation injury that diminishes the tooth's blood supply and innervation. A good restoration that prevents bacterial penetration into the tooth is essential for the success of a Cvek pulpotomy.

Treatment of calcified root canals in elderly people: a clinical study about the accessibility, the time needed and the outcome with a three-year follow-up

OBJECTIVE

Determination of accessibility, time needed and outcome of endodontic treatment of teeth with calcified root canals in a sample of elderly participants in a private practice limited to endodontics.

BACKGROUND

Due to demographic changes, gerodontology is becoming more and more important, also in the field of endodontology. Elderly patients can show up with severe calcifications of root canals. Root canal treatment, when needed, can be very challenging in these cases. Only few data exist about the treatment of calcified root canals and its outcome, especially in an elderly population.

MATERIALS AND METHODS

Forty-one participants (median age: 72 years) needing a root canal treatment were included. The total number of treated teeth was 41 with 114 negotiated root canals. A specialist limited to endodontics performed the treatment in a private practice. Outcome was assessed by applying the periapical index score on the basis of recall radiographs provided by the referring dentists. Likewise, time required to localise the root canals was measured.

RESULTS

All root canals have been detected using the operating microscope, and full working length could be established in 90% of the cases. Success rate was 80% after an observation time of 3 years. In three of five teeth, root canals could be localised within 15 min.

CONCLUSION

Calcified root canals of older people treated in this study were all accessible within a maximum of 60 min. The success rate after a follow-up of 3 years was 80%.

Long-Term Follow-Up of a Revascularized Immature Necrotic Tooth Evaluated by CBCT

This case study reports the successful treatment of an immature upper premolar with periapical pathosis and sinus tract using revascularization technique. Clinical and radiographic examination demonstrated the recovery of vitality, continued root development, and periapical healing at the 7-month follow-up. In addition, severe calcification of the canal was noted at the 36-month follow-up. At the 66-month follow-up, cone-beam computed tomography (CBCT) revealed complete periapical healing, apical closure, increase in root length and thickness of dentin, and severe calcification of the root canal. Even though the nature of tissue within the root canal is unknown, revascularization appears to give good clinical and radiographic success. This case report highlights that severe calcification of the canal is one of the long-term outcomes of revascularized root canals.

3D Computer aided treatment planning in endodontics

OBJECTIVES

Obliteration of the root canal system due to accelerated dentinogenesis and dystrophic calcification can challenge the achievement of root canal treatment goals. This paper describes the application of 3D digital mapping technology for predictable navigation of obliterated canal systems during root canal treatment to avoid iatrogenic damage of the root.

METHODS

Digital endodontic treatment planning for anterior teeth with severely obliterated root canal systems was accomplished with the aid of computer software, based on cone beam computer tomography (CBCT) scans and intra-oral scans of the dentition. On the basis of these scans, endodontic guides were created for the planned treatment through digital designing and rapid prototyping fabrication.

RESULTS

The custom-made guides allowed for an uncomplicated and predictable canal location and management.

CONCLUSION

The method of digital designing and rapid prototyping of endodontic guides allows for reliable and predictable location of root canals of teeth with calcifically metamorphosed root canal systems.

CLINICAL SIGNIFICANCE

The endodontic directional guide facilitates difficult endodontic treatments at little additional cost.

Modern Endodontic Planning Part 2: Access and Strategy

Poor access and iatrogenic damage can result in failed root canal treatment. Understanding tooth anatomy improves access and ensures that the clinician is cleaning and shaping the whole root canal system. If a canal is missed treatment usually fails. This paper revisits tooth anatomy and discusses how to ensure that access is optimized, but not at the expense of precious tooth structure. The concept of multi-visit root canal treatment is also addressed with emphasis on the, often overlooked, aspect of temporization. CPD/Clinical Relevance: Good anatomical knowledge of teeth is the cornerstone of endodontics. Once root treatment has begun the clinician must be logical about how many visits to take and how to temporize teeth between such visits.