Aspects of Clinical Malpractice in Endodontics

Dealing with Evidence in Dental Professional Liability Lawsuits-General Recommendations for Dental Expert Witness Work Using the Example of Germany: A Narrative Review

Dental treatment can lead to disputes between patients and dentists, which are then brought before the civil courts as medical malpractice cases. The court regularly commissions a dental expert to answer questions of evidence in court. In the majority of cases, the expert is able to answer these questions based on his professional expertise and practical experience. In order to make the assessment comprehensible and credible for the judge and the parties, it can be helpful and reasonable to cite relevant literature references from dental textbooks and specialist journals. In individual cases, it may be necessary to carry out a systematic literature search on specific topics. Based on the situation in Germany, this narrative review makes recommendations of how to perform a literature search and make citations specifically for expert opinions that are generally applicable independent of national jurisdiction.

The Safety of Removing Fractured Nickel-Titanium Files in Root Canals Using a Nd: YAP Laser

The fracture of nickel-titanium (Ni-Ti) instruments during root canal instrumentation leads to compromised outcomes in endodontic treatments. Despite the significant impact of instrument facture during a root canal treatment, there is still no universally accepted method to address this complication. Several previous studies have shown the ability of a Neodymium: Yttrium-Aluminum-Perovskite (Nd: YAP) laser to cut endodontic files. This study aims to determine safe irradiation conditions for a clinical procedure involving the use of a Neodymium: Yttrium-Aluminum-Perovskite (Nd: YAP) laser for removing fractured nickel-titanium files in root canals. A total of 54 extracted permanent human teeth (n = 54) were used. This study involved nine distinct groups, each employing different irradiation conditions. Groups 1 s, 3 s, 5 s, 10 s, and 15 s simply consist of irradiation for 1, 3, 5, 10, and 15 s, respectively. After identifying the longest and safest duration time, four additional groups were proposed (labeled A, B, C, and D). Group A was composed of three series of irradiations of 5 s each separated by a rest time of 30 s (L5s + 30 s RT). Group B consisted of three series of irradiations of 5 s each separated by a rest time of 60 s (L5s + 60 s RT). Group C consisted of two series of irradiations of 5 s each separated by a rest time of 30 s (L5s + 30 s RT), and group D consisted of two series of irradiations of 5 s each separated by a rest time of 5 s (L5s + 5 s RT). In all groups, during the rest time, continuous irrigation with 2.5 mL of sodium hypochlorite (3% NaOCl) was carried out. The variation in temperature during irradiation was registered with a thermocouple during irradiation with different protocols. The mean and standard deviation of the temperature increase was noted. The calculation of the temperature was made as the Δ of the highest recorded temperature at the root surface minus (-) that recorded at baseline (37°). Additionally, scanning electron microscopy (SEM) was used after irradiation in all groups in order to assess the morphological changes in the root dentinal walls. The Nd: YAP laser irradiation parameters were a power of 3W, an energy of 300 mJ per pulse, a fiber diameter of 200 µm, a pulsed mode of irradiation with a frequency of 10 Hz, a pulse duration of 150 µs, and an energy density of 955.41 J/cm2. Our results show that the safest protocol for bypassing and/or removing broken instruments involves three series of irradiation of 5 s each with a rest time of 30 s between each series. Furthermore, our results suggest that continuous irradiation for 10 s or more may be harmful for periodontal tissue.

The Use of Informed Consent in Endodontic Treatment in Saudi Arabia: A Cross-Sectional Study

INTRODUCTION

Informed consent is a legal process intended to protect patients' rights and ensure ethical medical practice. The aim of this cross-sectional study was to assess dentists' practice of obtaining informed consent and adherence to the recommended guidelines, and to investigate the types of consent, barriers, the process, and the quality of the information included in preoperative informed consent for endodontic treatment in Saudi Arabia.

METHODS

A validated self-administered online questionnaire was developed and distributed to dentists performing endodontic treatment in Saudi Arabia. Data were collected using a snowball sampling technique for three months (May to July).

RESULTS

Of the 452 participants included in the study, 79.4% (n = 359) obtained informed consent, and 63.5% of them followed the recommended guidelines. Dentists with over 10 years of experience used informed consent regularly (p < .005). The main barrier to obtaining informed consent was the lack of a standardized format (28.5%). Furthermore, only 36.3% of the participants obtained written informed consent. Most participants (75.4%, n = 341) reported that they discuss and disclose information about the treatment to patients themselves. Less than 5% of participants include all listed criteria in their consent process.

CONCLUSION

Although obtaining informed consent prior to endodontic treatment was a broadly adopted process among the participants, their practice appears to be inadequate. Issues such as the type and quality of informed consent need to be improved through educational and awareness programs and strict implementation by responsible authorities.

Can the Remaining Coronal Tooth Structure Influence the Mechanical Behavior of Nonpost Full Crowns?

OBJECTIVES

 This study investigated the impact of the remaining coronal tooth structure on the mechanical behavior of nonpost (NP) full crowns on endodontically treated maxillary central incisors.

MATERIALS AND METHODS

 Forty bovine incisors with NP and 2-mm of ferrule were divided into four groups based on the remaining structure: complete 2-mm ferrule (NP-2), absence of mesial and distal ferrule effect (NP-BL), absence of buccal and lingual ferrule effect (NP-MD), and no ferrule (NP-0). The specimens underwent a stepwise stress fatigue test until fracture occurred, and stress distribution was analyzed using in silico finite element analysis (FEA). Additionally, groups with endodontic posts (P) were simulated in the FEA.

RESULTS

 The results showed that the survival rates varied among the different groups under oblique loading. The NP-2 group exhibited the highest survival rate, with all samples enduring loads up to 200 N and some surviving up to 520 N. The NP-MD and NP-BL groups had lower survival rates, while the NP-0 group had the poorest survival rate. The predominant failure mode was a nonrepairable root fracture. FEA results indicated no significant difference between groups with and without posts. NP intraradicular restorations on nonweakened roots with a minimum height of 2mm and partial or total ferrule thickness of 1mm offer a promising treatment option.

CONCLUSION

 A complete 2-mm ferrule was found to be the most favorable configuration for NP full crowns. However, maintaining the remaining tissue is crucial, as both combinations with preserved ferrule effect exhibited superior behavior in terms of fatigue and fracture load compared to the group with no ferrule. These findings contribute to understanding the mechanical considerations for NP full crowns and provide insights into treatment planning and design choices in restorative dentistry.

Bioceramic versus traditional biomaterials for endodontic sealers according to the ideal properties

Odontology, as a scientific discipline, continuously collaborates with biomaterials engineering to enhance treatment characteristics and patients' satisfaction. Endodontics, a specialized field of dentistry, focuses on the study, diagnosis, prevention, and treatment of dental disorders affecting the dental pulp, root, and surrounding tissues. A critical aspect of endodontic treatment involves the careful selection of an appropriate endodontic sealer for clinical use, as it significantly influences treatment outcomes. Traditional sealers, such as zinc oxide-eugenol, fatty acid, salicylate, epoxy resin, silicone, and methacrylate resin systems, have been extensively used for decades. However, advancements in endodontics have given rise to bioceramic-based sealers, offering improved properties and addressing new challenges in endodontic therapy. In this review, a classification of these materials and their ideal properties are presented to provide evidence-based guidance to clinicians. Physicochemical properties, including sealing ability, stability over time and space, as well as biological properties such as biocompatibility and antibacterial characteristics, along with cost-effectiveness, are essential factors influencing clinicians' decisions based on individual patient evaluations.

Iontophoresis use for increasing drug penetration into root canals and dentinal tubules: A proof-of-concept study

INTRODUCTION

The success of endodontic treatment depends on the significant disinfection of the root canal system, its irregularities, and dentinal tubules. However, achieving complete disinfection remains challenging, with frequent failures and occurrence of secondary infections. Here, we propose using iontophoresis to increase the penetration and distribution of disinfecting agents into root canals, using methylene blue for proof-of-concept.

METHODS

The marker was applied in bovine root canals, and the radial distribution of the dye in the dentinal tubules was evaluated by optical microscopy. Iontophoresis was applied at 0.5 and 1.5 mA for 5 and 15 min.

RESULTS

A significant statistical difference (p < 0.05) was observed in the marker penetration between passive and iontophoretic applications. Both current density and application time had an important effect on methylene blue distribution, with a greater efficacy delivery to the apical region achieved after 1.5 mA for 5 min or 0.5 mA for 15 min, showing longer application time can compensate for lower application current.

CONCLUSION

Iontophoresis increases the penetration and distribution of methylene blue into bovine root canals and dentinal tubules, including its innermost portions.

CLINICAL SIGNIFICANCE

Iontophoresis has shown to be a promising technique for root canal and dentinal tubule disinfection.

Upper First and Second Molar Pulp Chamber Endodontic Anatomy Evaluation According to a Recent Classification: A Cone Beam Computed Tomography Study

(1) The possibility of knowing information about the anatomy in advance, in particular the arrangement of the endodontic system, is crucial for successful treatment and for avoiding complications during endodontic therapy; the aim was to find a correlation between a minimally invasive and less stressful endodontic access on Ni-Ti rotary instruments, but which allows correct vision and identification of anatomical reference points, simplifying the typologies based on the shape of the pulp chamber in coronal three-dimensional exam views. (2) Based on the inclusion criteria, 104 maxillary molars (52 maxillary first molars and 52 maxillary second molars) were included in the study after 26 Cone Beam Computed Tomography (CBCT) acquisitions (from 15 males and 11 females). And linear measurements were taken with the CBCT-dedicated software for subsequent analysis. (3) The results of the present study show data similar to those already published about this topic. Pawar and Singh's simplified classification actually seems to offer a schematic way of classification that includes almost all of the cases that have been analyzed. (4) The use of a diagnostic examination with a wide Field of View (FOV) and low radiation dose represents an exam capable of obtaining a lot of clinical information for endodontic treatment. Nevertheless, the endodontic anatomy of the upper second molar represents a major challenge for the clinician due to its complexity both in canal shape and in ramification.

Breaking the error chain with SEE: cascade analysis of endodontic errors in clinical training

The ongoing endeavors to uncover the link between the prevalent errors in clinical endodontic training and undergraduate education are founded on tentative assumptions. This investigation was aimed at determining if cascade analysis can provide an understanding of the origins and causes of errors and if the sensitivity of student reports to the impact of errors on treatment outcomes can be established.In 2021, a group of investigators from the endodontics department concerned with clinical dental education launched the Study of Endodontic Errors (SEE). Sixty-six undergraduate dental students at one dental teaching hospital submitted anonymous narratives of problems they witnessed in their root canal treatment practices. The reports were examined to determine the sequence of events and the major errors. We kept track of the consequences of treatment outcomes, both as reported by students and as deduced by investigators.In 77% of the narratives, a chain of errors was recorded. The majority of the errors that took place were related to the working length or width of root canals. A substantial portion, 86%, of these errors could have been prevented through a deeper comprehension of the concepts that underlie working length and width. 75% of the errors that initiated cascades involved losing the correct working length. When asked whether the treatment outcome was compromised, students answered affirmatively in 16% of cases in which their narratives described compromised outcomes. Unacceptable outcomes necessitating re-treatment accounted for only 3% of student-reported consequences, but when investigator-inferred consequences were considered, the percentage more than doubled (7%).Cascade analysis of student error narratives is useful in understanding the triggering chain of events, but students provide insufficient information about how treatment outcomes are affected. Misconceptions about working length and width appear to play a significant role in the propagation of procedural errors.

Apical Extrusion: Is It an Inherent Occurrence During Every Endodontic Treatment?

The aim of this literature review was to analyze all available scientific data on apical extrusion and to identify and associate the possible factors influencing the occurrence of apical extrusion, ranging from the choice of the canal shaping system, the irrigation technique, to the choice of diameter and the apical limit of preparation. A bibliographic search for relevant articles on apical extrusion of debris, irrigants, and bacteria was performed using the following databases: PubMed, Cochrane Library, and ScienceDirect. This search identified articles published between 2010 and 2023 in two languages (French and English). After selective sorting, 25 relevant documents were included. All the studies retained clearly agree on the inherent nature of apical extrusion during endodontic treatment. At the same time, we also understand that the amount of extrusion can be influenced by a number of parameters throughout endodontic therapy. According to this review, despite the undeniable nature of apical extrusion during endodontic therapy, studies with relatable experimental models that approach in vivo conditions are required to establish exploitable conclusions regarding apical extrusion and its prevention.

Non-surgical Root Canal Treatment of an Upper First Molar With an Unusual Morphology: A Case Report

This paper presents the unusual morphology of an upper right first molar with two roots, each containing a single canal, in a patient seeking emergency endodontic treatment. Clinical and radiographic examinations revealed the unusual root canal morphology of the tooth, which required further investigation using cone beam computed tomography (CBCT) imaging, which confirmed this unusual anatomical structure. It was also noted that the upper right first molar was asymmetrical to the upper left first molar, which had the normal three-root morphology. The buccal and palatal canals were instrumented using ProTaper Next Ni-Ti rotary instruments and enlarged to ISO size 30, with a taper of 0.7; irrigated with 2.5% NaOCl; filled with gutta-percha using the warm-vertical-compaction technique, with the aid of a dental operating microscope (DOM); and then confirmed via periapical radiograph. The DOM and CBCT are valuable aids that helped us to confirm the endodontic diagnosis and treatment of this unusual morphology.

Restorative and Endodontic Management of a Mandibular Canine With Two Roots and Two Canals: A Case Report

The existence of a permanent mandibular canine with two roots and two canals is rare. This case report presents restorative and endodontic management of a mandibular canine with two roots and two canals of a 32-year-old Saudi woman with multiple periradicular lesions of mandibular anterior teeth. Cone beam computed tomography (CBCT) was used for accurate diagnosis of the root canal morphology. CBCT helped to accomplish the restorative and endodontic treatment in a conservative approach.

Apical transportation with different root canal preparation techniques using edgEEvolve rotary instruments

BACKGROUND

This study aimed to investigate the extent of apical transportation following instrumentation with EdgeEvolve rotary instruments applying single-length and crown-down techniques.

MATERIALS AND METHODS

In this experimental in-vitro study, 60 mandibular molars with mesiobuccal curvatures of 20°-40° were selected, and digital radiographic images were taken. Teeth were randomly assigned into two groups of single-length and crown-down preparation techniques. In both mentioned groups, EdgeEvolve rotary system was used. After preparation, the same as the previous ones, digital radiographic images were taken from the canals. The data were analyzed using Student' t-test and ShapiroWilk normality test (P = 0.05).

RESULTS

The mean standard deviation (SD) for apical transportation in the single-length and the crown-down group was 4.42 (2.9) and 7.48 (3.9) degrees, respectively (P < 0.05). The mean SD of the preparation time in the single-length and crown-down group was 135.07 (30.8) and 109.07 (20.8), respectively (P < 0.05). The apical transportation and the time of preparation between the two groups were significant.

CONCLUSION

Using EdgeEvolve rotary instruments canal preparation with both single-length and crown-down techniques led to some degrees of apical transportation.

Exploring Professionalism among Final Year Dental Students and New Graduates: Translating Knowledge to Practice

OBJECTIVES

 The aim of this study was to evaluate senior students' and dental graduates' perception of professionalism as defined by international regulatory bodies and to assess students' ability to apply such knowledge in clinical-based scenarios.

MATERIALS AND METHODS

 Knowledge of professional competencies was conducted using a survey based on domains of professionalism for a newly qualified general dental practitioner as defined by international regulatory bodies. This survey consists of 32 items addressing participants' perception of three domains of professionalism. Application of the perceived professional competencies was tested by asking participants to answer questions following the observation of a clinical-based scenario video where participants needed to identify issues related to professional, ethical, and communication skills, which were embedded in the scenarios.

STATISTICAL ANALYSIS

 Differences were analyzed using ANOVA and t-tests (p<0.05).

RESULTS

 Data from 146 participants showed no significant differences in the survey scores between the participants' professional levels, place of practice, age groups, and genders. Analyses of correlation between the different domains of professionalism showed significant relationships between pair-wise comparisons of the total domain scores. Paired t-tests revealed that the mean score percentage for each of the three domains of professionalism was significantly higher than the responses reported in the relevant clinical-based scenario questions.

CONCLUSIONS

 This indicates that all domains of professionalism contributed in a similar way to their overall assessment. Furthermore, our findings show that dental practitioners may not be able to apply their knowledge of professionalism in real-life scenarios. This suggests that teaching professionalism at the early stages of the dental curriculum should incorporate innovative approaches to mimic real-life scenarios.

Effect of handpiece light and material used in pulp chamber on dentin removal during root canal retreatment

This study evaluated the effect of the use of glass ionomer cement (GIC) and flowable bulk-fill resin composite (BFRC) for filling pulp chambers and the type of high-speed handpiece light used on dentin removal during access preparation for endodontic retreatment in molar teeth. Twenty maxillary molars were treated endodontically. BFRC (Opus Bulk Fill Flow APS, FGM) was used to fill the pulp chamber and replace coronal dentin (n = 10). In the remaining teeth, the pulp chamber was filled with GIC (Maxion R, FGM). Conventional resin composite (Opallis, FGM) was used to restore the enamel layer in all teeth. The samples in each group were divided into two subgroups, and the root canals were reaccessed using a handpiece with white or ultraviolet light. The teeth were scanned using micro-CT before and after root canal reaccess. The dentin volume removed was calculated and analyzed using 2-way analysis of variance and Tukey's test (α = 0.05). The crown and pulp chamber locations with dentin removal are described using frequency distribution. During the access, fewer pulp chamber walls were affected and a lower volume of dentin was removed from the pulpal floor in the group restored with GIC than in the group restored with BFRC. No effect was observed on the coronal dentin walls with respect to the filling protocols and type of light used. For dentin removal from the pulp chamber, handpieces with white light performed better than those with ultraviolet light, irrespective of the filling protocol used. The use of GIC to fill the pulp chamber and use of white handpiece light reduced dentin removal from the pulpal floor and resulted in fewer affected dentin walls.

Fracture Incidence of Kedo-S Square Pediatric Rotary Files: A Prospective Clinical Study

Objective  The primary focus of this clinical study was to analyze the probability of occurrence of instrument fracture after root canal preparation of primary molars with the help of Kedo-S Square pediatric rotary file.

Materials and Methods  Three experienced specialists treated 100 primary maxillary and mandibular molars (335 root canals) using a standardized protocol over 2 months. Biomechanical preparations were carried out using Kedo-S Square file, as per the suggestions given by the manufacturer. Every instrument in Group A helped handle three clinical cases, while for groups B, C and D, they helped in handling 5, 9, and 12 cases, respectively. Making use of an operational microscope, the rotary files, after being pulled out from the canal, were observed. The values were tabulated, and descriptive statistics were performed.

Results  There were two fractures (2%), of which 1 occurred in group C in the apical 1/3rd of distobuccal canal of maxillary molar, and the other occurred in group D in the apical 1/3rd of mesiobuccal canal of maxillary molar.

Conclusions  The fracture rate of Kedo-S Square rotary file is quite low. It is primarily in the buccal canals of the maxillary molars and the apical third of the root canal that the instrument has a greater probability of separation.

Accidental Injection of EDTA Instead of Anesthesia Solution during Root Canal Treatment: Case Report

Background/Aim: Many irrigation solutions are used during root canal treatment. It is unacceptable to confuse irrigation solutions with anesthetic solution and inadvertently inject the patient. After such an error, local and systemic serious complications can be seen in the patient. The purpose of this case report is to show how careless use of etilendiamin tetraacedic acid (EDTA) can result in important complications, and offer some treatment methods for curing symptoms resulting from such complications.

Case Report: A 17% EDTA solution, was inadvertently injected in the buccal mucosa of a 20-year-old male during routine root canal treatment. Severe pain, bleeding and mucosal swelling occurred shortly after the injection. Irrigation with saline was performed by sliding the mucoperiosteal flap at the injection site. Then the flap was sutured primary. At the control one week later, there were no areas of necrosis in the patient, but ecchymosis occurred. Decalcified areas were not detected in dental volumetric tomography examination.

Conclusions: The dentists must apply the precautions of EDTA irrigation solution during the root canal treatment and manage the treatment of this clinical complication.

Masticatory Myofascial Pain Syndrome: Implications for Endodontists

INTRODUCTION

Masticatory myofascial pain syndrome can present similarly to other dental conditions in odontogenetic structures. Endodontists should be familiar with the symptomology and pathophysiology of masticatory myofascial pain syndrome to avoid misdiagnosis, incorrect treatment, and medicolegal repercussions. The aim of this review was to provide a foundational summary for endodontists to identify and correctly manage masticatory myofascial pain syndrome.

METHODS

A narrative review of the literature was performed through a MEDLINE search and a hand search of the major myofascial pain textbooks.

RESULTS

Masticatory myofascial pain syndrome is a musculoligamentous syndrome that can present similarly to odontogenic pain or refer pain to the eyebrows, ears, temporomandibular joints, maxillary sinus, tongue, and hard palate. Currently, the most comprehensive pathophysiology theory describing masticatory myofascial pain syndrome is the expanded integrated hypothesis. The most widely accepted diagnostic guidelines for masticatory myofascial pain syndrome are the Diagnostic Criteria for Temporomandibular Disorders; however, their diagnostic capability is limited. There is no hierarchy of treatment methods because each patient requires a tailored and multidisciplinary management aimed at regaining the muscle's range of motion, deactivating the myofascial trigger points, and maintaining pain relief.

CONCLUSIONS

The pain patterns for masticatory myofascial pain syndrome are well-known; however, there is a lack of consensus on the most proper method of trigger point diagnosis or pain quantification. The diagnostic strategies for masticatory myofascial pain syndrome vary, and the diagnostic aids are not well developed.

Legal Liability of a Dentist: Inferior Alveolar Nerve Damage After Calcium Hydroxide Extrusion

ABSTRACT

During root canal treatments, calcium hydroxide can extrude through the apex causing chemical, mechanical, and/or thermal injuries to the inferior alveolar nerve, which can lead to neurological disorders. Unfortunately, dental practitioner negligence can produce this potentially life-changing injury that can compromise the patient's life. The aim of this study is present a case of dental negligence by calcium hydroxide extrusion causing inferior alveolar nerve damage, discuss the methods of prevention, and characterize the medico-legal aspects of complication.

Impact of Endodontic Instrumentation on Surface Roughness of Various Nickel-Titanium Rotary Files

OBJECTIVES

 The aim of the present study was to evaluate the surface roughness (SR) of various nickel-titanium (NiTi) rotary endodontic instruments (ProTaper Next [PTN], WaveOne Gold [WOG], and ProTaper Gold [PTG]) before and after root canal instrumentation.

MATERIALS AND METHODS

 For each type (PTN, WOG, and PTG), the endodontic instrumentation was performed using extracted mandibular molar teeth's curved mesial root canals (curvature: 20-40 degrees) after determining the working length. Each NiTi file was cleaned, and sterilized following preparation of four root canals and characterized for surface properties before and after endodontic instrumentation using a contact-mode three-dimensional surface profiler. The data were analyzed statistically using Statistical Package for the Social Sciences for SR parameters including average surface roughness value (Sa), root mean square roughness (Sq), and peak to valley height (Sz).

RESULTS

 Preinstrumentation assessment revealed a significant difference for all the three SR variables (p < 0.05) for the cutting blade and the flute area. WOG instruments showed the highest SR values (p = 0.000). The postinstrumentation assessment revealed significant differences in SR values in the blade and the flute between the three groups (p < 0.05), with WOG and PTG exhibiting the highest values in the blade and flute sections, respectively.

CONCLUSIONS

 The SR parameters of intact PTN, WOG, and PTG NiTi files vary and that was increased following the endodontic instrumentation.

Endodontic disease detection: digital periapical radiography versus cone-beam computed tomography-a systematic review

Purpose: To assess the comparative diagnostic performance of digital periapical (PA) radiography and cone-beam computed tomography (CBCT) imaging on endodontic disease detection and to provide study methodology and design recommendations for future studies comparing the diagnostic performance of imaging modalities on endodontic disease detection. Approach: A search of the Medline, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials databases was conducted. Studies that compared the performance of CBCT to digital PA radiography for detecting endodontic disease had an independent reference standard determining the presence of endodontic disease and conducted data analysis including either sensitivity, specificity, receiver operating characteristic (ROC) analysis or free response operating characteristic analysis were included. Of the 20,530 identified studies, only 3 fulfilled the inclusion criteria. Results: Most studies assessed for eligibility were excluded due to limitations and biases in study design-15 of 18 studies had no reference standard. Only one retrospective clinical study reported on the diagnostic performance of CBCT and showed a sensitivity of 86% and specificity of 26%. Two cadaver studies reported sensitivity ranging from 60% to 100%, specificity ranging from 79% to 100%, and an area under the ROC curve of 0.943 for CBCT. The reported sensitivity for digital PA radiography ranged from 27% to 60%, specificity was 99%, and the area under the ROC curve was 0.629. Conclusions: There is a lack of quality evidence and insufficient data to compare diagnostic performance of digital PA and CBCT imaging. This emphasizes the need for well-designed studies to inform clinicians about the relative diagnostic performance of these imaging modalities.

Comparative evaluation of dentin volume removal and centralization of the root canal after shaping with the ProTaper Universal, ProTaper Gold, and One-Curve instruments using micro-CT

Background. The main goal of our study was to assess the volume of dentin removed and transportation in root canals using ProTaper Universal (PTU), ProTaper Gold (PTG) and One-Curve (OC). Ni-Ti rotary instruments in extracted human teeth using by micro-CT.

Methods: Thirty human upper 1st premolar teeth with two separate root canals and sturdy, mature root tips were used in the present study. Specimens were decoronated and root length was standardized for micro CT scanning before root canal preparation done. The teeth were randomly separated into three categories (n = 10) according to the rotary NiTi system used for canal instrumentation, i.e., PTU (Dentsply, Maillefer), PTG (Dentsply, Maillefer), and OC (Micro-Mega SA). After root canal preparation, samples were scanned again on micro-CT by the same scanning parameters. Surface area, canal volume, structure model index (SMI), percentage of uninstrumented area and transportation parameters were obtained for each sample before and after micro-CT analyse.

Results: No significant differences between the PTG and PTU in terms of the total volume of removed dentin, surface area and percentage of uninstrumented areas were found. However, regarding to parameters above, OC showed a lower efficacy than PTG and PTU in coronal section. Regarding canal transportation, PTG and OC showed lower mean transportation values at all levels.

Conclusion: This paper demonstrated the root canal shaping abilities of the PTU, PTG, and OC NiTi file systems. The PTG and OC systems were associated less canal transportation and a better ability to preserve dentinal walls than PTU. There was no significance different between all rotary file systems for SMI values however, PTU and PTG showed greater canal volume and surface area change than OC file systems in coronal section.

A Conservative Approach to Surgical Management of Root Canal Perforation

This study describes a conservative approach to surgical management of root canal perforation in maxillary lateral incisors. A patient was referred for retreatment of a maxillary lateral incisor. Her chief complaint was discomfort in the buccal mucosa. Periapical radiography showed radiopaque material consistent with sealing material inside the root canal. A CBCT scan was acquired and revealed a gutta-percha cone outside the root canal, from the middle third to beyond the root apex. The imaging examination showed that the pulp cavity had not been affected. Thus, we took the clinical alternative of surgically managing the perforation by sealing with MTA, thereby avoiding endodontic treatment, and followed up with only clinical and radiographic control. At the two-year follow-up, after the surgical procedure to remove the extruded filling material, we observed bone tissue formation and positive response to pulp tests, without any clinical signs or symptoms. Root perforation is considered an unpleasant error in an operative procedure. Once a perforation is properly diagnosed, located, and sealed with biomaterial, a favorable prognosis is often achieved. MTA offered good sealing of the perforation, with promising results. Decision-making using the CBCT scan enabled us to adopt a conservative approach and favored more reliable treatment predictability.

Morbidity and Mortality Review in a University Dental Hospital: A Necessary Tool to Improve Quality of Care

OBJECTIVE

 The study aimed to describe and to analyze the first morbidity and mortality review (MMRs) set up within a Dental University Hospital using detailed case reports to highlight the benefits of MMRs for patients, practitioners, teachers and to implement appropriate protocols to prevent recurrence.

MATERIALS AND METHODS

 The MMRs were performed within the dentistry departments of the hospital over the 1-year study period. Each case was reviewed according to a protocol based on a tool defined by the Clinical Risk Unit and the Association of Litigation and Risk Management (ALARM).

RESULTS

 Four cases were selected based on an oral report by a doctor from the dental service, a downstream service, or by the attending physician. The first case report related to a patient who suffered a breathing shock. The second concerned a tooth inhalation by a young disabled boy. The third was a therapeutic failure instigated by a student during a tooth preparation, and the fourth case involved an unexpected face-to-face meeting between a prisoner accompanied by police guards and an ancient victim at the dental hospital.

DISCUSSION

 Clinical incidents were investigated with the ALARM protocol. This process is also less focused on the individual who makes the error and more on contributing systemic factors. The systematic analysis of cases associated with bibliographic reviews improves learning and performance outcomes. Clear answers were given in response to the problems raised during these MMRs.

CONCLUSION

 In dental hospitals, the culture of MMRs needs to be integrated into resident training like in medical hospitals.

Ethical Aspects concerning Instrument Separation and Perforations during Endodontic Treatment: A Cross-Sectional Study

Aim

During endodontic treatment, dentists may face various unwanted procedural accidents, at any stage of the treatment that might compromise endodontic treatment outcome and bring obstacles to dentists as well. This study aimed to address and analyze several ethical concerns relating to the behavioural conduct of dentists towards endodontic instrument separation as well as perforation of the crown and/or root during root canal treatment in Riyadh, Saudi Arabia.

Method

Hundred and eleven questionnaires were distributed among dentists working in Riyadh in university clinics and government and private sectors. Data were collected, reviewed, and statistically analyzed by Fisher's exact and chi-square tests at a 5% significance level, using SPSS software.

Results

54.5% of the respondents have encountered instrument separation. 53.2% stated that they would inform the patient about the instrument separation. 43.6% of the respondents had experienced perforation during root canal treatment, and 54.9% reported that they would inform the patient of the accident.

Conclusion

Within the limitation of this survey, we concluded that most of the dental professionals did not hesitate to adhere to the correct ethical conduct, and they would inform the patient if an incident occurred.