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Human teeth with periapical pathosis after overinstrumentation and overfilling of the root canals: A scanning electron microscopic study

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Abstract

The aim of this study was to determine whether overinstrumentation followed by immediate overfilling could be a potential risk in the treatment of infected root canals. Thirty-five human teeth with infected root canals were overinstrumented and overfilled approximately 45 min after their extraction. The experimental teeth were enlarged up to size 40 and the overinstrumentation and overfilling were checked with the aid of a magnifying glass. The specimens were fixed in glutaraldehyde plus sodium cacodylate solution and prepared for scanning electron microscope examination. Bacteria were detected on the flute of the files and mostly at the root apices around the main foramen, remaining firmly attached to resorptive lacunae despite the fact that the apices had undergone great changes, including fracture or zipping. A control group consisting of 10 human teeth root canals containing vital pulps were also overinstrumented and overfilled. No bacteria were detected on the flutes of the files, at the apices or on the extruded master cone overfilling these samples. The high percentage of bacteria adhering to the resorptive lacunae or in the flutes of files used in overinstrumented human teeth with infected root canals carry a potential risk for postoperative pain, clinical discomfort and flare-ups. The hazards observed in these circumstances do not support the one-visit treatment of teeth having acute or chronic periapical abscesses.

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... On the contrary, some clinicians suggested that repeated use of small patency files could push apical debris. They accused it by its responsibility for acute periapical inflammatory response and as a result, severe post operative pain 9,10 . The concept of creating and maintaining canal patency is still controversial . ...
... It should be noted that using large instruments at the patency length could result in severe periradicular injury, causing lack of apical stop and extrusion of a large amount of infected debris, which predisposed to the occurrence of postpreparation discomfort and /or jeopardized the outcome of endodontic therapy 10,44 . A scanning electron microscope investigation showed cementum fractues and dentinal chips at the apex after penetration of a # 15 k-file through the foramen 10 . ...
... It should be noted that using large instruments at the patency length could result in severe periradicular injury, causing lack of apical stop and extrusion of a large amount of infected debris, which predisposed to the occurrence of postpreparation discomfort and /or jeopardized the outcome of endodontic therapy 10,44 . A scanning electron microscope investigation showed cementum fractues and dentinal chips at the apex after penetration of a # 15 k-file through the foramen 10 . In this study, small files (# 10 K-file) were used gently to guarantee that the canal was only negotiated without any futher apical enlargement. ...
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Objective: This study was conducted to compare the post-preparation pain experience following root canal preparation with or without achieving and maintaining apical patency during root canal preparation. Materials and Methods: Root canal preparation was completed in the first visit for eighty patients. The patients were divided randomly into two groups where patency was either established and maintained during preparation or not. Pain was recorded before treatment, 6,12,18,24 and 48 hours after treatment. Patients assessed their severity of pain over the first two days following root canal preparation using a modified visual analog scale of (0-9).
... To date, no comparison was done regarding the accuracy of these devices. This information is of outmost importance since overinstrumentation may push microorganisms, debris, irrigation solutions, medications, and filling materials into the periapical tissues [22][23][24][25]. ...
... Although this range is considered acceptable in the current literature [30-34], overextension of 0.5 mm from the AL might be regarded as overinstrumentation. As seen in Figs Overinstrumentation may bare more adverse results on periapical healing [22][23][24]. Overinstrumentation poses the risk of forcing microorganisms, debris, irrigation solutions, medications, and filling materials into the periapical tissues [22][23][24]. This may contribute to flare-up, postoperative pain, delayed healing, and even treatment failure [22][23][24][25]. ...
... As seen in Figs Overinstrumentation may bare more adverse results on periapical healing [22][23][24]. Overinstrumentation poses the risk of forcing microorganisms, debris, irrigation solutions, medications, and filling materials into the periapical tissues [22][23][24]. This may contribute to flare-up, postoperative pain, delayed healing, and even treatment failure [22][23][24][25]. ...
Article
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Aim The objective of this study was to compare the accuracy of working length (WL) determination by X-Smart Dual, ENDOAce, and Gold Reciproc motor, in manual mode and mechanical preparation set to auto apical reverse (AAR) mode. Materials and methods Forty-five anterior teeth were included in the study. The canal length was determined by introducing #10 file into the canal until it emerged at the apical foramen. The incisal edges were adjusted to obtain 18 mm standard length. The teeth were embedded in Plexiglas tubes, filled with alginate, and measured in manual and AAR modes. Results Within and between the groups, there was no significant difference in WL measurements, both in manual and AAR modes. In the X-Smart Dual group, all manual measurements were within root canal limits, while 13 % of AAR mode measurements were recorded when the file tip passed the apical foramen. In the ENDOAce group, 13 and 7 % of the measurements, in manual and AAR modes respectively, were recorded when the file tip passed the foramen. In the Gold Reciproc motor group, 27 and 33 % of the measurements, in manual and AAR modes respectively, were recorded when the file tip passed the foramen. Conclusion With the limitation of this ex vivo study, the tested devices presented no significant differences in length measurements and were within the clinical accepted margin of error. Clinical relevance Mechanical preparation must be confined to the root canal system. The adverse results of overinstrumentation emphasize the need to reconsider the ±0.50 mm margin of error that is clinically acceptable for WL measurements.
... [9] In reality, the prognosis for an endodontically treated tooth with overfi lling depends on the response of the periradicular tissue to the canal obturation material which is, in its own way, a consequence of the complex, and at times an unpredictable interaction between the materials and the host defences. [11] According to the American Dental Association, overfilling by more than 2 mm past the radiological apex represents a technical error ascribable to overinstrumentation , inadequate measuring, or a lack of an apical stop. However, the latter was difficult to obtain, as in the presence of resorbed roots caused by infl ammatory processes or by particularly wide apices. ...
... The prognosis for an endodontically treated tooth with overfi lling depends on the response of the periradicular tissue to the canal obturation material which is, in its own way, a consequence of the complex, and at times an unpredictable interaction between the materials and the host defences. " [11] Over instrumentation, in particular, may extrude infected material contained in the canals beyond the apex, interfering, or impeding the healing process of the periapical tissue. Gutt a-percha cones, which had been extruded past the apices, have demonstrated the presence of a " biofi lm " on the cones. ...
... [17] Finally, the prognosis for an endodontically treated tooth with overfi lling depends on the response of the periradicular tissue to the canal obturation material which is, in its own way, a consequence of the complex and, at times, an unpredictable interaction between the materials and the host defences. [11] CONCLUSION Knowledge of dento-antral relationships as well as the skill of the operator is important particularly in the prevention of sinusal accidents. The anatomical and clinical signifi cance of the maxillary sinus in relation to conventional and surgical endodontic therapy is considered. ...
Article
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Complications may occur during and after endodontic treatment, which may be due to negligence of the operator. The surgical treatment of a case presenting pain and persistent pus discharge and swelling due to the extrusion of the root canal filling to the base of the nasal floor between left maxillary lateral and canine teeth is presented in this report. First, carelessness was during root canal treatment that was over obturated and second time during extraction in which overextended gutta-percha remained in the bone, caused the complications like pain, persistent pus discharge, and headache. Clinicians should be aware of the fact that endodontic instruments and filling materials (solid or liquid) can be extended in such a degree that can lead to neurological or sinus complications.
... Therefore, WL transfer between the KF and the subsequent mechanical shaping instruments should be extremely precise in order to equally prevent over-and under-instrumentation. Over-instrumentation with nickel-titanium (NiTi) rotary or reciprocating files of augmented taper may have clinical implications, including apical transportation [10] and overfilling [11] with defective apical seal control, especially in curved canals, and greater incidence of post-operative pain [12,13]. On the other hand, under-instrumentation may predispose the creation of blocks and ledges, which can negatively influence the long-term prognosis of the endodontic treatment, leaving a residual bacterial load inside the root canal [3]. ...
... Alternatively, under-instrumentation can create ledges, blocks and other canal aberrations that may lead to inadequate shaping and filling, negatively affecting the disinfection and the long-term prognosis of the root canal treatment [1,3,15,19]. Therefore, over-and under-instrumentation should be both equally reduced in order to achieve antimicrobial and sealing efficiency [10][11][12][13]. ...
Article
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The present paper evaluated the accuracy of two different methods for transferring working length (WL) between manual endodontic instruments and nickel–titanium (NiTi) shaping files. Thirty root canals of extracted permanent teeth were used. Root canals were divided according to canal length (CL) and canal curvature (CC). The reference cusp and the root end were flattened to provide reproducible and accurate measurements. During shaping, the WL measurements were obtained with manual k-files (KF) and transferred to WaveOne (W1) NiTi reciprocating files using the traditional method with the endodontic ruler (method I) and an alternative clinical procedure based on the comparison of the instruments side by side from tip to shank (method II). For each file and each tested method, two measures were taken by two examiners using Rhino (ver. 4.0, McNeel, Seattle, WA, USA) software for a total of 360 (30 × 3 × 2 × 2) measures. Analysis of variance was performed by taking the difference in length (Delta WL, DWL) between files used for the same canal. The difference between methods I and II for WL transfer was found to be statistically significant (df = 1; F = 71.52; p < 0.001). The DWL absolute values obtained with method II were found to be closer to 0 mm (i.e., same length as corresponding KF) than those obtained with method I. Both CL (df = 2; F = 1.27; p = 0.300) and CC (df = 1; F = 2.22; p = 0.149) did not significantly influence WL measurements. With respect to WL transfer, method II seemed to better preserve the correct WL transfer between instruments during the clinical endodontic procedures.
... Using large instruments to maintain apical patency also led to disruption of apical stop and periapical extrusion of a large amount of infected debris, which led to postoperative discomfort and hampered the outcome of endodontic therapy. [24,25] Gutiérrez et al. showed that #15 K-file when passed through apical foramen fractured, the cementum and dentinal chips were seen under scanning electron microscope. [24] In this study, small files (#10 K-file) were used gently to guarantee that the canal was negotiated without any further apical enlargement. ...
... [24,25] Gutiérrez et al. showed that #15 K-file when passed through apical foramen fractured, the cementum and dentinal chips were seen under scanning electron microscope. [24] In this study, small files (#10 K-file) were used gently to guarantee that the canal was negotiated without any further apical enlargement. Hence, we can say that maintaining apical patency during instrumentation did not significantly affect the incidence or intensity of postoperative pain. ...
... At the same time however, warm vertical compaction techniques also result in a greater risk of the obturation material being extruded into peri-radicular tissues [10]. Authors have reported significant cytotoxicity of both commonly used cements, and gutta-percha following research studies carried out in vitro with SEM (scanning electron microscope) [11]. This cytotoxicity can induce peri-radicular inflammation, or necrosis of the periodontal ligament, and for this reason over-filling should be avoided as much as possible because it can lead to failure of short term treatment or a negative long term prognosis [12]. ...
... Over-instrumentation, in particular, may extrude infected material contained in the canals beyond the apex, interfering, or impeding the healing process of the periapical tissue. Guttapercha cones which had been extruded past the apices and subsequently examined under a scanning electron microscope, have demonstrated the presence of a "biofilm" on the cones [11]. This "biofilm" allows undisturbed growth of the bacteria and renders them particularly resistant to the defences of the host, and may be responsible for foreign body reactions. ...
Article
Full-text available
The toxicity and tissue reactions to dental materials are receiving more attention as a wide variety of materials are used and as federal agencies demonstrate more concern in this area. A further indication of the importance of the interaction of materials and tissues is the development of recommended standard practices and tests for the biological interaction of materials.
... Factors contributing to postoperative endodontic pain are many, and identifying these factors is critical to minimizing pain experienced by patients between appointments or after treatment. Factors that have previously been identified are preoperative pain, overinstrumentation (24), obturation material such as gutta-percha (25) and silver points (26), and extrusion of debris (24), irrigants (27,28), and intracanal medicaments such as calcium hydroxide (Ca(OH) 2 ) (29-31). Moreover, extrusion of sealer has been shown to have cytotoxic effects on the periapical tissues, causing periapical inflammation, necrosis (25), and pain (32). ...
... Factors that have previously been identified are preoperative pain, overinstrumentation (24), obturation material such as gutta-percha (25) and silver points (26), and extrusion of debris (24), irrigants (27,28), and intracanal medicaments such as calcium hydroxide (Ca(OH) 2 ) (29-31). Moreover, extrusion of sealer has been shown to have cytotoxic effects on the periapical tissues, causing periapical inflammation, necrosis (25), and pain (32). However, to date no study has evaluated the direct effect of sealers on trigeminal nociceptor activation. ...
Article
Endodontic sealers are selected on the basis of their antimicrobial properties and ability to provide a tight seal. Sealer extrusions, whether intentional or unintentional, are common during obturation procedures. Such events have been correlated with increased postoperative discomfort and persistent pain states. However, the mechanisms underlying this phenomenon are largely unknown. Thus, we sought to evaluate the effect of commonly used endodontic sealers on peripheral nociceptors. We hypothesized that endodontic sealers can directly activate trigeminal nociceptors in a concentration-dependent manner, resulting in release of calcitonin gene-related peptide (CGRP), a potent modulator of neurogenic inflammation. Rat trigeminal sensory neurons were exposed in vitro to vehicle, zinc oxide-eugenol (ZOE)-based sealer, AH Plus, EndoSequence BC sealer, or RealSeal SE. Neuronal activation was measured by quantification of neuropeptide (CGRP) release. In addition, cultured neurons were also subjected to the set form of all 4 sealers. The concentration of CGRP released was quantified by using a radioimmunoassay. Data were analyzed by using one-way analysis of variance with Newman-Keuls multiple comparison post hoc test. Both ZOE-based sealer and AH Plus in their fresh form evoked greater CGRP release than the control groups. Conversely, EndoSequence BC and RealSeal sealers both reduced basal GCRP release at all concentrations tested. Evaluation of the set sealers revealed that only ZOE-based sealer evoked significant CGRP release compared with its control group. Overall, our results suggest that sealers can directly activate trigeminal nociceptors, leading to a robust release of CGRP, and may therefore lead to pain and neurogenic inflammation. This direct activation along with the immunologic response may underlie the symptoms and flare-up occurrences often seen with sealer extrusions.
... Another recommendation for reducing the degree of transportation was the use of patency files although it is still controversial. In the present study, no. 8 K-flex file was used as a patency file based on the findings of Gutiérrez et al. [28], Gonzalez Sanchez et al. [29], and Goldberg and Massone [12]. Gutiérrez et al. [28] reported that cementum fractures and dentinal chips occur at the apex after the penetration of a no. ...
... In the present study, no. 8 K-flex file was used as a patency file based on the findings of Gutiérrez et al. [28], Gonzalez Sanchez et al. [29], and Goldberg and Massone [12]. Gutiérrez et al. [28] reported that cementum fractures and dentinal chips occur at the apex after the penetration of a no. 15 file through the main foramen. ...
Article
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The aim of this ex vivo study was to evaluate the effect of using a patency file on apical transportation and curve straightening during canal instrumentation with the ProTaper rotary system. Seventy permanent mandibular first molars with mesiobuccal canals, measuring 18-23 mm in length and with a 25-40° curvature (according to the Schneider method), were selected. The working lengths were determined and the teeth were mounted and divided into two experimental groups: (A) prepared by the ProTaper system without using a patency file (n = 35) and (B) prepared by the ProTaper system using a patency file (n = 35). Radiographs taken before and after the preparation were imported into Photoshop software and the apical transportation, and curve straightening were measured. Data were analyzed using independent t-test. Partial correlation analysis was performed to evaluate the relationship between the initial curvature, transportation, and curve straightening (α = 0.05). Using a patency file during canal preparation significantly decreased both apical transportation and curve straightening (P < 0.001). There were significant relationships between the angle of curvature, transportation and curve straightening in pairs (P < 0.001). Apical patency is recommended during root canal preparation with the ProTaper rotary system.
... This suggests that the apical preparation limit plays a more significant role in bacterial extrusion than the instrument's kinematics. Based on our findings, extending root canal instrumentation by 1 mm beyond the apical foramen could potentially pose a greater risk to treatment outcomes, regardless of the instrument's kinematics, and may contribute to treatment failure [27]. In asymptomatic chronic periradicular lesions, there exists a delicate balance between microbial aggression and host defense mechanisms [28]. ...
Article
This in vitro research assessed the influence of the instrument kinematics (rotary and reciprocating) and the apical preparation limit on the root canal disinfection and apical bacterial extrusion. After 21 days of Enterococcus faecalis biofilm formation in 72 mesial root canals of mandibular molars, the root canals were distributed into 2 groups (n = 36) according to the systems used for preparation: ProDesign S and Reciproc. The groups were redistributed according to the limit of apical preparation (n = 11): (a) 1 mm up to the apical foramen (TL-1); (b) at the apical foramen (TL = 0); (c) 1 mm beyond the apical foramen (TL + 1). After preparation, the remaining biofilm adhered to the dentin walls at the apical third was removed by sonication. The aliquots of bacterial suspension released, and the irrigating solution leaked through the apical foramen during preparation were plated for colony-forming units (CFUs) counting. Data were statistically assessed by the Kruskal–Wallis and Dunn tests (α = 5%). Both systems promoted decontamination of the apical third, regardless the limit of apical preparation (p > 0.05). A larger quantity of bacteria was extruded from the root canals prepared 1 mm beyond the apical foramen, regardless the instrumentation kinematics (p < 0.05). The apical third of the root canal was efficiently decontaminated after preparation, regardless the instrumentation kinematics and the apical limit. However, a larger quantity of bacterial extrusion was observed when preparation was performed beyond the anatomical root canal limits.
... A study comparing single-visit and two-visit root canal treatment showed a decrease in periapical lesion size after six months in both groups, with no statistically significant differences observed between them [42]. In the current study, calcium hydroxide dressing was preferred due to the presence of several cases with clear clinical symptoms (sinus tracts, periapical swelling, suppuration) associated with large periapical lesions [43]. Many researchers believe that root canal treatment with calcium hydroxide dressing improves bone healing and regeneration [44]. ...
Article
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Objective This study aims to assess the efficacy of bioceramic (BC) sealer when applied using the single cone technique (SCT), in comparison to AH Plus sealer applied with the cold lateral condensation technique (LCT), concerning their impact on the healing of large-sized periapical lesions in both untreated and retreatment cases. Materials and methods A randomized controlled trial was conducted on 41 patients who had 60 permanent teeth in the maxillary incisors that were accompanied by large-sized periapical lesions. The included teeth were radiographed with cone beam computed tomography (CBCT) images and divided equally into two groups according to the endodontic treatment statute (30 untreated previous cases and 30 retreated cases). Subsequently, teeth received uniform preparation, irrigation, and dressing procedures. Then each group was divided equally according to the used sealer (15 teeth obturated using AH plus sealer with LCT and 15 teeth obturated using BC sealer with SCT). All cases were followed up after 6 and 12 months with CBCT images. Subsequently, the change in periapical lesion diameter (PLD) was observed as an indicator to determine the treatment outcome score. One-way ANOVA and Mann–Whitney U test were used to analyze the PLD changing and scoring the treatment outcome during the follow-up periods. The significance level was set at α = 0.05. Results There were no statistically significant differences between untreated and retreatment cases neither using AH plus sealer with LCT nor BC sealer with SCT regarding changes in PLD in the follow-up periods. Moreover, there were no significant differences between groups regarding treatment outcome scores in the follow-up periods. All groups showed a high success rate. Conclusions Successful treatment was achieved for untreated or retreatment maxillary incisor cases accompanied by large-sized periapical lesions using either BC sealer with the SCT or AH Plus sealer with LCT with a similar high success rate up to 12 months follow-up period.
... which might contribute to higher reports of over-instrumentation. Another possible explanation might be that the apical third of the HYB group was instrumented using Ni-Ti 0.04 hand files, whereas the apical third of the WOG group was instrumented with the reciprocation, which in novice hands might cause loss of apical control. This could be considered a problem regarding the clinical outcomes, as previous articles have shown apical changes 35 and a decrease in prognosis following over-instrumentation. 36 However, our results showed that over-instrumentation did not affect the outcomes in this particular sample size and population. ...
Article
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Objectives This study compared, retrospectively, the incidence of clinical errors and effects on treatment outcomes, when students were exposed to two different instrumentation techniques: a hybrid rotary technique (HYB), consisting of both hand instrumentation with hand stainless steel and Ni‐Ti files plus the use of a rotary system (Vortex Blue, Dentsply Sirona), versus a full reciprocation instrumentation technique (WaveOne Gold [WOG], Dentsply Sirona). Methods A total of 368 endodontic cases ( n = 184) in anterior and premolar teeth, completed by dental students at the University of Michigan School of Dentistry from 2013 to 2022, were used for the study. The groups were evaluated by two calibrated clinicians, observing the incidence of clinical errors: file separations, over‐instrumentation, ledges and transportations. Treatment outcomes were also observed. Data were analyzed statistically by Fisher's exact test and Mann–Whitney U test ( p < 0.05). Results No significant difference in file separations, ledges, and transportation was observed between the two groups. However, the WOG Group experienced significantly more over‐instrumentation than HYB group, although this did not significantly affect tooth survival or periapical index (PAI). Cases with PAI scores of 5 were found to have significantly less tooth survival compared to the other PAI scores. Conclusions It can be concluded that both techniques in our study are well suited to advancing the endodontic dental education of students and novice operators, anticipating relatively successful outcomes of tooth survival, as long as the cases selected are less severe in progression preoperatively.
... Holland et al. (24), in 2005, assessed periapical healing after maintaining apical patency during instrumentation. It was seen that nonmaintenance of apical patency showed better healing (25). If large instruments are used to maintain apical patency, they can hamper the outcome of endodontic therapy by causing post-operative pain and discomfort (26)(27). ...
Article
Full-text available
Objective: Several prevalence studies have estimated the region-specific impact of oral diseases on oral health-related quality of life. However, none of them reported and compared the same from a global perspective. This meta-analysis aims to evaluate pooled epidemiologic data about child-oral impacts on daily performance (C-OIDP) globally. Methods: A search was conducted in PubMed, Science Direct, SciELO, Semantic scholar, and Cochrane databases up to January 2023. Studies evaluating OIDP among 11-18-year-olds were included in the review. Quality of the included studies was evaluated using the health states quality index for cross-sectional studies. The meta-analysis used R package software version 4.3.0. A common effect model was used to calculate the pooled prevalence. The protocol was registered in the PROSPERO (CRD-NIHR) database with Reference ID CRD42023393798. Results: The systematic literature search yielded 257 unique citations. After screening titles and abstracts, 214 irrelevant citations were excluded, leaving 55 for full-text review. Overall, 43 studies from 23 countries were included. The meta-analysis reported a pooled prevalence impact C-OIDP of 53.36% (CI: 52.78-53.95, 43 studies, 16,622 participants). The prevalence of C-OIDP scores among South America, Asia, Europe, Africa and Oceania was 83%, 63%, 58%, 33% and 47%, respectively. The maximum prevalence was reported in South America while the least prevalence was noted in the African population. Conclusion: Oral diseases affect the oral health-related quality of life of more than half of children and adolescents globally. Huge variations were noted in the prevalence of oral impacts across different regions. These findings can be utilized by policymakers to draft measures required for reducing impacts of oral diseases and improving the health-related quality of life.
... Holland et al. (24), in 2005, assessed periapical healing after maintaining apical patency during instrumentation. It was seen that nonmaintenance of apical patency showed better healing (25). If large instruments are used to maintain apical patency, they can hamper the outcome of endodontic therapy by causing post-operative pain and discomfort (26)(27). ...
Article
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Purpose: The purpose of this study was to determine the effect of apical patency versus non-apical patency filing on post-endodontic pain in root canal treated teeth in permanent dentition. Methods: A search was conducted in Medline, Google Scholar, Scopus, Web of science, and Cochrane databases for randomized controlled trials and clinical trials comparing post-endodontic pain with apical patency and without apical patency maintenance with a follow-up period of 12 h, 24 h, 2 days, and 7 days. Certainty of evidence was determined using the grading of recommendations, assessment, development, and evaluations assessment tool. A random-effect model was used to assess the mean differences between the two used techniques. Results: Five studies met the inclusion criteria. A total of 372 patients with apical filling versus 372 with no apical filling were available for analysis at end of 24 and 48 h. Apical patency maintenance was associated with lesser post-endodontic pain with a statistically significant difference at 12 h (MD = −1.49; p = 0.003) and 2 days (MD = −0.85; p = 0.04). Certainty of evidence for this association was moderate. Conclusion: This meta-analysis presents evidence for reduced post-endodontic pain in permanent dentition when the apical patency technique is used for recapitulation. Clinical trials are further recommended so that research evidence may again be substantiated in the future. Keywords: Apical patency; post-endodontic pain; root canal treatment
... Holland et al. (24), in 2005, assessed periapical healing after maintaining apical patency during instrumentation. It was seen that nonmaintenance of apical patency showed better healing (25). If large instruments are used to maintain apical patency, they can hamper the outcome of endodontic therapy by causing post-operative pain and discomfort (26)(27). ...
... It should be emphasized that the small extrusion of a sealer is generally well-tolerated by the periapical tissues [49][50][51]. However, some authors found a higher risk of non-healing lesions in cases with sealer extrusion [52,53]. ...
Article
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The main goal of root canal treatment (RCT) is to eradicate or essentially diminish the microbial population within the root canal system and to prevent reinfection by a proper chemo-mechanical preparation and hermetic final obturation of the root canal space. The aim of this study was to assess the quality of the root canal filling and the number of visits needed for completing RCT by operators with different experience, including dentistry students (4th and 5th year), general dental practitioners (GDPs), and endodontists. Data from medical records of 798 patients were analyzed , obtaining 900 teeth and 1773 obturated canals according to the inclusion and exclusion criteria. A similar number of teeth was assessed in each group in terms of density and length of root canal filling and number of visits. The larger number of visits and the lower quality of treatment was observed for 4th year students than for other groups (p < 0.05); in contrast, the endodontists needed the lowest number of visits to complete RCT and more often overfilled teeth than other operator groups (p < 0.05). Interestingly, no statistical difference in quality of root canal filling was noted between 5th year students, GPDs and endodontists. The treatment of lower teeth demanded statistically more visits than that of upper teeth (p < 0.05). The results of the study emphasize that most of the root canal filling performed by operators was considered adequate, regardless of tooth type, files used and number of visits.
... Several in vitro research studies have reported relevant cytotoxic effects of both gutta-percha and root canal sealers [14]. When extruded beyond the apex, these obturation materials could act as foreign bodies, inducing histological reactions ranging from simple periradicular inflammation to more severe necrosis of the periodontal ligament [15]. ...
Article
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This study describes 6 cases of endodontic overfilling with successful clinical outcomes during long-term (up to 35 years) radiographic follow-up. Successful endodontic treatment depends on proper shaping, disinfection, and obturation of root canals. Filling materials should completely fill the root canal space without exceeding the anatomical apex. Overfilling may occur when the filling material extrudes into the periapical tissues beyond the apex. The present case series describes 6 root canal treatments in which overfilling of root canal sealer and gutta-percha accidentally occurred. Patients' teeth were periodically checked with periapical radiographs in order to evaluate the outcomes during long-term follow-up. All cases showed healing and progressive resorption of the extruded materials in the periapex. The present cases showed that if a 3-dimensional seal was present at the apical level, overfilling did not negatively affect the long-term outcomes of root canal treatment.
... The smaller size files were advocated to prevent the embolus effect of a similarly sized file and reduce further apical debris extrusion [10,31,33]. It has also been suggested that instead of using a mechanical approach, apical patency and debris removal should be achieved with abundant irrigation [34] and intracanal dressing [35], as even the penetration of a #15 file through the main foramen can cause apical transportation [36] or the buildup of cementum and dentinal chips at the apex [37]. However, in teeth with necrotic pulp accompanied with periapical lesions, bacteria is present beyond the apical constriction [38] and within the lesion itself [39]. ...
Article
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This study evaluated the long-term clinical outcomes of single-visit root canal treatments with apical enlargement on patients with necrotic pulp tissue retrospectively. A total of 137 teeth with necrotic pulp tissue which underwent single-visit root canal treatments were included. The root canals were shaped up until the apical constriction, which was determined by an apex locator. The outcomes were evaluated by two independent and calibrated endodontists clinically and radiographically. Teeth were dichotomized into healed (PAI ≤ 2, no signs or symptoms) and nonhealed (PAI > 2, with/without signs or symptoms) groups. Each patients' preoperative PAI and lesion size were recorded to evaluate the preoperative periapical status as well as several other prognostic factors. Statistical analyses were performed (p = 0.05) on ninety teeth. The mean observation time was 60 months. Out of ninety teeth, 87 (96.7%) were healed and 3 (3.3%) were nonhealed. No correlations were found between the prognostic factors and the outcomes (p > 0.05). Cohen's kappa and Gwet's agreement coefficient scores between the preoperative PAI scores and preoperative lesion sizes showed good agreements, with values of 0.834 and 0.898, respectively. Apical enlargement is a viable treatment option for single-visit root canal treatments.
... Engine-driven instruments with their rotational movement produce less extruded debris than hand filing techniques using the push-pull motion and they have a tendency to pull debris in their flutes [7][8][9][10] . It is proven that no instrumentation technique can eliminate the extrusion of debris [11][12][13] . ...
... Iatrogenic disruption of the apical constriction might occur due to inaccuracy in calculation of the working length which might facilitate apical extrusion of dentinal debris, irrigating solutions, and filling materials; all of which would predispose to inflammatory response. (16,17) Many methods were suggested to help in working length determination, including tactile sensation, radiographs, and electronic apex locators. Tactile sensation and radiographic methods are not precise methods to determine the apical constriction and cannot be relied upon them solely. ...
... This location is clinically important because many root canals are unintentionally instrumented beyond the apical foramen, and slight overinstrumentation may not be radiographically detected in every case. 6 An efficient irrigant should ideally come into direct contact with all parts of the canal system. 1 Although injection of NaOCl into a canal using a syringe and needle is the most commonly used method, 7 there is limited delivery of the irrigant to the apical third and irregular parts of the root canal system. 8,9 To enhance dispersion of the irrigant throughout the root canal, different irrigation devices have been developed. ...
Article
Objective: To evaluate the safety of sodium hypochlorite (NaOCl) irrigation using three different techniques during the final rinse in overinstrumented root canals. Background data: The effect of irrigant activation on irrigant extrusion from overinstrumented root canals is still unclear. Method: A total of 30 single-rooted teeth were decoronated. The working lengths were determined and the roots were divided into two groups of 15 teeth each: group 1, instrumentation 0.5 mm short of the apical foramen and group 2, instrumentation 0.5 mm beyond the apical foramen (overinstrumented). Needle irrigation (NI), sonic irrigation with EndoActivator (EAI), and laser-activated irrigation (LAI) were used for the final rinse in each group; each root underwent the three irrigation procedures in a randomized crossover manner. A modified container-foam model was used to collect apically extruded NaOCl. The weight of the extruded NaOCl was calculated by subtracting the initial weights of the containers from their final weights. All data were statistically analyzed. Results: The amount of NaOCl extrusion was similar with all three irrigation systems in group 1. In group 2, the amount of extruded NaOCl was significantly greater with EAI than with NI and LAI. EAI and LAI caused significantly greater extrusion in group 2 than in group 1. Conclusions: EAI, NI, and LAI are equally safe for irrigating canals with intact apices. However, the risk of irrigant extrusion can increase in overinstrumented canals, with EAI associated with a greater risk compared with NI and LAI.
... However, these procedures are not exclusive to young patients with immature roots. Completely formed teeth can suffer alteration in the terminal portion of the root by pathological (2,3) or iatrogenic (4) factors and develop open apices. The current study revealed 38.0% of procedures were performed in patients ≥ 20 years of age). ...
Article
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Background: This paper analyzed the distribution of treatments for permanent teeth with necrotic pulps and open apices according to the stage of root development. Material and Methods: Dental records from all root canal procedures performed in permanent teeth with necrotic pulps and open apices over a period of 14 years by residents of the Speciality of Endodontics, University of Guadalajara, Mexico, were analized. Results: Records from 206 treatments were mainly divided into the following 3 different stages according to criteria described by Cvek: stage IV (n = 79, 38.3%), stage V (n = 66, 32%) and stage III (n = 53, 25.7%). Few cases involved the initial stages of root development (stages I and II) (n = 8, 3.8%). Such teeth were submitted to four different treatments: MTA apical barrier (n = 69), Ca(OH)2 replacements (n = 34), gutta-percha (n = 67) and a plug of Ca(OH)2/gutta-percha (n = 36). The teeth with intermediate root development (Cvek stage III) showed a predilection for the MTA apical barrier and Ca(OH)2 replacement techniques (P ≤ 0.001). Furthermore, the stage of root development did not influence the apical extent of the root filling. Conclusions: The finding of permanent teeth with necrotic pulp and open apices is not exclusive to young patients with an open apex. Moreover, teeth with fragile, irregular and divergent apical morphologies, such as Cvek’s stages´ I and II, were not common and may be considered to be unusual findings. The diverse endodontic procedures were reliable regardless of the stage of root development.
... Furthermore, Gutiérrez et al 35 showed that cementum layer may fracture at the apex after penetration of #15 K-file through the main apical foramen. By contrast, in an ex vivo study, Sanchez et al 36 found that when a #10 reamer or #8 K-Flexo file be used, no transportation may be seen. ...
Article
Introduction: The apical portion of the root canal is very complex and challenging during endodontic treatment. Root canal preparation and obturation to the apical constriction may provide the best prognosis. Incomplete debridement, foramen transportation, and inadequate seal in the apical portion are considered to be responsible for treatment failure. The technique "apical patency" is considered as a way for maintaining the apical part the free of the debris by recapitulation, using a small K-file through the area of the apical foramen. This term was firstly proposed by Buchanan. In this technique, the smallest diameter file is set 1 mm longer than working length and recapitulated after each instrument to prevent packing of debris in the apical part. Apical patency has been found to be effective in achieving an apical seal with gutta-percha. Teeth prepared with a step back method and with maintained apical patency may show less leakage when obturated with cold lateral condensation technique. Data regarding the effect of apical patency on the healing of periapical tissue are very scarce, and it has been shown that the patency file has detrimental effect on the healing of periapical tissues in animal studies. However, using patency file in endodontic treatment is controversial and further studies are needed. The purpose of this article is to review the effect of using a patency file on the extrusion of root canal contents, the apical seal, postoperative pain, and healing of periapical tissues. Furthermore, the effect of establishing patency on reaching irrigation solutions to the apical portion of the canal and prognosis of root canal treatment are discussed. Clinical significance: Keywords: Apical patency, Apical seal, Apical transportation, Postoperative pain, Prognosis.
... One study showed that contaminated patency files can be effectively disinfected by 5.25% NaOCl solution (31). Gutierrez et al. (32) have reported that cementum fractures when #15 file is penetrated though the apical foramen. ...
... While a general success rate of 85-95% has been reported for root canal treatment, these numbers are lowered to 76% in overobturated cases [9]. The response of the periapical tissues to the canal obturation material is largely dependent on the unpredictable interaction between materials and host defences [10]. In the present case, the extruded GP could have acted as a foreign body producing chronic inflammation in the patient's periapical tissue thereby preventing satisfactory healing and acting as a cause of persistent pain to the patient. ...
Article
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Complete cleaning and shaping of the root canal system is essential for success of endodontic treatment. Accurate measurement of working length and 3D obturation till the apical constriction is necessary for ensuring fluid tight seal. One of the disadvantages of overextended root canal obturations is post-operative pain. The treatment options in such cases are endodontic surgery to remove the extruded filling material or Intentional Replantation. This case report discusses the advantages of Intentional Replantation and the procedure involved in endodontic retreatment of a mandibular molar with this technique.
... Another contributing factor of tissue damage that can occur is with improper preparation of the root canal and excessive widening of the apical foramen, with disappearance of constriction. 12 This is often responsible for the passage of materials beyond the apex and can cause tissue damage by chemical, mechanical, or infectious means. ...
Article
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Accidental overextension of filling material during endodontic treatment may cause mechanical and chemical irritation of the adjacent tissue. In this case series, seven patients who complained of neurologic complication after overextension of canal filling material during endodontic treatment were presented. Overextensions of filling material into the surrounding tissues, such as the mandibular canal, bone marrow, and submucosal layer, were confirmed with panoramic radiograph and computed tomographic images. When patients complain of neurological disturbances after root canal treatment, proper radiographic images should be taken to verify any overextension of materials and to determine the specific location of the overfilled materials.
... 1 Finally, the prognosis for an endodontically treated tooth with overfilling depends on the response of the periradicular tissue to the canal obturation material which is, in its own way, a consequence of the complexand, at times, an unpredictable interaction between the materials and the host defences. 10,11 ...
... 14 Undoubtedly, instrumentation beyond the apical foramen reduces the success rate of the endodontic treatment. 9,[15][16][17][18][19] Cross-sectional geometry, helical angles, pitch length and taper of files are the factors which have been investigated to be involved in the screw-in effect of Ni-Ti rotary files. Diemer and Calas evaluated the effect of pitch length on the torsional stress and tendency to screw-in using two instruments with same cross-section (triple helix; 0.6% taper). ...
Article
Full-text available
Nickel-titanium (Ni-Ti) rotary instruments have some unexpected disadvantages including the tendency to screw-in to the canal. The purpose of this study was to evaluate the influence of root canal curvatures on the screw-in effect of Ni-Ti rotary files.
... More attention should be paid when using more tapered rotary instrument to prevent or reduce the screw-in forces so as not to hamper the endodontic success. 22,23 Further studies are needed to investigated on other factors that may be involved in the screw-in effect and to find techniques to control this effect during rotary instrumentation. ...
Article
Full-text available
The introduction of nickel-titanium alloy endodontic instruments has greatly simplified shaping the root canal systems. However, these new instruments have several unexpected disadvantages. One of these is tendency to screw into the canal. In this study, the influence of taper on the screw-in effect of the Ni-Ti rotary instrument were evaluated.
... Gutierrez (31) en su estudio encontró fracturas de cemento después de la utilización de la lima K#15. Más recientemente, Adorno et al. (32) demostraron que el uso de limas rotatorias más allá del formanen apical podía producir fracturas del cemento apical. ...
Article
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The maxillary second molar usually exhibits 3 roots (2 buccal roots and 1 palatal root), as well as 3 root canals (1 root canal corresponding to each root). Even though it is unusual to find variations in its morphology, it is important to know the possible alterations that could occur if such variations are found, in order to prevent operative accidents. This paper reports a case of endodontic treatment applied to a maxillary second molar with 4 root and 5 root canals.
... Undoubtedly instrumentation beyond the apical foramen reduces the success rate. [8][9][10][11] Gutierrez et al. 12) using scanning electron microscopy, found that overinstrumentation of root canals of human teeth provoked different types of apical cementum perforations and/or the production of zipping. By chance, many root canals can be inadvertently prepared beyond the apical foramen, which can be deleterious to the periapical tissues to heal in teeth with infected canal. ...
Article
Full-text available
Screw-in effect is one of the unintended phenomena that occurs during the root canal preparation with nickel-titanium rotary files. The aim of this study was to compare the screw-in effect among various nickel-titanium rotary file systems. Six different nickel-titanium rotary instruments (ISO 20/.06 taper) were used: (SybronEndo, Glendora, CA, USA), (VDW GmbH, Munchen, Germany), NRT with safe-tip and with active tip (Mani Inc., Shioya-gun, Japan), ProFile (Dentsply-Maillefer, Ballaigues, Switzerland) and ProTaper (Dentsply-Maillefer, Ballaigues, Switzerland). For ProTaper, S2 was selected because it has size 20. Root canal instrumentations were done in sixty simulated single-curved resin root canals with a rotational speed of 300 rpm and single pecking motion. A special device was designed to measure the force of screw-in effect. A dynamometer of the device recorded the screw-in force during simulated canal preparation and the recorded data was stored in a computer with designed software (LCV-USE-VS, Lorenz Messtechnik GmbH, Alfdorf, Germany). The data were subjected to one-way ANOVA and Tukey's multiple range test for post-hoc test. P value of less than 0.05 was regarded significant. ProTaper produced significantly more screw-in effects than any other instruments in the study (p < 0.001). produced significantly more screw-in effects than , and ProFile (p < 0.001). There was no significant difference among , NRT, and ProFile (p > 0.05), and between NRT with active tip and NRT with safe one neither (p > 0.05). From the result of the present study, it was concluded, therefore, that there seems significant differences of screw-in effect among the tested nickel-titanium rotary instruments. The radial lands and rake angle of nickel-titanium rotary instrument might be the cause of the difference.
... Apical constriction may be disrupted iatrogenically because of improper working length determination, which facilitates increased apical extrusion of dentinal debris, endodontic irrigants, and filling materials; all of which predisposes to inflammatory response and delay in healing.[67] Neither radiographic nor tactile methods can adequately determine the constriction,[89] while electronic apex locators (EALs) are claimed to be capable of accurate measurement and give the exact location.[1011] ...
Article
To compare the efficacy of an integrated apex locator and an apex locator and endodontic motor assembly in maintaining the working length when operated under autoreverse mode. Thirty distobuccal roots of intact maxillary first molars were taken and access cavities were prepared. The teeth were divided into Group I: Prepared with TCM Endo V and Group II: Prepared with ProPex and NSK assembly. The instrumentation was ended in ProTaper F3 file, which was cemented in the canal. The roots were sectioned, observed under a stereomicroscope and the distance from instrument tip to the apical foramen was measured. Mean difference in the deviation of two groups was 0.075 mm, P = 0.34 (>0.05) which was statistically insignificant when assessed with unpaired t-test. The assembly of ProPex-NSK Endo-mate DT and the apex locating endomotor TCM Endo V Nouvag are clinically acceptable.
... 7e9 The intensity of the acute inflammatory response depends on the number and/or virulence of the extruded microorganisms. 9 Gutierrez et al 20 periapical area. He has proposed that canal contents being pushed through result in an antigeneantibody complex that can damage cell membranes, resulting in a series of immunological processes that ultimately cause pain for the patient. ...
Article
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Background/purpose: The aim of the this study was to compare the amount of debris apically extruded during endodontic retreatment using two rotary nickel–titanium (NiTi) instruments (K3 and R-Endo) and Hedström files. Materials and methods: Forty-five extracted human mandibular premolar teeth were used in this study. Root canals of the teeth were filled before being randomly assigned to three groups. In group 1, gutta-percha was removed with K3 (SybronEndo, West Collins, CA, USA) rotary NiTi instruments. In group 2, gutta-percha was removed with R-Endo (Micro-Mega, Besançon, France) rotary NiTi instruments. In group 3, gutta-percha was removed using Hedström files (Dentsply Maillefer, Ballaigues, Switzerland). Debris extruded from the apical foramen was collected into Eppendorf tubes. The liquid inside the tubes was dried, and the debris in each group was weighed and compared. Data were statistically analyzed using one-way analysis of variance, and Kruskal–Wallis test and Mann–Whitney U test. Results: Although all retreatment techniques resulted in apical extrusion, groups 1 and 2 produced significantly less apical extrusion than group 3 (P0.05). Conclusion: All retreatment techniques produced extruded debris during endodontic retreatment; however, both rotary NiTi systems were associated with less apical extrusion than manual instrumentation with Hedström files.
... Thus, the foramen remains unblocked and patent. However, the concept of apical patency is considered controversial because of the differences in the amount of extruded material found in cases with and without patency filing (78)(79)(80). If a patency file is used, the smallest file size possible should be used as it was found that more material was extruded apically as the diameter of the apical patency increased (80). ...
Article
Full-text available
Ledge formation, that is the iatrogenically created irregularity in the root canal that impedes access of instruments to the apex, and canal blockage caused by packing dentin chips and/or tissue debris are the least-studied parameters of root canal instrumentation. Variables associated with ledge formation and canal blockage by dentin chips and/or tissue debris are presented. Emphasis is given to their most common causes, recognition, management, prognosis, and prevention.
... It is likely that the risk of overfilling is increased after overinstrumentation of the canal. A study with freshly extracted human teeth that were overinstrumented and overfilled revealed bacteria at the root apices around the main foramen, remaining firmly attached to resorptive lacunae despite the fact that the apices had undergone great changes, including fracture or zipping (205). Although direct evidence of the potentially negative consequences of overinstrumentation is lacking, it can be speculated that overinstrumentation, with the possible exception of the smallest hand files of size #06-#10 for apical patency (and in certain special situations such as drainage through the canal), should be avoided because of the following reasons: (i) direct physical trauma to periapical tissues, (ii) extrusion of necrotic canal contents including dead and living microorganisms into the periapical area that could cause a flare-up, bacteremia, or even a persisting infection, such as periapical actinomycosis, (iii) overinstrumentation may stimulate bleeding into the root canal that provides nutrients for intracanal bacteria, (iv) increase of the foramen size and consequently improved possibilities for bacteria to receive nutrients from the periapical area, e.g. ...
Article
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Debridement of the root canal by instrumentation and irrigation is considered the most important single factor in the prevention and treatment of endodontic diseases. In clinical practice, instrumentation of the root canal(s) within the affected tooth is usually the most time consuming and technically demanding element of the treatment. The technical success of the treatment, as judged by the post-operative radiograph after the root filling, is based on optimized root canal instrumentation. Mounting evidence from epidemiological research is also indicating that the combination of high-quality coronal restoration and technically satisfactory root canal treatment is associated with the greatest long-term prognosis. Therefore, it is not surprising that for several decades of endodontic research, a substantial number of articles on instruments and instrumentation have been published in the scientific literature. Although interest in the effects of instrumentation on intracanal infection is not new, it is obvious that during the last few years a renewed focus of interest has appeared on the relationship between instrumentation and infection control in the root canal. The ongoing discussion in international endodontics about one-appointment therapy in the treatment of apical periodontitis has naturally further motivated the newly emerged research activities. The goal of this review is to gather the relevant and most recent literature and provide an updated analysis of the effect of preparation (instrumentation and irrigation) on the microbial infection in the necrotic root canal.
Article
Nerve injury associated with root canal treatment is relatively rare, but can lead to significant morbidity. The role of 2D and 3D radiography in case assessment is explored and a new three-tier grading system is proposed to aid in risk assessment and clinical decision-making. This grading system would assist dentists to fully appraise patients, gain appropriate informed consent and guide treatment of endodontic cases where there is an increased risk of nerve injury. CPD/Clinical Relevance: A new three-tier grading system to assist in the pre-operative assessment and risk management of endodontic cases where there is an increased risk of nerve injury is proposed.
Article
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Abstract Objectives This study aimed to investigate patterns and risk factors related to the feasibility of achieving technical quality and periapical healing in root canal non-surgical retreatment, using regression and data mining methods. Methodology This retrospective observational study included 321 consecutive patients presenting for root canal retreatment. Patients were treated by graduate students, following standard protocols. Data on medical history, diagnosis, treatment, and follow-up visits variables were collected from physical records and periapical radiographs and transferred to an electronic chart database. Basic statistics were tabulated, and univariate and multivariate analytical methods were used to identify risk factors for technical quality and periapical healing. Decision trees were generated to predict technical quality and periapical healing patterns using the J48 algorithm in the Weka software. Results Technical outcome was satisfactory in 65.20%, and we observed periapical healing in 80.50% of the cases. Several factors were related to technical quality, including severity of root curvature and altered root canal morphology (p
Article
Endodontic treatment can result in the extrusion of dental sealant material beyond the apex of a tooth. Dental sealant materials are known to have potentially cytotoxic properties and can cause damage to biological structures. This article describes the case of a patient who had experienced a sustained painful dysaesthesia of the left inferior alveolar nerve as a result of extrusion of material beyond the apex of the tooth into the nerve canal, and the surgical approach taken to directly treat the nerve and improve her symptoms. CPD/Clinical Relevance: Awareness of the potential and sustained effects of dental sealant material on biological tissue, as well as the proximity of important anatomical structures, such as the inferior alveolar nerve, will help practitioners in the safe treatment of patients. Additionally, an awareness of the signs and symptoms of foreign body reactions within soft tissues will aid diagnosis and prompt onward referral for specialist treatments.
Article
The present report describes a case of permanent labiomandibular paresthesia subsequent to a root canal treatment in a molar in which a bioceramic sealer extrusion occurred. A 23-year-old black woman attended the endodontics clinic at university, complaining of loss of sensation in the mucosa and skin on the right side of her face in the lower lip region, which began after an endodontic treatment in the second lower right molar. A bioceramic sealer (MTA; Angelus, Londrina, PR, Brazil) was used to fill the canals. The periapical radiographic examination revealed an amount of extruded sealer by mesial and distal roots reaching the interior of the mandibular canal. Then, treatment with a corticosteroid and a vitamin B complex was initiated, and demarcation of the affected area was performed. One week later, paresthesia was still present in equal intensity in the affected area. Thirty-nine days elapsed after the endodontic therapy; the paresthesia continued, encompassing the same area, although with a small reduction in intensity. In the following 6 months, a very subtle decrease in intensity but not in the affected area was noticed. From 6 months to 1 year, no changes were observed. According to the patient's report, the paresthesia affected her quality of life in several aspects. The short distance between the root apices and the upper cortical bone of the mandibular canal seemed to have acted as a predisponent factor to the present long-term paresthesia. In conclusion, bioceramic sealers may also induce permanent facial paresthesia, if extruded.
Article
Aim To investigate the impact of apical extent of root filling on vertical root fracture (VRF) in a case‐control study. Methodology Eighty‐six patients (119 roots) diagnosed with VRF in crowned root filled anterior and posterior teeth were selected. The cases were matched individually with control teeth in a ratio of 1:1 for age (± 5 years), gender, tooth type, instrumentation method, master apical file (MAF) size and taper, technique of canal filling and time period after root filling. All root canals had been prepared using nickel titanium (NiTi) rotary instruments and filled using the lateral compaction technique. The apical extent of root filling (overfilled to or beyond the radiographic apexor not overfilled and short of the radiographic apex) was recorded as the dependent variable by two individual examiners. Inter‐examiner agreement was obtained using Kappa statistics. Recorded numbers of overfilled and not overfilled canals in cases and controls were analyzed using Chi‐square test, Conditional logistic regression and Odds ratio was calculated. In addition, frequency distribution of vertical and cross‐sectional extension and course of VRF were evaluated. Results The mean age of patients with VRF was 50 ± 10. years with 27 (31%) males and 59 (69%) females. The Kappa score for inter‐observer agreement was 0.832 (P<0.001). There was a significant difference between cases and controls with respect to apical extent of root filling (P <0.0001). When compared to roots not overfilled, overfilled roots had 11.5 times higher odds for occurrence of VRF (OR = 11.5; CI: 4.99 – 26.48). Most VRFs had a complete corono‐apical longitudinal extension and were present bucco‐lingually. Conclusion After matching for age, gender, tooth type, MAF size and taper, canal filling technique and time period after root filling, root canals filled to or beyond the radiographic apex following lateral compaction had a greater association with VRF than canals filled short of the radiographic apex. This article is protected by copyright. All rights reserved.
Chapter
The use of a patency file in endodontics remains a controversial issue. Using a small K file inserted passively and intentionally by 1 mm through the foramen is advocated by some investigators and clinicians as an important procedure designed to help the cleaning and shaping process, to aid in delivering irrigating solutions to “hard to reach areas” of the root canal system, as well as to the apical third. This procedure is even cited as an important step in achieving clinical success. Detractors of the use of the patency file have concerns with the increased extrusion of debris and irrigants through the foramen, higher incidence of postoperative pain, lack of proper studies showing its ability to improve cleaning of the complex anatomy of the root canal system in the apical third, and limited information on the influence of the use of the patency file on the prognosis of the root canal treatment. Histological sections of the apical thirds of teeth that were appropriately cleaned with the use of this procedure and then examined usually show remnants of organic tissue and biofilm. The objective of this chapter is to analyse the current literature that addresses the use of the patency file in endodontic therapy.
Article
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The main prerequisite for a successful treatment of pulp disease in apex periodontium is knowledge of morphological characteristics of root canal system, especially one third of his apex. The aim of this work was to define the exact distance of the main and auxiliary openings from the top of medial and distal roots of the first lower permanent molars. Methods: as a research material it was used a hundred extracted first lower molars of the patients of both gender, divided into three age groups. The analysis of the one third of apex was done with the help of binocular magnifying glass and digital roentgenography analysis half of the samples, which were filed with capillary contrast. Results: The results obtained showed that the longest average distance of the main opening from the top of medial root was 0.84mm, and the shortest was 0.61mm; while for the distal root the longest average distance was 0.89mm, and the shortest was 0.62mm. Maximum distance of the auxiliary openings from the top of medial root in the first group was 3.5mm, and the maximum distance of the auxiliary openings from the top of distal root was 2, 5 mm. The results obtained with digital rentgenography showed that the longest average distance of the main opening from the top of medial root was the one noticed in the second age group (0.91mm) then the one from the first group (0,83), and the shortest one in the third age group (0,71mm); as for the distal root: the longest average distance of the main opening from the top of the root was noticed in the third age group (0,95mm) then in the first (0,90mm) and than shortest in the second age group (0,89mm). Conclusion: The distance of the main and auxiliary openings from the top of medial and distal root of the first lower molar varies in the range from 0 to 3,5mm and it depends on the tooth age. .
Article
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Background: To compare the amount of debris extruded apically by using conventional syringe, Endovac & Ultrasonic irrigation. Materials & methods: Thirty freshly extracted mandibular premolars were selected, working length was determined and mounted in a debris and collection apparatus. The canals were prepared. After each instrument change, 1 ml. of 3% sodium hypochlorite was used as irrigation. Debris extruded apically by using conventional syringe, endovac& ultrasonic irrigation tech, was measured using the electronic balance to determine its weight and statistical analysis was performed. The mean difference between the groups was determined using statistical analysis within the groups &between the groups for equal variances. Results: Among all the groups, significantly less debris were found apically in the Endovac group (0.96) compared to conventional and ultrasonic group (1.23) syringe. Conclusion: The present study showed that endovac system extrudes less amount of debris apically as compared to ultrasonic followed by conventional so incidence of flare up can be reduce by using endovac irrigation system. How to cite this article: Tambe V H, Nagmode P S, Vishwas J R, Saujanya K P, Angadi P, Ali F M. Evaluation of the Amount of Debris extruded apically by using Conventional Syringe, Endovac and Ultrasonic Irrigation Technique: An In Vitro Study. J Int Oral Health 2013; 5(3):63-66.
Article
Re-treatment of primary root canal treatment associated with post-treatment disease has become an important component of daily endodontic practice. Basically, the management of cases requiring re-treatment should comply with the general rules of primary root canal treatment namely accurate diagnosis, antiseptic treatment consisting of cleaning and shaping the root canals, followed by effective disinfection, canal filling, and a coronal restoration that prevents re-infection. Nevertheless, re-treatment represents a distinct treatment modality of its own, which in several respects differs from primary treatment of teeth with vital or necrotic pulps. The aim of this review is to present current knowledge on root canal preparation and filling during root canal re-treatment.
Article
Two hundred and seventy extracted human teeth of unknown age were evaluated for apex to foramen and apex to constriction distances, in addition the topography of the apical portion of the root canal was studied under × 20 magnification. The mean A–F distance was 0.38 mm and the mean A–C distance 0.89 mm, although it must be stressed that a wide range of values was observed. Four distinct types of apical constriction were routinely found, whilst a proportion of canals were apparently blocked. The study confirms the view that it is impossible, with complete certainty, to establish the position of the apical canal constriction during root canal therapy, but indicates that a combination of methods might be more successful than reliance on one.
Article
Deviation of the major apical foramen from the anatomical root apex is a recognized phenomenon. To determine the frequency, position and mean distance of the major apical foramen from the anatomical root apex, 230 roots of permanent teeth were examined stereomicroscopically and radiographically. Radiographic analysis was used to establish how accurate the conventional radiograph was in displaying such a deviation. The frequency of deviation of the major foramen, determined stereomicroscopically, was 76%, and depended on the type of teeth examined. Radiographic analysis of the same sample revealed 57% of root canals had asymmetry of the root canal foramen. Agreement of stereomicroscopic and radiographic findings was found to be 61%. The most frequent deviation of the major foramen was on the distal root surface (29%), but this was not statistically significant. The mean distance between the deviation of the major foramen and the anatomical root apex was 0.99 mm. The study indicates that the clinician should consider deviation of the foramen during root canal treatment, as the deviation could not easily be detected radiographically.
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Samples were collected from the root canals of 30 teeth of patients with apical periodontitis and assayed for endotoxin content. The detection rates of endotoxin and endotoxin content were higher in symptomatic teeth, teeth with radiolucent areas, and teeth with exudation than in those without them.
Article
Light and electron microscopy were used to analyze nine therapy-resistant and asymptomatic human periapical lesions, which were removed as block biopsies during surgical treatment of the affected teeth. The cases that required surgery represented about 10% of all of the cases which received endodontic treatment and root fillings during the period 1977 to 1984. These cases revealed periapical lesions when they were examined 4 to 10 yr after treatment. The biopsies were processed for correlated light and electron microscopy. Six of the nine biopsies revealed the presence of microorganisms in the apical root canal. Four contained one or more species of bacteria and two revealed yeasts. Of the four cases in which bacteria were found, only in one biopsy could they be found by light microscope. In the other three specimens, the bacterial presence could be confirmed only after repeated electron microscopic examination of the apical root canal by serial step-cutting technique. Among the three cases in which no microorganisms could be encountered, one showed histopathological features of a foreign body giant cell granuloma. These findings suggest that in the majority of root-filled human teeth with therapy-resistant periapical lesions, microorganisms may persist and may play a significant role in endodontic treatment failures. In certain instances such lesions may also be sustained by foreign body giant cell type of tissue responses at the periapex of root-filled teeth.
Article
There were 87 vital and 24 nonvital teeth for a total of 111 specimens from 47 patients. The specimens were prepared to a thickness of 500 microns with a Buehler Isomet Bone Saw. Distances were measured and recorded with a Bioquant II Image Analysis System. The mean age of the patients was 48.9 years. The median age was 52 years. The range was 51 years, with a maximum of 77 years and a minimum of 26 years. There is a positive correlation, which could not have occurred by chance, that as age increases the deviation and the width of the foramen opening both increase. This increase appears to be a result of apical cemental thickening that occurs as the patient ages. The tissue in the apical area seems to be capable of generating additional cementum as the tooth ages. The cementodentinal junction width, or most apical extent of the dentin, remains constant.
Article
The prevalence of black-pigmented Bacteroides species in the root canals of 72 teeth with apical periodontitis was evaluated. Twenty-two of the canals contained one or more species of black-pigmented Bacteroides. Bacteroides intermedius (14 strains) and Bacteroides endodontalis (5 strains) were most common. Of the species Bacteroides gingivalis, Bacteroides loeschei, and Bacteroides denticola, 2, 3, and 1 strains, respectively, were isolated. The median number of bacterial cells recovered from the root canals containing black-pigmented Bacteroides was 2.8 x 10(5) and from the other canals 3.0 x 10(3). The mean number of strains was 7.9 and 3.3, respectively. Sixteen of the 22 root canals containing black-pigmented Bacteroides species were associated with acute apical abscesses and purulent drainage through the root canal. The other six teeth with black-pigmented Bacteroides were asymptomatic. One additional abscess was present among the 72 cases. This root canal contained Actinomyces israelii and Actinomyces naeslundii.
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Apical radicular and intracanal surfaces of extracted teeth with apical lesions were examined by means of scanning electron microscopy. The distribution of apical and intracanal resorption areas varied with the presence of a granuloma or a cyst. Teeth bearing granulomas showed an apical resorption centered on the main foramina whereas the hard tissue underlying a cyst showed little or no resorption. Intracanal resorption was always marked in the apical third and more scattered in the middle and cervical third. The resorption disrupted the anatomical structures.
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. The aetiology and pathogenesis of three types of root resorption—surface, inflammatory and replacement—are reviewed, and their occurrence after certain types of orthodontic, periodontal, paedodontic and endodontic treatment is described.
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Periapical pathosis cases were classified and the effect of bacteria on clinical symptoms was examined. A positive correlation between bacterial growth and clinical symptoms was found. Peptococcus magnus and Bacteroides species were commonly found in clinically acute cases, while oral streptococci and enteric bacteria were frequently isolated from clinically asymptomatic cases.
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Roentgenograms taken from both mesiodistal and buccolingual directions were used in an in vitro study of the number of root canals and their different divisions in each root and tooth; the influence of age on the root canal; the curvatures of the root canals in both directions; the ramifications of the main root canals; the location of foramina and the frequency of deltas.
Article
Eight hundred and seventy-seven teeth were examined to determine the frequency, direction, and distance of deviation of the major formen from the anatomic root apex. The frequency of deviation averaged 92.4 per cent, depending on the class of tooth examined. The predominating direction of deviation was dependent on the class of tooth examined. The average distance between the anatomic apex and the major foramen opening in those teeth presenting a deviation averaged approximately 0.59 mm.
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Sixty extracted canine teeth and sixty lower incisors were prepared mechanically, and the root canals were flushed with saline solution, sodium hypochlorite, or EDTA.
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The prevalence of “pathological granules” in the unexposed cementum of 20 teeth with pulpitis was compared with that of 20 teeth with heavily infected root canals. It was found that 35% of the teeth with microbe-laden root canals exhibited this cemental change. Teeth with pulpitis, but without massive numbers of bacteria in their root canals, did not have this structural change. The results support the suggestion that bacteria play an important role in the formation of pathological granules in cementum and the underlying dentin.
Article
Nineteen patients with acute periapical abscess, i.e. frank soft tissue swelling associated with an endodontically involved tooth, were treated using a single-visit endodontic protocol. Only teeth with one or two canals were included in case selection. The treatment consisted of (a) soft tissue incision and drainage of the fluctuant swelling; (b) standardized endodontic preparation and obturation procedures; and (c) proper antibiotic regimen. None of the patients treated according to this protocol experienced exacerbations of presenting signs and symptoms after treatment. Complete resolution of swelling was achieved within 3 to 7 days. All of the patients who were contacted at 24-h postoperatively gave the subjective impression that their initial pain had been significantly decreased or completely resolved. At the 1-yr recall appointment, 11 of the original 19 patients returned. All were asymptomatic and showed radiographic evidence of reduction in lesion size.Diezinueve pacientes con absceso periapical agudo, por ej. franco edema de los tejidos blandos asociado a un diente con patología endodóntica fueron tratados en una sola sesión endodóntica. El tratamiento consistió en (1) incisión del tejido blando y drenaje del edema fluctuante, (2) preparación endodóntica estandardizada y obturación del o los conductos, y (3) indicación correcta de antibiótico. Ninguno de los pacientes tratados de esta forma experimentó exacerbaciones de los signos y síntomas presentes después del tratamiento. La resolución completa del edema se obtuvo entre los 3 y 7 días. Todos los pacientes con los que se puso en contacto a las 24 hs del postoperatorio, dieron la impresión subjetiva de que el dolor inicial habíá disminuído significativamente o había desaparecido. Once de los 19 pacientes regresaron para un control postoperatorio al cabo de un año. Todos estaban asintomáticos y habia evidencias radiograficas de reduccion en el tamaño de la lesión.
Article
The pH changes in dental tissues of monkeys were studied by means of pH indicators after endodontic treatment with calcium hydroxide. Untreated teeth with pulpal necrosis showed a pH of 6.0 to 7.4 in pulp, dentin, cementum, and periodontal ligament. Replanted and nonreplanted teeth with completed root formation and treated with calcium hydroxide showed pH values in the circumpulpal dentin of 8.0 to 11.1, and in the more peripheral dentin of 7.4 to 9.6. In teeth with incomplete root formation, the entire dentin showed a pH of 8 to 10. The pH of the cementum was not influenced by the calcium hydroxide. However, in resorption areas, an alkaline pH was also observed at the exposed dentinal surfaces.
Article
The cellular cementum, representative of normal and periapically diseased teeth, was examined under the scanning electron microscope. All specimens were fractured and left untreated with the organic compo- nent intact to obtain a cross sectional view of the cellular cenlentum. Our findings were as follows: The diseased cellular cementum contained more projections, more cementum lacunae, and fewer fibers compared with normal cellular cementum, which indicated increased calcification. Cemental resorption was also a consistent observation. An interrupted, uniform, amorphous layer or zone was seen in all the diseased specimens. It was located along the periphery of the fractured cellular cementum and seemed to follow the outline of the periapical lesion associated with the tooth. The diseased cellular cementum! contained a higher Ca and lower P level than the normal specimens, as seen thru the energy dispersive X-ray spectrometry. The amorphous laver or zone had higher P and lower Ca levels than its underlying diseased cellular cementum. This amorphous layer is a pathologic entity, and its signilicance at this time is unknown.
Article
The bacteria present in infected root canals include a restricted group of species compared with the total flora of the oral cavity. Conditions exist in the root canal that permit the growth of anaerobic bacteria capable of fermenting amino acids and peptides, whereas bacteria that mainly obtain energy by fermenting carbohydrates are restricted by lack of available nutrients. During the course of infection interrelationships develop between microbial species and population shifts are produced as a result of these interactions. Strong associations between certain species are present. These associations are most likely based on nutritional demands and nutritional relationships. The pathogenicity of the polymicrobial root canal flora is dependent on bacterial synergy.
Article
The apical region of the roots of 38 maxillary incisors, 25 mandibular incisors, 29 maxillary second premolars, 92 mandibular first and second premolars, 12 maxillary first molars, and 17 mandibular first molars were prepared and studied with the use of a scanning electron microscope. The number and size of the main apical foramina, their distance from the anatomic apex, and the existence and size of accessory foramina were recorded, summarized, and statistically analyzed. More than one main foramen was observed in all groups except for the palatal root of maxillary molars and the distal root of mandibular molars. Accessory foramina were also observed in all groups of teeth. The distal roots of mandibular molars had the largest size main foramen (mean value, 392 microns), whereas the maxillary premolars had the largest accessory foramina (mean value, 53.4 microns) and the most complicated apical morphologic makeup. The distance of the main foramen from the anatomic apex never exceeded 1 mm. The highest values were observed at the mandibular incisors (978 microns), the distal root of mandibular molars (818 microns), and the upper premolars (816 microns). All values showed satisfactory fitting to normal distribution.
Article
To determine (1) the frequency of the incidence of abscess, granuloma, and radicular cyst among human periapical lesions obtained with extracted teeth; and (2) whether periapical cysts occur in two categories when histologically analyzed in relation to the root canals. A total of 256 lesions were analyzed. The specimens were decalcified and embedded in plastic. Serial sections or step-serial sections were prepared, and the sections were evaluated on the basis of predefined histopathologic criteria. The 256 specimens consisted of 35% periapical abscess, 50% granuloma, and 15% cysts. The latter occurred in two categories, the apical true cysts and the apical pocket cysts. These results show (1) the low incidence of radicular cysts among periapical lesions as against the widely held view that almost half of all periapical lesions are cysts; and (2) the occurrence of two classes of radicular cysts. We are of opinion that the pocket cysts may heal after root canal therapy but the true cysts are less likely to be resolved by conventional root canal treatment.
pH changes in dental tissues after root canal filling with calcium hydroxide Correlation between clinical symptoms and microorganisms isolated from the root canals
  • L Tronstad
  • Jo Andreasen
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  • M Yoshida
  • Fukushima
  • Yamamoto
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Apical changes in human teeth following overinstrumentation of the root canal.
  • Gutiérrez JH
Lanatomie canalaire et son intreprétation radiographique.
  • Laurichesse JM
Study of the apices of human permanent teeth with the use of a scanning electron microscope.
  • Moris A