Endodontics

5. Retention or replacement?

This study aimed to explore the values that patients have when selecting treatment for a tooth with apical periodontitis (AP); namely retention via root canal treatment (RCT), extraction without replacement, or replacement with implant-supported crowns or fixed or removable partial prostheses. Two surveys, one of patients and one of dentists showed that patients considered communication and trust (94%), tooth retention (90%), aesthetic outcome (84% regardless of location), cost (83%), longevity (83%), and preoperative pain (81%) as the most important decision values. Dentists overrated the importance of patients’ previous experience with the treatment options (94% vs 72%), dental insurance (90% vs 70%), and intraoperative pain (79% vs 60%) while underestimating the importance of maintenance cost (60% vs 79%). Dentists should respect patients’ views about aesthetic outcome, longevity, and cost associated with treatment options for a tooth with AP. In particular, these surveys highlighted the value of preservation of the natural tooth through RCT over implant-supported crown replacement when planning treatment for a tooth with AP.

Azarpazhooh A et al. Patients’ values related to treatment options for teeth with apical periodontitis.
J Endodontics 2016 42: 365-370.

Q In what order of importance did patients rate the following values?
A Longevity, preoperative pain, aesthetic outcome
B Communication and trust, tooth retention, aesthetic outcome
C Communication and trust, preoperative pain, tooth retention
D Cost, aesthetic outcome, longevity

6. When is enough, enough?

What is the anaesthetic success of an inferior alveolar nerve block (IANB), and supplemental articaine buccal infiltration after a failed IANB, in first and second molars and premolars in patients presenting with symptomatic irreversible pulpitis? Emergency patients presenting thus (n=375) received 2% lidocaine with 1:100,000 epinephrine via an IANB. After profound lip numbness, endodontic access and instrumentation were initiated. If the patient felt moderate to severe pain, a supplemental buccal infiltration of a cartridge of 4% articaine with 1:100,000 epinephrine was administered before treatment continued. Success was defined as the ability to access and instrument the tooth without pain, gauged by a visual analogue scale. IANB success was 28%, 25% and 39% for first, second molars, and premolars respectively with no significant differences between molars and premolars. For the supplemental infiltration, success was 42%, 48% and 73% with were no significant differences between molars but a significant difference compared to premolars molars. The success rates were not high enough to ensure profound pulpal anaesthesia.

Fowler S et al. Anesthetic success of an inferior alveolar nerve block and supplemental articaine buccal infiltration for molars and premolars in patients with symptomatic irreversible pulpitis. J Endodontics 2016 42: 390-392.

Q Profound pulpal anaesthesia in teeth with symptomatic irreversible pulpitis was achieved with:
A 2% lidocaine with 1:100,000 epinephrine via an IANB alone
B 2% lidocaine with 1:100,000 epinephrine via an IANB with a supplemental infiltration
C 4% articaine with 1:100,000 epinephrine IANB alone
D None of the above

7. Pre, post and pain perception

This prospective study aimed to investigate the correlation between the intensity of preoperative pain and the presence of postoperative pain, taking into account the variables of gender, tooth type, arch and tooth vitality. Routine endodontic patients (n=270) with pulpal pathology had conventional endodontic treatment carried out in a single visit. The chemomechanical preparation of root canals was performed with ProTaper instruments, and canals were obturated with a warm gutta-percha obturation technique. Data were recorded on gender, age, type of tooth, location and pulp diagnosis and patients recorded their pre- and postoperative pain on a visual analogue scale. Postoperative pain and the need for analgesic consumption were assessed at 4, 8, 16, 24, 48 and 72h post-treatment. Variables that were associated with a higher preoperative pain intensity (female, mandible and molar) also had a higher value of postoperative pain leading to the conclusion that the presence of preoperative pain is the variable that most influences the prevalence of postoperative pain.

Ali A et al. Influence of preoperative pain intensity on postoperative pain after root canal treatment: a prospective clinical study. J Dent 2016 45: 39-42.

Q Which factor most influences the level of pain after endodontic treatment?
A Being female
B The level of preoperative pain
C Whether the tooth is in the mandible or maxilla
D The amount of anaesthetic used during the procedure

8. Restoring the pulp chamber

To evaluate the effect of the restorative protocol on cuspal strain, fracture resistance, residual stress, and mechanical properties of restorative materials in endodontically treated molars, 45 molars received MOD Class II preparations and endodontic treatment followed by direct restorations using three restorative protocols: composite resin (CR) only, resin modified glass ionomer cement in the pulp chamber in combination with CR, conventional glass ionomer cement in combination with composite resin. Cuspal strain was higher and fracture resistance was lower when using CR only compared with the techniques that used glass ionomer. Using CR only resulted in higher residual stresses in enamel and root dentine close to the pulp chamber than the combinations with glass ionomers. The choice of restorative protocol significantly affected the biomechanical behaviour of endodontically treated molars. Using glass ionomer to fill the pulp chamber is recommended when molars receive direct composite restorations as it reduces cuspal strain and increases fracture resistance.

Pereira R et al. Effect of restorative protocol on cuspal strain and residual stress in endodontically treated molars. Operative Dent 2016 41: 23-33.

Q In root treated teeth, what reduces cuspal strain and increases fracture resistance?
A Restoring using only composite resin
B Using composite resin to fill the pulp chamber and then glass ionomer
C Filling the pulp camber with glass ionomer and completing with a composite resin
D Using resin modified glass ionomer cement throughout