A Cochrane Systematic Review Finds No Evidence to Support the Use of Antibiotics for Pain Relief in Irreversible Pulpitis
James V. Keenan, DDS (FAGD), Allan G. Farman, BDS, PhD, DSc, Zbigniew Fedorowicz, BDS, LDS, RCS (Eng), Jonathan T. Newton, BA, PhD
The Cochrane Systematic Review promotes evidence-based outcomes studies. The review summarized here was conducted in an attempt to achieve reliable evidence concerning the effectiveness, or otherwise, of prescribing antibiotics for patients having irreversible pulpitis. A competent search strategy was developed and used across several databases including MEDLINE to identify randomized controlled trials for inclusion. Assessment of methodological quality was based on criteria defined by The Cochrane Collaboration. Clinical outcome, expressed in terms of pain relief, was examined. There was a relative dearth of research providing a high level of evidence. Only one methodologically sound trial was found that compared pain relief with systemic antibiotic/analgesic treatment against a placebo/analgesic combination during the acute preoperative phase of irreversible pulpitis. Although the selected study used a relatively small, low-powered sample, it did provide some evidence that there is no significant difference in pain relief for patients with untreated irreversible pulpitis who received antibiotics versus those who did not. These findings increase the rationale to investigate the teaching of safe and effective antibiotic prescribing in endodontics and to advance the development of appropriate evidence-based clinical guidelines.
Enterococcus faecalis: Its Role in Root Canal Treatment Failure and Current Concepts in Retreatment
Charles H. Stuart, DDS, Scott A. Schwartz, DDS, Thomas J. Beeson, DDS, Christopher B. Owatz, DMD
Enterococcus faecalis is a microorganism commonly detected in asymptomatic, persistent endodontic infections. Its prevalence in such infections ranges from 24% to 77%. This finding can be explained by various survival and virulence factors possessed by E. faecalis, including its ability to compete with other microorganisms, invade dentinal tubules, and resist nutritional deprivation. Use of good aseptic technique, increased apical preparation sizes, and inclusion of 2% chlorhexidine in combination with sodium hypochlorite are currently the most effective methods to combat E. faecalis within the root canal systems of teeth. In the changing face of dental care, continued research on E. faecalis and its elimination from the dental apparatus may well define the future of the endodontic specialty.
Pulpal Inflammation and Incidence of Coronary Heart Disease
Kaumudi J. Joshipura, ScD, Waranuch Pitiphat, ScD, Hsin-Chia Hung, ScD, Walter C. Willett, DrPH, Graham A. Colditz, ScD, Chester W. Douglass, PhD
Pulpal inflammation is primarily caused by coronal caries, and leads to root canal therapy (RCT). Chronic inflammation has been associated with various cardiovascular diseases. This study evaluates the association between pulpal inflammation (using RCT as a surrogate) and incident coronary heart disease (CHD). We report results among males from the Health Professionals Follow-Up Study (HPFS), excluding participants with prior cardiovascular disease or diabetes. We obtained RCT data from the HPFS cohort (n = 34,683). Compared to men without RCT, those with ≥1 RCT had a multivariate RR of 1.21 (95% CI 1.05-1.40) for CHD. The association was limited to dentists (RR = 1.38; 95% CI 1.14-1.67). There was no association among nondentists (RR = 1.03). Dental caries was not associated with CHD. The results suggest a possible modest association between pulpal inflammation and CHD.
Prevalence of Enterococcus faecalis at Multiple Oral Sites in Endodontic Patients Using Culture and PCR
Christine Sedgley, PhD, Gwendolyn Buck, BS, Oliver Appelbe, BS
There are conflicting data on the occurrence of Enterococcus faecalis in the oral cavity of endodontic patients. This study investigated the prevalence of E. faecalis in multi-site oral samples (n = 136) from 41 endodontic patients using culture and polymerase chain reaction (PCR). Additionally, culturable strains were investigated for virulence traits. Overall, E. faecalis was detected in at least one tongue, oral rinse, or gingival sulcus sample in 68% of patients and in the root canals only in 5% of patients. In 21 patients from whom samples were obtained from all four sites, E. faecalis was detected in more tongue than gingival sulcus, oral rinse, and root canal samples (43, 14, 10, and 10%, respectively; p = 0.0148, χ2), and in proportionally greater numbers of patients with gingivitis/periodontitis compared to healthy periodontium (73% versus 20%; p = 0.03, Fisher’s exact test). PCR was more sensitive than culture in detecting E. faecalis in oral samples (32% and 4%, respectively; p < 0.0001, McNemar’s test). Multiple virulence traits were identified in culturable strains.
Multiplex Polymerase Chain Reaction Detection of Black-Pigmented Bacteria in Infections of Endodontic Origin
Jung-Hwan Seol, DDS, Byung-Hoon Cho, DDS, MSD, PhD, Chong-Pyoung Chung, DDS, MSD, PhD, Kwang-Shik Bae, DDS, MSD, PhD
The purpose of this study was to detect the presence of Porphyromonas endodontalis, P. gingivalis, Prevotella intermedia, P. nigrescens, and P. tannerae from clinical samples using multiplex polymerase chain reactions (PCR). Two different multiplex PCR protocols were used (one for the two Porphyromonas species and the other for the three Prevotella species), each one using a primer pair specific for each target species. The results were compared to those of the conventional culture procedures. Microbial samples were taken aseptically from 40 infected root canals and abscesses from patients. Samples were cultured in an anaerobic condition for conventional identification using a Rapid ID 32 A kit. Multiplex PCR was processed using the DNA extracted from each sample. At least one of the five species of black-pigmented bacteria (BPB) were detected in 65% (26 of 40) of the samples using multiplex PCR, and in 15% (6 of 40) using the conventional culture procedures. Multiplex PCR was more rapid, sensitive, specific, and effective in detecting BPB than the conventional culture procedures.
Influence of Orthodontic Dental Movement on the Healing Process of Teeth With Periapical Lesions
Ricardo Sampaio de Souza, PhD, Luiz Gonzaga Gandini Jr, PhD, Valdir de Souza, PhD, Roberto Holland, PhD, Eloi Dezan Jr, PhD
The purpose of this study was to histomorphologically evaluate (in dog’s teeth) the influence of tooth movement in the healing of chronic periapical lesions. Thirty roots of incisors and premolars of two dogs (1-year-old) were used in this research. After pulpectomy, the root canals remained exposed to the oral environment for 6 months for achievement of periapical lesions. Twenty root canals were biomechanically prepared and received a calcium hydroxide dressing for 14 days before being filled with gutta-percha points and Sealapex sealer. After root canal treatment, some incisors were submitted to orthodontic movement, whereas the other roots remained without orthodontic movement. The orthodontic appliance was removed at 5 months and 15 days after treatment, the dogs were killed 15 days later and the specimens were prepared for histomorphological analysis. The results showed that the orthodontic movement delayed, but did not hinder, the periapical healing process.
Effects of an Intracanal Glass Ionomer Barrier on Coronal Microleakage in Teeth with Post Space
Joseph C. Mavec, DDS, MS, Scott B. McClanahan, DDS, MS, Glenn E. Minah, DDS, PhD, James D. Johnson, DDS, MS, Robert E. Blundell Jr, DDS
Bacterial microleakage of the remaining gutta-percha in teeth prepared for post space with and without the use of an intracanal glass ionomer barrier was evaluated. Forty distal roots of mandibular molars were instrumented, obturated with gutta-percha and AH Plus sealer, and post spaces created. Teeth were divided as follows: Group I, 3 mm of gutta-percha; group II, 4 mm of gutta-percha; group III, 2 mm of gutta-percha plus 1 mm of Vitrebond; and group IV, 3 mm gutta-percha plus 1 mm Vitrebond. The roots were suspended in Rogosa SL broth and Lactobacilli casei was used as a microbial marker. At the end of 92 days, the mean number of days for the broth to turn turbid was group I, 23.8; group II, 43.0; group III, 57.4, and group IV, 70.5. A two-way ANOVA showed differences between the groups and a post hoc Tukey HSD analysis revealed the following significant differences (p < 0.05): Group I leaked faster than groups III and IV and group II leaked faster than group IV. In clinical situations of teeth with compromised crown-root ratio that require a post and core, 1 mm of Vitrebond over 2 or 3 mm remaining gutta-percha could reduce the risk of recontamination of the apical gutta-percha.
Penetration Depth of Warm Vertical Gutta-Percha Pluggers: Impact of Apical Preparation
Franck Diemer, DCD, Aline Sinan, DCD, Paul Calas, DCD, DU
The warm vertical gutta-percha compaction technique requires canals to be sufficiently flared to allow the tip of the plugger to penetrate to the apical third. The aim of the present study was to determine whether apical preparation or finishing instruments could be used to improve the penetration depth of pluggers. Single-root canals (48) were prepared using different rotary Ni-Ti instruments: M File System (I), ProTaper (II), HEROShaper (III), and EndoK3 (IV). Finger and heat (Endotwinn) pluggers were introduced into the canals, one after the other, and their penetration depths were measured. The apical thirds of the canals were then flared with specific instrumentation and the penetration depths of the pluggers were once again measured. After the initial preparation, the smallest diameter pluggers (No. 1 and F) could be inserted 5 to 7 mm short of working length without difficulty. Apical flaring improved the maximum penetration depth of the finger plugger by 1.76 mm and the heat plugger by 1.52 mm The deepest penetration was obtained with the EndoK3, ProTaper, and HEROShaper instruments. By accentuating the taper, apical flaring facilitated the penetration of warm vertical gutta-percha compaction pluggers.
Bacterial Leakage in Roots Filled With Different Medicaments and Sealed With Cavit
Claudia R. Barthel, PD, Dr. med. dent, Felix F. Zaritzki, Dr. med. dent., Wolfgang H.-M. Raab, Prof. Dr. med. dent., Stefan Zimmer, Prof. Dr. med. dent.
The aim of this study was to evaluate the time required by four different root canal medications coupled with the temporary filling material Cavit (ESPE, Seefeld, Germany) to prevent penetration of bacteria into the root canal. There were 145 roots prepared in a standardized manner. Four groups with 15 samples each were dressed with calcium hydroxide (Ca(OH)2), a 5% chlorhexidine gel (CHX), a chloromono-campherphenolic compound (ChKM), and Ledermix (LM), respectively, and sealed with Cavit. Four control groups contained identical medications but the roots were left unsealed. The 25 remaining roots served as additional controls. A standard setup for bacterial leakage studies was chosen with Staphylococcus epidermidis as test strain. Cavit application resulted in a significantly better seal compared with the unsealed groups. In the Cavit-sealed groups, all groups differed significantly from one another except for the CHX and the ChKM groups. The Ca(OH)2 medicated roots provided the longest protection (median of 36 days), followed by the Ledermix-group (27 days) and the CHX (18 days) or ChKM groups (19 days). It may be concluded that Cavit-sealed and medicated root canals do not provide adequate protection against bacterial leakage for more than 1 month.
Setting Times of Resilon and Other Sealers in Aerobic and Anaerobic Environments
Benjamin A. Nielsen, DMD, William J. Beeler, DMD, MS, Christina Vy, DMD, J. Craig Baumgartner, DDS, PhD
Eleven sealers, including Resilon sealer, were mixed according to manufacturer’s instructions. Setting times were determined in both aerobic and anaerobic environments. Two samples of each sealer were mixed and placed in the following conditions: (a) uncovered in an aerobic incubator; (b) covered with a glass cover-slip in the aerobic incubator; (c) covered with phosphate buffered saline in an aerobic incubator; (d) uncovered in an anaerobic incubator; (e) light cured and then placed in the aerobic incubator (Resilon only). All samples were tested for setting times with a Gillmore needle at 15, 30, and 60 minutes, then hourly up to 8 hours, then at 24, 48, and 72 hours, and then weekly up to 3 weeks. Ketac Endo and Kerr Tubliseal, were the fastest sealers to set in aerobic environments. Ketac Endo and Resilon were the fastest sealers to set in anaerobic environments. Roth 801 and Roth 811 were the slowest sealers to set, taking over 3 weeks to set in either anaerobic or aerobic environments. Resilon sealer set in 30 minutes in both anaerobic environments. However, in the presence of air, Resilon took a week to set and when placed in PBS, an uncured layer remained on the surface.
Bondability of Resilon to a Methacrylate-Based Root Canal Sealer
Franklin R. Tay, BDSc (Hons), PhD, Noriko Hiraishi, DDS, PhD, David H. Pashley, DMD, PhD, Robert J. Loushine, DDS, R. Norman Weller, DMD, MS, W. Trent Gillespie, DMD, MPH, Michael D. Doyle, DDS
Resilon broadens the dimensions of endodontic adhesion by introducing the possibility of creating monoblocs between root canal filling materials and intraradicular dentin by using methacrylate-based sealers. The adhesive strength of Resilon to RealSeal, a methacrylate-based root canal sealer, was evaluated using a modified microshear bond testing design. Flat Resilon surfaces with different roughness were created for bonding to the sealer and compared to a composite control. The composite control exhibited mean shear strength 7.3 to 26.9 times higher than those of the Resilon groups. Shear strength differences among the Resilon groups of different surface roughness highlighted the contribution of micromechanical versus chemical coupling in sealer retention. Ultrastructural evidence of phase separation of polymeric components in Resilon suggested that the amount of dimethacrylate incorporated into this filled, thermoplastic composite may not yet be optimized for effective chemical coupling to methacrylate-based sealers.
Killing of Enterococcus faecalis by MTAD and Chlorhexidine Digluconate with or without Cetrimide in the Presence or Absence of Dentine Powder or BSA
Isabelle Portenier, DDS, PhD, Tuomas Waltimo, DDS, PhD, Dag Ørstavik, DDS, PhD, Markus Haapasalo, DDS, PhD
The antibacterial efficacy of irrigating solutions and local disinfectants used in endodontics appears poorer in vivo than in vitro. One explanation may be inactivation by compounds present in the root canal. MTAD (a mixture of tetracycline isomer, acid, and detergent) is a new root canal irrigation solution with antibacterial activity. The aim of this study was to investigate the antibacterial activity of MTAD and chlorhexidine towards two strains of Enterococcus faecalis and the inhibitory effects of dentine and bovine serum albumin on the antibacterial activity. Survival of bacteria exposed to the medicaments in the presence or absence of inhibitors was monitored in an in vitro model. Full concentration (100%) MTAD and 0.2% chlorhexidine rapidly killed both strains. Combining chlorhexidine with cetrimide further reduced the time required for killing. The presence of dentine or BSA caused a marked delay in killing by both medicaments. The two E. faecalis strains tested showed minor differences in their susceptibility to the disinfectants.
Accuracy of Root Length Determination Using Tri Auto ZX and ProTaper Instruments: An In Vitro Study
Everdan Carneiro, DDS, MS, Clovis Monteiro Bramante, DDS, MS, PhD, Fábio Picoli, DDS, MS, Ariadne Letra, DDS, MS, Ulisses Xavier da Silva Neto, DDS, MS, Renato Menezes, DDS, MS
The accuracy of the electronic apex locator feature of Tri Auto ZX was assessed. Twenty distobuccal roots were selected and, after endodontic access, placed in plastic cylinders filled with 2% agar until completely covered. The roots were divided in two groups according to the calibration of the automatic apical reverse mechanism of Tri Auto ZX, at 1 and 2 mm from the apical foramen. Preparation was performed with ProTaper instruments connected to the device. Afterwards, the last file used was introduced into the canal and fixed in place with acrylic resin. The roots were removed from the agar and ground until exposure of the file. The distances between file tip and apical foramen were submitted to statistical analysis. The distances reached were actually shorter than the preset distances in every case, however, they were considered clinically acceptable. Setting the reverse mechanism at 1 mm was more reliable than at 2 mm.
In Vitro Evaluation of the Antimicrobial Effects of a Root Canal Sealer-Antibiotic Combination Against Enterococcus faecalis
Anita A. Hoelscher, DDS, MS, James K. Bahcall, DMD, MS, James S. Maki, PhD
The purpose of this in vitro study was to evaluate the antimicrobial effects of five antibiotics when added to Kerr Pulp Canal Sealer EWT against Enterococcus faecalis. Five antibiotics: amoxicillin, penicillin, clindamycin, metronidazole, and doxycycline, were added separately to Kerr sealer. Thirty brain heart infusion agar plates were inoculated with E. faecalis and sterile paper discs containing a sealer-antibiotic combination were randomly assigned to the inoculated plates. Kerr sealer on a sterile paper disc and a blank sterile paper disc served as the controls. Fifteen plates were incubated aerobically and the remaining 15 plates were incubated anaerobically at 37°C. The zones of inhibition were measured at 48 hours. No significant differences (p > 0.05) were found between aerobic and anaerobic groups. The groups were combined and data analysis using a one-way ANOVA and Tukey’s post hoc test was performed. Results revealed that sealer-antibiotic combinations containing amoxicillin, penicillin, clindamycin, and doxycycline had a significant difference (p < 0.001) in the mean zones of inhibition when compared to Kerr EWT sealer alone. No significant differences (p > 0.05) were found between the metronidazole-sealer combinations and Kerr EWT sealer alone.
Antimicrobial Efficacy of Medicated Root Canal Filling Materials
Kevin B. Melker, DDS, Frank J. Vertucci, DMD, Maria Fernanda Rojas, DMD, Ann Progulske-Fox, PhD, Myriam Bélanger, PhD
Bacteria remaining within the root canal system are a significant factor in endodontic failures. The aim of this in vitro study was to evaluate the antimicrobial efficacy of commercially available gutta-percha formulations against common endodontic pathogens. Standard, tetracycline, or iodoform (also called medicated gutta-percha; MGP) containing gutta-percha were tested against Actinomyces israelii, A. naeslundii, Enterococcus faecalis, and Fusobacterium nucleatum using the agar diffusion method. Resilon points and tetracycline disks/E-tests were used as negative and positive controls, respectively. Resilon did not display antimicrobial properties. Standard gutta-percha and MGP inhibited F. nucleatum and A. naeslundii, with MGP also inhibiting A. israelii. Tetracycline containing gutta-percha was found to inhibit growth from all four bacterial species tested. The results of this study suggest that the use of tetracycline containing gutta-percha as an obturation material may be useful as a complement to the cleaning and disinfection phase of root canal procedures.
Peripheral Ameloblastoma: A Case Report and Review of the Literature
Demetrick W. LeCorn, DMD, Indraneel Bhattacharyya, DDS, MSD, Frank J. Vertucci, DMD
Peripheral ameloblastoma is a rare, benign odontogenic tumor that histologically resembles an intraosseous ameloblastoma but develops in the soft tissues of the gingiva and mucosa and exhibits an innocuous clinical behavior. We report a case of a recurrent peripheral ameloblastoma in a 61-year-old man that presented as a painless swelling on the maxillary anterior labial attached gingiva. Clinical and histopathologic features of this lesion are discussed. The peripheral ameloblastoma should be included in the differential diagnosis of a gingival lesion clinically resembling any of the myriads of entities seen on the gingiva including a pyogenic granuloma, peripheral giant cell granuloma, or parulis/gumboil. We believe this case highlights the need for submitting excised tissue for microscopic examination.