JOE Review: March 2019-May 2019

By Lauren E. Jensen, D.D.S., M.S.

Three articles, one each from the March, April, and May 2019 issues, respectively, of the Journal of Endodontics, arguably the premier journal for endodontics, were selected for brief review.


  1. In “Anesthetic Efficacy of Intranasal 3% Tetracaine plus 0.05% Oxymetazoline (Kovanaze) in Maxillary Teeth,” Capetillo et al. explored needle-free anesthetic delivery, a potentially favorable alternative to traditional anesthetic administrative routes. They sought to determine both pulpal anesthetic efficacy of and patient preference for a 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray in maxillary lateral incisors and first premolars.  In a single-blind cross-over design, 50 adults, in two appointments separated by at least one week, received two distinct anesthetic protocols: a 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray and mock infiltration, and a mock nasal spray and 2% lidocaine with 1:100,000 epinephrine infiltration.  Selected teeth were free of caries, large restorations, periodontal disease, and history of sensitivity or trauma.  Pulpal anesthesia was evaluated with an electric pulp tester (EPT). Anesthetic success was significantly lower for the Kovanaze nasal spray and mock infiltration (22%-37%) than for the mock nasal spray and lidocaine infiltration (89%-91%). Further, subjects reported nasal drainage and congestion, burning, pressure, and sinus congestion subsequent to the Kovanaze nasal spray. Prior to study participation, 56% of subjects claimed to prefer the nasal spray route versus a standard infiltration (44%). Afterward, 100% of study participants preferred a standard infiltration. Capetillo et al. concluded that not only was 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray significantly less effective at providing pulpal anesthesia to maxillary teeth, but also was less preferable for patients than traditional maxillary infiltration. Given that painless endodontic treatment, which is paramount from both a clinician and patient standpoint, relies in part on successful anesthesia, clinicians should continue to hone their anesthetic administrative techniques in order to enhance not only anesthetic success and efficacy but also patient experience.
  2. Patel et al. had two aims in “The Impact of Different Diagnostic Imaging Modalities on the Evaluation of Root Canal Anatomy and Endodontic Residents’ Stress Levels: A Clinical Study.” First, they aimed to compare the impact of periapical radiographs, cone-beam computed tomography (CBCT) imaging, and 3D Endo software on the interpretation of both root canal anatomy and radiographic quality of endodontic treatment. Second, they aimed to determine how each imaging modality affects clinicians’ stress levels during primary root canal treatment on molar teeth. Sixty patients in need of primary endodontic treatment on a first or second maxillary or mandibular molar were allocated randomly into three groups: group 1, conventional, periapical radiographs only; group 2, periapical radiographs and CBCT imaging; and group 3, periapical radiographs, CBCT imaging, and 3D Endo software. Five, first-year residents in a four-year endodontic specialty training program in the United Kingdom performed all endodontic treatment in two visits using a standardized protocol. Each resident completed a questionnaire, which evaluated their stress level, as well as their perceived usefulness of each imaging modality. Two experienced endodontists evaluated the radiographic quality of the completed endodontic cases. Groups 2 and 3 proved significantly better than group 1 for assessing number of root canals and anatomy, as well as for determining working length. Group 3 yielded significantly more accurate working lengths. In group 1, there were significantly more cases obturated both short of the apex and with radiographic voids compared to those in group 3. Treatment procedures were moderately or very stressful in 75%, 5%, and 0% in groups 1, 2, and 3, respectively. Patel et al. concluded that 3D Endo software followed by CBCT imaging were more useful for determining root canal anatomy and working length, and also seemed to decrease stress levels during endodontic treatment. Considering these results, residents in endodontic specialty programs should become proficient in the use of adjunctive imaging modalities in order to facilitate both endodontic diagnosis and treatment. Further, if using CBCT in particular, endodontic practitioners should be familiar with the May 2015 revised joint position statement on CBCT, on which the AAE (American Association of Endodontists) and AAOMR (American Academy of Oral and Maxillofacial Radiology) collaborated.
  3. Despite high rates of success and survival of endodontic treatment, intervention is sometimes required.  For teeth that are extracted, dental implant therapy is a treatment alternative for the replacement of missing teeth. Sebring et al. performed a retrospective analysis of patient files and radiographs in “Indications for Extraction before Implant Therapy: Focus on Endodontic Status.” They aimed to evaluate endodontically treated teeth prior to extraction, and to determine their impact on both treatment planning for and outcomes of dental implant therapy. A total of 596 Swedish individuals (with 2,367 implants) participated in a clinical and radiographic examination. Patients were categorized according to diagnosis at the time of tooth extraction, namely if the extraction was primarily due to periodontitis, caries (including apical periodontitis and root fracture), trauma, or a mix of the aforementioned causes. Details related to treatment planning such as timing of implant placement, and early or late implant failure, were assessed. Tooth status, namely whether the tooth had been endodontically treated and whether there was an apical lesion, were also assessed. The majority of patients (64%) had their tooth or teeth extracted because of caries or a caries-related diagnosis. Fifty-one percent of all extracted teeth had been endodontically treated.  One-third of all teeth showed apical periodontitis. At sites that had an apical lesion, immediate implant placement was less common. Endodontic status, however, was not associated with treatment outcomes. The mixed diagnosis category was associated with early implant loss, and the periodontitis diagnosis category was associated with a higher risk for peri-implantitis. From this retrospective study, Sebring et al. concluded that endodontic status prior to extraction had minimal impact on treatment planning and was not associated with either early or late implant failure or peri-implantitis. They also found that immediate implant installation after tooth extraction was less commonly performed at sites with apical lesions. While endodontists especially seek to preserve patients’ natural dentition, all dental practitioners should be aware of alternative treatment options and outcomes when endodontic treatment can’t be or isn’t selected and when a tooth is extracted.

Publications such as these from the March, April, and May 2019 issues of the Journal of Endodontics may both inform and also inspire endodontists to, perhaps, improve upon a clinical technique, become familiar with 3D imaging techniques, and understand treatment planning considerations with respect to implants.  In this way, endodontists can continue to seek to provide the best quality of care to their patients.

Dr. Lauren E. Jensen is a member of the AAE’s Resident and New Practitioner Committee. She can be reached at