Evidence Based Dentistry--Question, literature, LOE (level 1 onlybased on expertise and pts preference) Chong, LindenboomIRM and MTA

same for prognosis Rud Andreasen 1972histo (success, failure (inflammation) and scar (success)) and radio (complete, incomplete (scar), uncertain (reduced radiolucency w/ no symptoms) or failure) classification of success/failure for retreatment, Molven is similar with pictorial representation (Orstavik PAI not apply to surgical retx) Allisonlat con spreader to within 1 mm Ove PetersCBCT to study RC morphology Engstromhealing/non-healing can be determined by 4 years Inflammatory root resorptioninflammatory cells present, prostaglandins, cytokines Replacement resorptiongiant cells, no inflammatory cells Fabriciustalked about bacterial composition (aerobic vs anaerobic, anaerobic more in necrotic) Sundquistsynergestic effects of bacteria Sjogren IEJ 1991CaOH seven days in canal for efficient elimination of bacteria Peters and Wesselink 2002Paper pt using for CaOH app, drying it out, but CaOH not beneficial Rickert and Dixon 1941hollow tube theory (stagnation of fluid causes infl), falsenon-sterile Morse electrophoresis to determine cystsRCT successful treated Ingle 1969standardized instruments into ISO Weines classification, IOUY, mechanical shaping (final shape should encompass original shape), stepback technique Langeland1967, instrument to apical constriction tactile, no standard mm measurement Overfilling is overinstrumentation (transp of canal), no seal Strindberg 1956, first to classify heal/fail, healed (PDL normal, lamina dura intact), partial (scar), nonhealing (same RL) fail (larger RL or non resolution) Hoshino 1990-E. faecalis invasion into dentinal tubules Langelandaccessory canals dont cause lesions, just portal of entry Siquiera IEJ 2003infection most significant factor in flare up pathogenesis Morseshould put on Abs if necrotic w/ PAP, most others say no Abs (wont help with pain) Hasselgrenpulpotomy only is nec for vital pulp emergency, calcified canals dont need RCT if asympto OKeefepain before tx makes 5X more likely to exp pain after treatment Schneiderif local corticosteroids used, use systemic antibiotics to prevent infection from invasion ADA Spec 28dictated torsional resistance and bending force Daltonrotary and hand instruments same for microbiological debridement

Delivanisbacteria study, entomb the bacteria, starve them and theyll die Andreasennever do RCT on day of trauma, mendicaments cytotoxic to PDL at periapex SjogrenGP no unfavorable reaction, set sealer not toxic ADA standard 28: 35, 45, 60 degrees to test rotary files OrstavikE faecalis penetrate 250 microns into tubules, Haapasalo300-400 microns Harrisonlooked at concentrations of NaOCl, recommends 5.25% Sjogren and Bystrom showed much higher success if no bacteria Mulleriodine/H2O2 protocol for disinfecting rubber dam Sundquistanaerobic sampling of bacteria Spangberg0.5% NaOCl to limit accidents Smith/Weller GP flow 2-3 mm when heated Molven Hulsmann and Fristad (sp?)(Fristad is the radiologist) Molven has nonsurgical and surgical (surgical has the addition of scar tissue formationincomplete healing) nonsurgical healing is favorable, uncertain, and unfavorable Chen, Sahlerabi, Lazarskisurvival studies (insurance data) 93%+ Torebinejad study that GP leaks at 30 days w/ complete bacterial penetration to apex Cross-sectional studies of endo successBuckley, Spangberg, Kirkevang Nair shows extraradicular infections (actinomycosis) Summary of Lit Review
Reit C Dahlen G U of Goteborg, Sweden

An in vivo human study showing: Treatment of teeth with apical periodontitis should be done with 2 appointments with interappointment Ca(OH)2 dressing. If bacteriological testing techniqu individualized treatment strategies for each case. Critique:

Stabholz A Friedman S Hebrew U Jerusalem, Isreal Hayes SJ Dummer PMH U of Wales, Cardiff, UK Reit C

They retested canals after no intracanal medicament, so any bacteria present in very minute numbers could have multiplied. The sensitivity and specificity was not as high as desirable. A review article suggest guidelines for treatment planning for endodontic retreatment, involving two levels of treatment: GAINING ACCESS TO THE ROOT CAN crown or not) and GAINING ACCESS TO THE APICAL FORAMINA (bypass post).

A single case report of late RCT failure 17 years s/p NSRCT for which SRCT was the performed retreatment. Coronal leakage was identified as a possible poin

The study shows that a practitioners values influence their treatment choice for root canal retreatment cases. The manifestations of these values varied subs

Kvist T U of Goteborg, Sweden Hamilton RS Gutmann JL Texas A&M Baylor Matosian Pitt Ford TR Rhodes JS London, England

individuals. Because of this, the consumer must be more involved in the decision-making process.

Literature review showing: Orthodontic movement can affect vitality, teeth with prior RCT show less resoroption than vital teeth, RCT teeth can be moved as well as vital teeth, traumatiz little is known about moving SRCT teeth,

Dental professionals must recognize the fact that the preservation of debilitated natural teeth, no matter how "noble" a concept, may offer patients a poorer p removal of such teeth and their pre-emptive replacement with a dental implant. Treatment planning paradigms need to be updated Article discussing reasons for failure and treatment options. Failure of RCT: Biological (no rubber dam, incorrect irrigants, prepared short, missed canals, poor obturation) and Other (root fracture, poor coronal resto economic constraints). Assessment of Success and Failure: Success defined as relief from symptoms, healing of sinus tract, and reduction or resolution of periapical radiolucency. options include Review, RCReTx, Root end surgery, or Extraction. Factors that may affect outcome: Periapical radiolucency, Size of radiolucency, Technical difficulty of retreatment, and Perforations. Treatment Planning: If one can improve upon existing RCT and cause minimal harm, then retreatment should be considered. 200 4 200 6 Review of literature regarding extensively damaged teeth with heavy implant bias.

Cho G USC Torabinejad M Goodacre CJ Loma Linda

A review paper addressing systemic and local health, pt comfort and perception, pulpal and periodontal status, biologic and environment, color chara procedural complications, adjunctive procedures, treatment outcomes (success rates).

Pulpal Pathology Bender Seltzer 1963 OOO, pulpal pathology varying degrees, previous pain best indicator Michaelson/Holland IEJ 2002, painless pulpitis 40% of teeth, esp older pts Stashenko1998 oral Biol MedPMNs first, monocytes, excavate PA bone to make room for inflammatory mediators Jontell1998 Oral Biol Med-Dendritic cells-antigen presenting cells inside pulp vs caries/macrophages, initiate response Hargreaves/Goodis2006 JDRLow temp decrease pain (CGRP) low pH increase pain (CGRP) Kamal 1997 JOEPulp reacts early to caries, lay down reparative dentin, closer caries got, more rxn Massler IDJ 1967active and arrested carious lesion, acidogenic, proteolytic phases (indirect) Lundy 1969 OOOpulpal response to mechanical insult, repairs itself.

Reeve Stanley OOO 1966reparative dentin is pathologic and is leaky (0.5 mm to pulp causes infla)

Van Hassel and Harrington OOO 1969 Localizing EPT between teeth, about 80% Max/Ant better Bender OOO 1995pulp diagnosis classification by pain (mildtreatable conserv, severeRCT) Bender AEJ 2000prev hx of pain, irreversible, mild w/o prev pain: reversible Abbott and Yu 2007 AEJclassif based on symptoms, remove restorations Peters JOE 1994If cold and EPT tests both negative, very likely necrotic, cold is enough in 20-50 yrs Iqbal JOE 2007sharp-pulp, dull-PDL, cariessymptomatic, pulp pain more likely to Ex care Friend OOO 1968EPT test to localize, max and ant more accurate, overall hard to localize 40-60% Levin et al 2008 Consensus conference, similar to Abbott 2007 Ca(OH)2 Tronstad JOE 1981CaOH makes dentin more alkaline, promotes repair and inhibits infl resorption Evans IEJ 2002E. faecalis resistan to CaOH, ppi make less resistant, not built up resist to NaOCl or stress proteins Zerella OOOOE 2005CHX and CaOH in retreat is better for E. faecalis and same for others as H20 Hasselgren JOE 1988CaOH can dissolve tissue on its own, and increase eff of NaOCl in 2nd visit Safavi JOE 1993CaOH breaks down LPS (endotoxins) and inactivates them in vitro Haapasalo IEJ 2000dentin powder inhibit effects of CaOH and somewhat CHX and NaOCl Kvist JOE 20041 visit with 5%IPI is similar in bac redux to 2 visit CaOH (no NaOCl in 2nd) Sathorn IEJ 2007Meta-analysis shows CaOH has little effect between visits Periapical Path Torneck OOO 1966sterile, closed end tube, .25-.5mm ingrowth of CT, so sterile RCT should heal destroyed Rickert and Dixon hollow tube theory Lalonde, Luebke OOO 1968cyst: granuloma 50/50, not accurate, not enough sections, curetted Nair OOO 1996cysts only 15%, more sections, in toto, TEM, 2 types of cysts, true and pocket Torebinejad Oral Surg 1978immune causes of PA lesionscomplement, antibodies, etc, flare up immunological in nature Ricucci Endo Topics 2004Histologic cases, epithelium cellsprotective mechanism Valderhaug IJ Oral Surg 1974Monkeys, cysts developed within a year, labeled epith proliferate Jansson Swed D Jour 1993monkeys, sealed (anaerobic) infected teeth dev path faster than unsealed infected(aerobic) Svensater Endo Topics 2004biofilms create sp environment for bacs, nutrients, attachment, and antibiotic resistance. Stashenko JDR 1989T-helper in early lesion, T-suppressor in later lesion (to control lesion size)

Periapical diagnosis Ricucci and Langeland IEJ 1998Review, part 1, part 2, instr to constr best, 2 mm short of const is next best, long is worst, vital pulp stump okay, helps healing, dont follow mm by itself, tactile Kovacevic AEJ 2008pulp histology correlation with AP, bone resorption as early as pulpitis Ariji IJOMS 2002Submandibular abscess, cause trismus/dysphagia. 3rd molars very common, may be periocoronitis, not endodontic, bad symptoms assoc with parapharyngeal Seltzer JOE 2004Inflammation greater in overinstrumentation Teodorou 2003non-odontogenic tumors overview, inc bone, CT, vascular, cartilage, carcinoma, etc. Torneck OOO 1969inflammation induces cementum and dentin and recontouring, bone resorption on one side and deposition on side away from lesion (compensatory mechanism) used tetracycline Nair and Sundqvist OOOOE 2008abscess pathway of cyst formation, rat experiment

Current Lit Chivatxaranukal 2008E. faecalis penet into tubules (esp unprepared), greater adher to collagen Degerness JOE 2008lateral canals and isthmus majority in apical 3-4 mm, resect to this level Lindemann JOE 1986triazolam did not increase anesthetic success in IAN block Rania AEJ 2008pulp stem cells used to produce pulp-like tissue in rabbits, long way off in humans Tsesis JOE 20088.4% flare up incidence in meta-analysis, many others show lower but were excluded due to different definitions of flare-ups, more stringent Wiegand DT 2008Emdogain (Iqbal and Lam) reduces repl resorption, NaF not helpful (review) Witherspoon JOE 2008MTA apexification has more adv that CaOH2 and can be done in one visit with same success as two visits Tsukiboshi 2008photos, digital radios, and CT helpful in dental trauma

Endodontic Emergencies Weathers 1992Profit from emergency endo, fast and slick, schedule time for emerg Weine OOO 1975close vital teeth between appt, No kidding! August JOE 1982should close abscessed teeth between appt (prev left open by another dentist) 95% success Houck OOOOE 2000Trephination not helpful for prevent post-op pain (same w/ or w/o) Hasselgren 1989pulpotomy sufficient to remove pain (after 1 day), mendicament type doesnt matter Negm 2001corticosteroids intracanal to prevent post op pain should be done, Abs to prevent infection Grossman 1977endo emer not just toothaches, fxd tooth, fxd bone, post-op pain

Halvorson JEM 1985I&D for abscess if fluctuant, blunt dissection etc Matthews CDA 2008AAAs should be drained through canal or by I&D, Abs only for systemic probs or immunocompromised Carrotte 2004Exs before, during, and after Gatewood 1990AAE survey, times change, especially one visit and complete cleaning and shaping

Compromised teeth White 2006Cant compare implant survival vs endo success, implants more intensive in planning/execution Kim/Iqbal 2007Systematic review, equivalent success, decision should be based on individuals Kim/Iqbal 2007no diff in long-term prog (cheaper and quickerendo), implants great if endo prognosis is poor Doyle 2007smoking affects endo, overfill more failures, no diff in # of appts Mordohai 2007implants much better than endo, obvious bias with selective literature use Allen 2004endo for elderlybetter than implants, less trauma, cant tolerate removable prosthesis Yeng 2007treatment planning essential (restorable? Etc) refer if best for patient, communicate with referring doc Gorni/Gagliani 2003retreatment success much higher if root canal anatomy not violated (86 vs 48%)

Anesthetizing pulpitis Byers 1993pulp tissue less able to recover after exposure if lacking innervation (dental injury models) Claffey 2004septocaine and lidocaine no difference in IAN success (both low25%) Clark 1999mylohyoid nerve block does not provide numb by itself, does not enhance IAN Gallatin 2000corticosteroid reduce post-op pain vs saline Hargreaves 2002inflamed tissue harder to anesthetize, tachyphylaxis (repeated doses less effective) Nusstein 2003benzocaine topical only effective in max anteriorother areas no difference from no benzo Nusstein 2003X-tip intraosseous successful at profound anesthesia when IAN fails, only if no backflow Van Gheluwe 1997PDL effective if have backpressure, saline and anesthetic equally effective Walton 1986PDL is actually intraosseous injection, no tissue damage adjacent teeth anesthetized

Instrumentation mechanics Felt 1982reamers have fewer flutes, more vertical, more efficient, more clearing of debris Miserendino 1985cutting tips more efficient than flutes, can transport more easily

Bahcall 2000NiTi instruments not twisted, more effective than hand instrumentation Kazemi 1996NiTi instruments more efficient than stainless steel Roane 1985Balanced force techniqueplacement (pressure clockwise screw in), cutting (pressure counterclock), and debris removal (non pressure clockwise) Rowan 1986torsional failure same for SS and NiTi, clockwise more torque than counterclockwise Guppy 2000no positive rake angles, no lube was used, Profiles produced smaller chips (more negative angle) Schafer 2001rhomb/triang most flexible (depends on cross-section--lower surface area), triangle least likely to fx Buckley 1995PAP more in mx than md, ant than molars, overfill/short root-filled more likely, root-filled 12 times more likely to have PAP Molven 2002long-term followup 10-17 years, 83% agreement between self and other examiners of PAP, good? Peters 2002microbes grow between visits, no benefit to CaOH between visits, do one visit (CaOH dried)

Dental TraumaDiagnosis Andreasen Text Book chaptercomplete clinical and radiological of teeth and soft tissue Andreasen 1995avulsed teeth high risk of need for RCT, 34% heal if have open apex, 1/3 PDL heal Andreasen 1986transient apical breakdown4% of luxations have it, most of these have color changes also, most are mature permanent teeth, blunting of apices and pulp canal obliteration Feliciano 200654 different trauma classifications exist, Ellis simplified by number, Andreasen soft tissue as well Haas 2008PDL loss after trauma, greater in extracted than trauma intrusion lost more apical, extracted in cervical Hammarstrom 1986avulsed teeth 2 hrs in saliva, 6 hrs in milk, if dry, after one hour, scrape tooth clean before Hammarstrom 1996Ab tx in avulsed teeth, early (not late) systemic Ab and early endo tx prevent root resorption Cvek 1978partial pulpotomy w/CaOH 96% success (normal, healthy), size and interval of tx no difference Bjorndal 1998stepwise excavation 94% success, save many more teeth

Trauma Treatment Goldberg 1984CaOH2 makes dentin bridge, porous, leaky, irregular from dye and SEM studies, need restoration Pitt Ford 1996MTA as pulp cap materialmakes thicker bridge, prevents microleakage, more biocompatible Andreasen 2004horizontal root fx, less developed roots(more blood supply)better healing, less displacement, more healing, rigid splinting, less circ poorer healing, repositioning have sig effect on healing if less than 1 mm Cvek 2002cervical root fx, good prognosis, oblique better than transverse AAE Guidelinestake radiographs, follow up, check chart Flores 2007splint most 7-10 days, systemic antibiotics/ tetanus

Cvek 2004horiz root fx, no RCT unless necrotic, only fill coronal part, higher success if apexification of coronal seg first, then fill coronal part Flores 2007

Cleaning and Shaping Kerekes 1979Success of Ingles standardized instruments91%, PARL present significantly lower success, first study to look at results of standardized instruments, first study to get >90% Bergenholtz 1979overinstrumented/overfilled retreated cases, more pap found in overfill cases (result of zip perf because of overinstrumentation, not bacteria extruded from canal.) lower success than RCT (62% w/o overfills) Goerig 1982step-down techniquecoronal flaring first (Hedstrom and GG) wiped in anticurvature, then make apical stop 1 mm short and step back to flare. Morgan 1984crown-down technique (pressureless) provided better preparations than circumferential Pruett 1997cyclic fatigueused radius and angle to measure curvature. Sharper curves, less cycles to failure, angles greater than 30 cycles to failure decreased, not affected by RPM, larger files less cycles to failure. (40>30) Hinrichs 1998no significant difference in debris extrusion between different rotary files (except in apical), amount of debris correlated to amount of irrigation. Pettiette 1999niti hand vs ss handniti less deviation (4.4 vs 14.4 degrees), also fewer strip perfs Kirkevang 2002longitudinal studies best, good quality makes a difference for healing (PAI) Usman 2004apical cleanliness det by instrument size, not length (40 better than 20), histological model Patino 2005rotarys--# of times used best indicator of breakage, (no visible sign) (greater curve, more breakage) Barroso 2005coronal flaring enables better IAF determination

NiTi instrumentation Klevant IEJ 1983leaving bacteria-free canals unfilled caused same healing rate as bacteria-free filled canals (percolation may not exist) Dalton JOE 1998no diff in bact reduc between NiTi and SSK, bigger sizes better, sig reduc after filing Trope 19991visit vs 2, no difference statistically, but 2 visit cleans more bacteria, clinically significant Card JOE 2002larger apical sizes can remove almost all bacteria, 1 visit more viable option (w/ irrigation) Portenier IEJ 1999LightSpeed causes less displacement of center of root canals (flex shape, noncutting shaft) Versumer IEJ 2002LS vs ProFile, no difference in safety or shape, ProFile fewer instr and faster Iqbal JOE 2007no diff in safety between LS1 or LSX, (LSX more efficient) Peters INJ 2001NiTi instruments still leave 35% of canal surface uninstrumented (by uCT scanning) Shen JOE 2008cutting efficiency better with irrigation, similar between instruments

Parashos JOE 2006fx instrument should be removed only if able w/o excessive dentin removal

Irrigation Sen 1999Candida resistant to NaOCl when in biofilm on canal walls. Use antifungal if predisposed to candida. Rasimick 2008interaction of EDTA and CHX, ppt, but no carcinogen (like w/naocl and CHX) and little degradation Khademi 200630/.06 effective for debris and smear layer removal. Poor study design., SEM Peters 2000LS vs ProFile in debris removalLS better because larger size, design doesnt matter, water similar to naocl and EDTA, SEM Hulsmann 1999Careful with NaOCl, treat w/antibiotics and compresses Baumgartner 1984NaOCl better at removal of debris, citric acid better at removing smear layer, SEM Van der Sluis 2007NaOCl with ultrasonication better than passive NaOCl better than water (removal of CaOH from artificial groove) Zehnder 2006overview of irrigants

Root canal antiseptics Law 2004meta-analysisCaOH2 reduces bacteria as medicament, may not have opened far enough Messer 1984CMCP (chlorophenol) 90% lost after 24 hours, may not be effective as intracanal medicament Molander 1999CaOH2 does not work better if left in canal longer than 7-10 days, IPI doesnt increase antibacterial effect, but may be more effective against E. faecalis. Orstavik 1990Smear layer delayed (but not abolished) med effects, CMCP and CaOH2 both effective (CMCP more vs E. faecalis), IKI better than NaOCl better than CHX, dentin acts as buffer Shabahang 2003MTAD more antimicrobial effectiveness vs NaOCl (use less of NaOCl, no tissue dissolve by MTAD) Portenier 2006CHX same as MTAD for E. faecalis, dentin powder buffered, delayed effect Siren 2004IKI or CHX w/CaOH2 better than CaOH2 alone, CaOH2 least toxic. Spangberg 1979IKI is least toxic and with substantial antimicobial of irrigants at the time (NaOCl not in play), CMCP, cresols toxic.

Sealershermetic seal, biocompatible, bacteriostatic, resorbable, dimensional stability, easy to mix Economidessmear layer removed improved quality of apical seal w/AH 26, no diff with Roth (flow leakage) BarbizamCaOH2 placed prior to obturation interferes with bonding of Epiphany (maybe not clinically sig) AllanSealers set from 1-3 wks, (or longer) set more quickly on glass slab than in ext tooth Kokkas 2004smear layer blocks sealer from entering tubules

Nielsen 2006Resilon doesnt set well in aerobic environment (including periradicular tissues) SalehAH plus and GS kill E. faecalis, other sealers dont kill as well. (even into tubules) Sari 2007Extruded AH Plus does NOT prevent PA healing, but may delay it in children Tay, Pashley 2006resin sealer cant hold to dentin as well as composite

Obturation materials Schilder 1967Warm vertical condensation produce 3-D filling, Peng 2007over-extension greater in warm GP vs cold lat, success equal Smith, Weller 2000Warm techniques better at filling canal irregularities, deeper heat better Tunga 2006resilon provides better seal than GP (but sealer not allowed to set w/ GP) Biggs 2006no difference between GP and Resilon for leakage and sealing ability Shipper/Trope 2005More inflammation (AP) with GP than with Resilon (coronal bacterial inoculation and leakage w/ GP) Hsieh 2008ZnO TPU new composite obturation material stronger than resilon or GP Cotton 2008Resilon and GP same in healing outcome

Endodontic Radiography Goldman 1972agreement between examiners less than 50% on interpret (not read) radiographs Goldman 1974agreement with self (2 yrs later) only about 80% of the time Reit/Hollender 1983very low agreement between examiners (PARLs and apical seal)open to interpretation Bender/Seltzer 1963doesnt show up on radiograph until cortex is eroded, trabecular pattern is from junction, Barbat 1998lamina dura disruption shows on the radiograph, not reaching cortex. Woolhiser 2005no difference in length determination accuracy between digital and film Nair 2007CCD is the best for contrast and resolution, CBCT for 3-d (For surgery prep)

Digital Radiology Patel 2007CBCT (Coneshaped beam, lower radiation) iCat can limit view to size of PA film, 7.5 units vs 5 for PA Cohenca 2007Trauma, CBCT better for fxs, may not be feasible. PAs many views required (MRI for soft tissue) Cohenca Part 2root resorption, CBCT helpful in locating resorption to plan tx Sogur 2007CBCT vs digital vs film for det length and density of obt, digital better images than CBCT (Same as film)

Loushine 2001calibrated digital software better for length determination than uncalibrated Matherne 2008find addt canals w/CBCT, digital, etc. CBCT better than 2-d methods for finding addtl canals Fan 2008Dig Subtraction Radiographyaccurately determine canal anatomyc-shaped canals Simon 2006evaluate cyst vs granuloma by CBCT, 13/17 correct, other 4 questionable

Apex Locators Kakehashi 1965no infection in germ-free mice with pulp exposure, present in control animals Blank 1975Old ALs high current, 85% accuracy (w/in .2 mm), endometer vs sonoexplorer no stat difference Trope 1985AL need to use strict guidelinesget 90.6% accuracy to apical foramen (Subtract-0.5 mm to constr) Shabahang 1996Root zx 96% accuracy, but 30% beyond apex (still counted as accurate because w/in 0.5 mm) Jenkins 2001Root ZX reliablie w/in 0.3 mm, can work in any irrigant no stat difference Tselnik 2005Root zx and Elements ALno difference, both accurate Williams 2006compared radiographic WL with actual length in extracted teethif file long, actually longer than appears, if file short, closer by 0.5 mm to foramen than it appears Wilson 2006AL and EPT safe for pacemakers/defibs? Safe for use, no interference, no abnormalities by EKG

Current Lit March 2009 BashutskiGTR, memb and grafts Mainly used in endo surgery w/through and through lesions, perio-endo comm. Gu(Hsu, Weller, Kim for isthmus) highest isthmus from 4-6mm FilhoMB2 in 53-67% of cases, CBCT helpful Schirrmeistermicrobes in PARLs of root-filled teeth (facultative anaerobes, many perio bugs) (gram negative have LPS endotoxin) microbes in PARL if symptomatic (acute lesion) Tawileval retrofill materialscomposite if have long post (dome shape), MTA and IRM same histo, geristore less favorable histo, all same radiographically KuahEDTA w/ultrasonication w/NaOCl flush gives best result for smear layer removal (1 min each) MatthewsArticaine as buccal infiltration is 50% effective if IAN block fails (none or mild pain) Yamanebiofilms in apical area in persistent PAP may contribute to failures of RCT (resistant to RCT) (grampositive rods identified)

Vital Pulp Therapy Leksell 1996stepwise excavationfewer pulp exposures w/stepwise. Also, after initial removal, easier to see demarcation between soft and hard dentinCaOH2 dries out and disinfects carious dentin

Magnusson 1977stepwise w/primary teeth, much lower pulp exposuregood for maintaining tooth until exfol Jordon 1978indirect pulp cap-50% resolved PARLs, PARLs may not indicate irreversible condition IL-1 and TNF-betainitiate osteoclasts to form resorptionthese are activated by inflammation (not necessarily necrosis) in pulp. Once get bacteria into PA region, get PMNs and pus, now diff animal. Caliskan 1995full pulpotomy in vital teeth w/PAP24/26 healed w/ only Lim and Kirk 1987reviewolder paper, original state of pulp and immunological capacity are important Fitzgerald 1979mech exposureclot lysis, fibroblasts and endothelial cells move in, org and diff into odontoblasts. Odontoblasts form from fibroblasts. No mitosis in odontoblasts layer, but happening in fibroblasts showing they diff into odontoblasts. Tziafas 2002MTA shows hard tissue formation as pulp capping, two layered hard tissue barrier Barthel 2000carious exposurepulp cappoor long term prognosis 13-37%, (prolong vitality for apex closure)

Ultrasonics Plotino 2007review of ultrasonicsmany uses refine, surgical, irrigation, instr removal, condense MTA Van Der Sluis 2007ultrasonic irrigation, NaOCl best, cavitation is mech, center of canal, non-cutting file Lui 2007EDTA vs +surfactants. No difference between them, ultrasonics w/EDTA is better than w/o Min 1997root end prepssome fxd thin dentin walls w/ high power ultrasonic (more than low power or bur) Ettrich 2007water w/medium power best for keeping heat down during post removal Huttula 2006post-removal with irrigation results in lower heat in the PDLsafer

Vertical Root Fractures Chan 199940% of VRFs occur in nonendo treated teeth, higher in molars than anteriors (for nonendo teeth) Cohen 2006pain found to be significant predictor, 40+ much more likely, radiograph not predictive Pitts 1983review paper, may be partial length of root, sx tx vs ext Meister84% of VRF due to condensation forces Fuss 2001VRFs60% had posts, 40% w/o posts, crowns dont prevent, Vrfs caused while prep and post placing Lertchirakan 2003small radius of curvature (sharper curvature), greater stress concentration Trope 1992glue 2 halves of tooth together(GI bone cement), 5 minutes out of socket, replanted after HBSS bath Walton 1984fxs make open pathway for irritants, 90% of fxs complete (full B-L dimension) Stains-- Stained with H&E (soft and hard tissue), Brown and Brenn or McCallums (bacteria), and Wilders reticulum (granulation tissue)

Current Lit April 2009 Alves 2009cryogenic DNA bacteria sampling to compare apical bacs to coronal bacs, high variability within tooth and between pts (same area of tooth), but some overlap from apical to coronal Hammad 2009voids in various obturation materials using uCT, GP has lowest gaps/voids, but resilon bonded Kirakozova 2009intracanal corticosteroids in replantation (dogs teeth) sig improve healing (high potency) Martos 2009major foramen average 0.69 mm from apex, deviated from center 60% of time Chen 2009DL roots in Taiwan (10%)shorter than DB root (about 2 mm), extreme curvature of DL Zadik 2009barodontalgiapain in scuba or flightif pulpitis or necrosis, need to treat and fill empty space Del Fabbro 2009PA surgery post op, sulcular vs papilla based incision, PBI better for pain, swelling, and meds Zehnder 2009Review of enterococcus in rc systemnot early invaders, may enter during or usually after tx from food

Root Resorption Gartner 1976Dx internal vs ext root resorptionInternal-smooth margins, attached to larger canal (can begin in crown), Extirregular border, smaller canal, detached from canal on angled radiograph Fuss 2003causes resorptioninternal inflammatory w/ vital pulp, External--pulpal infection (apical) tx w/RCT, pressure (apical or midroot) remove pressure, perio infection (cervical) clean and restore, external can also be vital in the case of invasive cervical resorption Frank 1987cervical resorption not invading pulp, how to treat, locate surgically expose, CaOH2 over pulp, restore Frank 1998tx of ext invasive resorptionidiopathic, vital pulp. RCT before debridement in case of pulp exp Smidt 2007 cerv resorption case--use of ortho extrusion plus surgical exposure, restoration and RCT to restore Nikolidakis 2008cerv resorptionusu asymp, idiopath, disc on x-ray. Case report, no RCT, just surg exp and rest De Souza 2009ortho movement in endo txd teeth, CaOH2 based sealer Baumrind 1996resorption can occur in adults during ortho movement, men>women Root Canal Morphology 1 Mannocci 2005isthmus in mes root of mand molars using uCTfound in majority of rootsup to 50% at 3 mm Appel 2002magnetic resonance (NMR) can show detailed 2D and 3D of canal anatomy, no rads, not used clin yet Kerekes/Tronstad 1977measurements of ant teeth, canal and root diameter, all can be round, some only to 1 mm Kerekes/Tronstad 1977molars, only buccal of max canals, and distal of mand molars, hard to do circle in molars Peters 2000uCT able to reliably reproduce 3D anatomy (but high radiation) Nielsen 2005mand incisors, M-D width small in pts 40+, only oval access needed (M-D width decrease w/age)

Deutsch 2005pulp chamber measurementspremolarsguy responsible for pulpout bur (7 mm short) Von Arx 2005endoscope, MB of max and M of mand highest isthmus (around 80%), D of mand molar around (36%)

Root Canal Morphology II Stropko 1999MB2 up to 73-93% (negotiated to 3-4 mm) (about half of full canals joined before foramen), more experience, higher rate of finding it, 1700 Hess 19172800 teeth, examine root canal anatomy w/pics, MB separates into 2 canals as teeth get older Kartal 1997M canals of mand 1st molars, MB more curved, more 2ndary curvature, (MB more likely to join ML) Green 1958canals round near foramen, more oval as go up, instrument to wide diameter of foramen (only gives averages in this paper, see Tronstad for actual measurements), P and mes of mand molars are more round Kuttler 1955foramen off center in older pts, constriction further in older pts (cementum apposition) Vertucci 1984different canal classification (max 2nd premolar most variable) Somma 2009Micro-CT for MB280%, very low sample (30), joined most coronal and midroot Kulild 199095% MB2 found, but most helpful in locating (included canals not instrumentable)

Prognosis of Surgical retreatment Tsesis 200691% success with modern tech (44% w/old style) (esp more success in molars), other factors found no effect of other factors on success (quality of filling, dx, etc.) Del Fabbro 2007Cochrane review, shows NS retreat, vs sx retreat, no difference (but used trad sx techniques, not applicable today) Wang 2004Toronto studysurg success 74% (but handfiled, loupes only, filled w/GP, unspecified depth of prep, not exclude fxs and other teeth not amenable to tx), smaller pa lesion, inadequate root filling more likely to heal. 17% had complication (crack in tooth, etc) Christiansen 2009retro prep and fill vs resect and smoothMTA: 96%, smoothed GP52% Von Arx 2001PA sx in molars, 88% (use endoscope) Taschieri 2006endoscope vs loupes, no diff between loupes and endoscope, also no diff in tooth location or if post Kim 199997% success rate for sx treatment, all tooth types, Super EBA, strict case selection Rubinstein and Kim 2002follow up on healed cases from 1999, 92% still healed, failures are fx, caries, perio Kim 2008healing of endo-perio lesions only 77.5%, 95.2% for endo only lesions w/ surgical tx

Prognosis of NSRCT Goldman 1972radiographs, 6/6 examiners agreed only 47%, 5/6 67%

Kerekes and Tronstad 1979longterm results of RCT, 2-3 visit, 5 yr follow up, 91% success, 5% failure, apical size not significant Bystrom Sundqvist 1986healing of PA lesions, 85% healed 2-5 yr f/u, size of lesion, more bacs (harder to disinfect)negative culture only means cant detect, still have Sjogren 1990overall 91%, no PAP better, PA on retreats only 62%, level of root filling, w/in 2 mm best, than over, then >2 mm short Friedman 2003PAI, 81% healed, 92% healed/healing. W/O PA lesion, better than w/ PA lesionmain prog factor (Toronto study)radiographic study Molven 200210-17 yr follow-up study, radiographic, suggests lesions can take a long time to heal, over-extension Salehrabi 2004epidemiological study, 97% retained for 8 yrs, 85% no crown, (unable to determine if PAP) Ng 2007meta-analysis31-96% success rate, variability due to criteria, low evidence for treatment factors

Restoration of Endodontically treated teeth Reeh, Messer 1989Endo only weakens tooth 5%, MOD restor weakens 63%, Occ access only may not need crown Huang, 1992dehydrated teeth more brittle, even though they are stronger (more likely to fx) Sedgley 1992no difference between vital and pulpless in brittleness Aquilino 2002teeth without crowns, 6 times more likely to be lost than teeth with crowns Chugal 2007PAP is more influential on tx outcome than whether or not crown was placed Ray, Trope 1995good crown more important than good RCTPoor rest: 44%, Poor endo: 67% success (compared to Tronstad study (different population(Sweden)) had opposite results Ricucci bergenholtz 2000no significant difference between open GP or restored, emphasizes quality of RCT fill and no patency (if had higher sample, would have been significant) Schwartz 2004-- Review of posts, glass fiber best because of modulus of elasticity same as dentin

Bergenholtz study on three teeth from hanging weights on there, pulp teeth have more proprioception than pulpless teeth, proprioceptors in pulp? Vire 1991endo failures of RCT teethonly 9% of failures are endodontic, 91% of failures are perio, restorative, etc. Current Literature 9/2009 Bryce JOE 2009NaOCl more effective than EDTA, CHX, at disrupting biofilms Richardson 2009information about preparing samples, light microscope best overall view, TEM and SEM more details Murayama 2009case report of auriculotemporal neuralgiarelieved by nerve block by tragus of ear for 6 mos De Paula-Silva 2009CBCT more sensitive for detecting PAP than PAs radiographs (.91 vs .77)

Subramanian 2009bacteria found in PAP 27/33 cases, DNA used to identify Simonton 2009In females, IAN closer to mand 1st molar, thinner mandibular bone. Thinner with age Huang 2009revascularization for immature apices w/ necrosis should be done before apexification (revasc can be done because of stem cells from papilla, pulp, pdl, or deciduous teeth) Iwaya was pioneer from Japan Zitzmann 2009review paper balanced, RCT vs implants, save tooth if possible to restore, many factors can influence decision,

Apical Size Delzangles 1988intracanal resorption found with PAPs, no difference whether cyst or granulomalarger apical size because of resorption (greater in apex than in coronal, Kasahara 1991showed larger apical sizes, showed less debris extrusion, adequate cleaning, except for ribbon shape and curved canals w/ stainless steel Ricucci and Langeland 1998most inflammation with overfilling, vital pulp stumphealed. Constriction best, short (>2) second, long is worst Wu wesselink 2000finish 2-3 mm short, leaves pulp stump and prevents overfilling in vital, in necrotic less than 2 mm from apex Coldero 2002bacteria reduction no diff between 35.04 and 20.04 w/NaOCl. Poorly designed, straight roots only, still at 35.04 1 mm short of WL Baugh 2005 review articleoverall result, larger apical size, cleaner canals, fewer bacteria, potential for success Weiger 2006to determine apical size, add 6-8 sizes from IAF Mickel 20074 sizes from IAF, bacteria found in SEM even when negative cultures Pecora 2008coronal flaring improves fit of IAF Retreatment Budd 2005measure heat increase during US post removal using thermal radiographyfound high temp increases above 20 deg C, w/ no coolant, air and water coolant reduced this (well above 10 deg C threshold for necrosis (Schwartz))no insulating factor measured Farzaneh 2004toronto studyoutcome of retx81% healed, 92 functional, (only 34% recall) Taintor 1983retreatment techniques and reasons, may be good to retx before sx to enhance success (Rud) Ruddle 2004retx reviewsays bacteria leakage is cause for apical pathoses Rawski 2003Survey for treatment options of endo txd teeth w/PAPendodontists and GPs agree Danin 1999compare surg vs non surg retxno diff stat, but surg had higher success (low sample, old tech) poor Fristad 2004retreatment long term 20-27 years (inc from 85-96% success from 10-17 to 20-27%), Molven and Halse did similar studies with initial RCTx Gorni and Gagliani 2004RCMR84%, RCMA-48%; success after 2 yr follow-up, (one-visit retx)

Current Lit Nov 2009 Bose, Hargreaves 2009outcome of regenerative endoTrimix better for dentin thickness, trimix and CaOH2 better for root length Al-Jadaa 2009ultrasonic activation superior to sonic activation for removal of pulp tissue from simulated lateral canals Treatment planningcurrent lit NOV 2009 DiFiore 2008endo vs implant for treatment planning, endo still preferred, implants more desirable for recent grads Friedman 2002post-treatment disease etiology and treatment (this term preferred to success/failure), nonsurg vs surg retreatdepends on individual situationnonsurg is primary choice, surg is compromised situation (Karabucak and Setzer similar paper 2007) Wang, Huang 2009thickening in revasc is due to ingrowth of cementum-like, bone-like or PDL-like tissue from apex

Endo-Perio lesionssame disease(bone lesion) from different origins, can be diagnostic challenge, one or the other, not usually both Seltzer 1978pulpal inflammation found in majority of perio diseased teeth, no negative control (no pulp necrosis until perio gets to apex) Rubach 1965accessory canals shown to contain perio granulation tissue in perio lesion, causing pulp involv Czarnecki 1979no correlation between pulpal involvement and perio involvement, perio NOT CAUSE pulp disease Mazur Massler 1969no correlation between perio dx and pulpal involvement, Bergenholtz 1978no path changes in pulp (only mild changes) with perio dx, after root planing, no pulp disease (no accessory canals found)(due to the predentin layer in vital pulp acting as a protection) Gutmann1978furcation canals prevalent 25-50%, unclear why not cause more problems??? Vertucci 197446% had furcation canals, higher rate in longer root trunk Kerekes 1990perio and endo flora are very similar, perio may be source of endo infection in intact teeth (hard to tell because they are so similar to start with) Kobayashi 1990more anaerobes in canal vs perio pockets, similar overall, perio may be source, but hard to tell because bacteria organize themselves in the canal a certain regardless of source (caries or perio) Trope 1988dark field microscopy to dx endo abscess vs perio abscessspirochetes in perio, no spiros in endo Ehnevid 1993PARL retards healing of periodontal lesions, infection in canal may leak out tubules and impair healing of perio w/tx Perio dx does not affect px of endo tx (sealed from inside, no bacteria ingress to PA lesion) If endo primarily, dont do root planing(wait and see if pocket heals, this way avoids removing good attachment)

Microbiology Kakehashi 1965no bacteria, no problem (21 germ free, 15 conventional rats) (still vital pulp at 8 days) Churnside 1958bacteria in dentin tubules (need to open apex larger or entomb bacteria), teeth not showing cultures may be due to location of sample taken (probably still have bacteria) Ando/Hoshino 1990bacteria present in dentinal tubules(up to 2 mm) similar to bacteria in deep layers of carious dentin Advent of anaerobic glovebox (better for culture of anaerobic bacs (contains N2 H2 and CO2) ( + cocci and rods fac aerobesstreptococcus, Actinomyces, and lactobacillussurface of caries, as caries gets deeper, get anaerobic component in deep layers (black pigmented Bacteroides species, now known as Porphyramonas (asacchrolytic) and Prevotella intermedia (saccharolytic)) Bergenholtz 2000review articlecomposites and pulp problemsmost likely due to bacterial leakage (shrinkage, removal of smear layer to open dentin tubules contribute) (dendritic cells are APC in dentinal tubules) Reeves and Stanley1966reparative dentin is pathologic, leaky, if caries gets here, game over Bergenholtz 1974when PA lesion present, bacteria is present in canals(85%, (sundqvist found 95%), if necrotic from trauma and no bacteria, no PARL Baumgartner 199168% of bacteria in apical 5 mm are anaerobicshows that apical area is selective for anaerobes (since coronal area is predominantly aerobic from saliva, etc) Sundqvist 1992ecology of RC flora (commensalism, antagonism(bacteriocins), oxidative potential (aerobic bacteria use up oxygen and select for anaerobic conditions) RCT is disruption of ecosystem to degree that it doesnt regroup Sundqvist 1979bacteria all caused PARLs, Bacteroides species caused apical abscesses. Sundqvist 1989Bacteroides are linked to acute apical abscess formation (16/22 w/ Bacteroides had abscess, 1/50 w/o bacteroides had abscess) Bystrompositive culture has lower success rate Sundqvist 1998retreatment bacteria were monomicrobial, positive culture during filling has lower success (74% of retreatments were successful Molander 1998retreatment, 69% facultative anaerobes, chloroform treated teeth had less growth (bacteria