The latest in endodontic research

Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research Effect of ibuprofen on masking endodontic diagnosis

Read JK, McClanahan SB, Khan AA,Lunos S, Bowles WR. Journal of Endodontics (2014) 40(8): 1058-62


Aim: An accurate diagnosis is of upmost importance before initiating endodontic treatment; yet there are occasions when the practitioner cannot reproduce the patient’s chief complaint because the patient has become asymptomatic. Ibuprofen taken beforehand may “mask” or eliminate the patient’s symptoms.In fact, 64%-83% of patients with dental pain take analgesics before seeing a dentist. The purpose of this study was to examine the possible “masking” effect of ibuprofen on endodontic diagnostic tests.
Methodology: Forty-two patients with endodontic pain underwent testing (cold, percussion, palpation, and bite force measurement) and then received either placebo or 800mg ibuprofen. Both patients and operators were blinded to the medication received. One hour later, diagnostic testing was repeated and compared with pretreatment testing.
Kishor GulabivalaResults: Ibuprofen affected testing values for vital teeth by masking palpation 40%, percussion 25%, and cold 25% on affected teeth with symptomatic irreversible pulpitis and symptomatic apical periodontitis. There was no observed masking effect in the placebo group on palpation, percussion, or cold values. When non-vital teeth were included, the masking effect of ibuprofen was decreased. However, little masking occurred with the bite force measurement differences.
Conclusion: Analgesics taken before the dental appointment can affect endodontic diagnostic testing results. Bite force measurements can assist in identifying the offending tooth in cases in which analgesics “mask” the endodontic diagnosis.

A comparative analysis of magnetic resonance imaging and radiographic examinations of patients with atypical odontalgia

Pigg M, List T, Abul-Kasim K, Maly P, Petersson A. Journal of Oral & Facial Pain and Headache (2014) 28(3): 233-42


Aim: To examine the occurrence of magnetic resonance imaging (MRI) signal changes in the painful regions of patients with atypical odontalgia (AO); and the correlation of such findings to periapical bone defects detected with a comprehensive radiographic examination including cone beam computed tomography (CBCT).
Methodology: A total of 20 patients (mean age 52 years, range 34-65) diagnosed with AO participated. Mean pain intensity (+ standard deviation) was 5.6 + 1.8 on a 0-10 numerical rating scale, and mean pain duration was 4.3 + 5.2 years. The inclusion criterion was chronic pain (greater than 6 months) located in a region with no clear pathologic cause identified clinically or in periapical radiographs. In addition to a clinical examination and a self-report questionnaire, the assessments included radiographic examinations (panoramic, periapical, and CBCT images) and an MRI examination. Changes in MRI signal in the painful region were recorded. Spearman’s rank correlation between radiographic and MRI findings was calculated.
Results: Eight of the patients (40%) had MRI signal changes in the pain region. The correlation to radiographic periapical radiolucencies was 0.526 (P=0.003). Of the eight teeth displaying changes in MRI signal, six showed periapical radiolucency in the radiographs.
Conclusion: MRI examination revealed no changes in the painful region in a majority of patients with AO, suggesting that inflammation was not present. MRI findings were significantly correlated to radiographic findings.

Incidence and characteristics of acute referred orofacial pain caused by a posterior single tooth pulpitis in an Iranian population

Hashemipour MA, Borna R. Pain Practice (2014) 14(2): 151-7


Aim: This study was designed to evaluate incidence and characteristics of acute referred orofacial pain caused by a posterior single tooth pulpitis in an Iranian population.
Methodology: In this cross-sectional study, 3,150 patients (1,400 males and 1,750 females) with pain in the orofacial region were evaluated via clinical and radiographic examination to determine their pain source. Patients completed a standardized clinical questionnaire consisting of a numerical rating scale for pain intensity and chose verbal descriptors from a short form McGill questionnaire to describe the quality of their pain. Visual analog scale (VAS) was used to score pain intensity. In addition, patients indicated sites to which pain referred by drawing on an illustration of the head and neck. Data were analyzed using chi-square, Fisher’s exact, and Mann Whitney tests.
Results: A total of 2,120 patients (67/3%) reported pain in sites that diagnostically differed from the pain source. According to statistical analysis, sex (P=0.02), intensity of pain (0.04), and quality (P=0.001) of pain influenced its referral nature, while age of patients and kind of stimulus had no considerable effect on pain referral (P>0.05).
Conclusion: The results of the present study show the prevalence of referred pain in the head, face, and neck region is moderately high. Therefore, in patients with orofacial pain, it is essential to carefully exam before carrying out treatment that could be inappropriate.

Incomplete caries removal: a systematic review and metaanalysis

Schwendicke F, Dorfer CE, Paris S. Journal of Dental Research (2013) 92(4): 306-14


Aim: Increasing numbers of clinical trials have demonstrated the benefits of incomplete caries removal, in particular in the treatment of deep caries. This study systematically reviewed randomized controlled trials investigating one- or two-step incomplete compared with complete caries removal.
Methodology: Studies treating primary and permanent teeth with primary caries lesions requiring a restoration were analyzed. The following primary and secondary outcomes were investigated: risk of pulpal exposure, postoperative pulpal symptoms, overall failure, and caries progression. Electronic databases were screened for studies from 1967 to 2012. Cross-referencing was used to identify further articles. Odds ratios (OR) as effect estimates were calculated in a random-effects model.
Results: From 364 screened articles, 10 studies representing 1,257 patients were included. Meta-analysis showed risk reduction for both pulpal exposure (OR [95% CI] 0.31 [0.19-0.49]) and pulpal symptoms (OR 0.58 [0.31-1.10]) for teeth treated with one- or two-step incomplete excavation. Risk of failure seemed to be similar for both complete and incomplete excavation, but data for this outcome were of limited quality and inconclusive (OR 0.97 [0.64-1.46]).
Conclusion: Based on reviewed studies, incomplete caries removal seems advantageous compared with complete excavation, especially in proximity to the pulp. Evidence levels are currently insufficient for definitive conclusions because of high risk of bias within studies.

Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars

Chailertvanitkul P, Paphangkorakit J, Sooksantisakoonchai N, Pumas N, Pairojamornyoot W, Leela-Apiradee N, Abbott PV . International Endodontic Journal (2014) 47(9): 835-42


Aim: To compare the treatment outcomes when calcium hydroxide and mineral trioxide aggregate are used for partial pulpotomy in cariously exposed young permanent molars in a randomized control trial.
Methodology: Eighty-four teeth in 80 volunteers (aged 7 to 10 years) with reversible pulpitis and carious pulp exposures were randomly divided into two groups. Exposed pulps were severed using high-speed round burs until fresh pulp was seen. Cavities were irrigated with 2.5% sodium hypochlorite, and the pulp exposures were photographed and measured. Dycal® or ProRoot® MTA was placed on the pulp. Vitremer™ was placed over the material until the remaining cavity was 2 mm deep; amalgam was then placed. Teeth were evaluated for clinical symptoms and radiographic periapical changes after 24 hours, 3 months, 6 months, 1 year, and 2 years. Mean survival times and incidence of extraction were calculated using exact binomial confidence intervals.
Results: The median survival time for both ProRoot MTA and Dycal groups was 24 months. Three teeth had unfavorable outcomes with the incidence rate of 0.20/100 tooth-months with ProRoot MTA (95% CI: 0.02-0.71) and 0.11/100 toothmonths with Dycal (95% CI: 0.001-0.60). The incidence of unfavorable outcomes was 0.05/100 (95% CI: 0.001 0.30) and 2.38/100 (95% CI: 0.29-8.34) tooth-months in teeth with small (5 mm2) pulp exposure areas, respectively.
Conclusion: Partial pulpotomy in teeth of young patients with reversible pulpitis, either using ProRoot MTA or Dycal, resulted in favorable treatment outcomes for up to 2 years. The incidence of unfavorable outcomes tended to be higher in teeth with pulp exposure areas larger than 5 mm2.

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