The latest in endodontic research

Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research

Histologic examination of con-densing osteitis in cadaver specimens 

Green TL, Walton RE, Clark JM, Maixner D Journal of Dental Research (2013) 39(8): 977-9 


Aim: Condensing osteitis is a radiographic finding, but with no reported histologic investigations in humans. The objectives of this study were to evaluate and describe histologically condensing osteitis in human cadaver jaws. Patterns of bone formation and presence/absence and nature of inflammation were examined. 

Methodology: Specimens of mandibles and maxillas were obtained from cadavers and examined radiographically. Those periapical areas with characteristics of condensing osteitis were removed en bloc, decalcified, and processed for light microscopy. For comparison, specimens that showed normal apical radiographic anatomy were also removed for examination. 

Results: Normal apical regions showed an intact periodontal ligament and a thin layer of alveolar bone proper surrounded by cancellous bone with fatty marrow. In contrast, areas of condensing osteitis exhibited areas of inflammation or no inflammation, occupied by connective tissue. This area was bordered by a rim of varying widths of dense lamellar-type bone replacing the cancellous bone and marrow. 

Conclusions: The histologic changes of condensing osteitis consisted of the replacement of cancellous bone with compact bone. Areas of fibrosis and an inflammatory infiltrate were seen in some but not all specimens. All teeth exhibiting condensing osteitis had an identifiable etiology that likely resulted in degenerative pulp disease. 


Efficacy of preoperative ibuprofen on the success of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: a randomized clinical trial 

Noguera-Gonzalez D, Cerda-Cristerna BI, Chavarria-Bolanos D, Flores-Reyes H, Pozos-Guillen A International Endodontic Journal (2013) 46(11): 1056-62 


Aim: To evaluate the effect of preoperative oral ibuprofen (IBU) on the success of inferior alveolar nerve blocks (IANBs) with mepivacaine containing 1:100000 epinephrine for patients with symptomatic irreversible pulpitis (SIP).

Methodology: The present study was a double-blind, randomized, placebo-controlled clinical trial. The study included two study groups each consisting of 25 patients who exhibited symptomatic irreversible pulpitis of a mandibular posterior tooth. The patients presented prolonged moderate or severe pain (>10s) after cold testing and indicated their pain scores on a Heft-Parker visual analogue scale. The patients received outwardly identical capsules containing either 600 mg IBU (IBUg) or gelatin (placebo, PLAg) 1 hour before administration of IANB with 2% mepivacaine containing 1:100000 epinephrine. After 15 minutes, the anesthetic blockade was assessed by a three-step examination (lip numbness, positive/ negative response to cold testing, and clinical discomfort during endodontic access). IANB success was defined as the absence of pain during any of these evaluations. The data were analyzed using the chi-square test.

Results: All of the patients reported moderate or severe pain before the preoperative procedure. Statistically significant differences were observed between the IBUg and PLAg (P < 0.05); the success rates for the IANB were 72% (IBUg) and 36% (PLAg). 

Conclusions: Preoperative oral adminis-tration of IBU significantly improved the efficacy of IANB in patients with symptomatic irreversible pulpitis. 


Radiographic healing after a root canal treatment performed in single-rooted teeth with and without ultrasonic activation of the irrigant: a randomized controlled trial 

Liang YH, Jiang LM, Jiang L, Chen XB, Liu YY, Tian FC, Bao XD, Gao XJ, Versluis M, Wu MK, van der Sluis L Journal of Endodontics (2013) 39(10): 1218-25


Aim: The aim of this study was to compare the outcome of a root canal treatment with and without additional ultrasonic activation of the irrigant. 

Methodology: Single-rooted teeth with radiographic evidence of periapical bone loss were randomly assigned to two treatment groups. In both groups, syringe irrigation was performed, and in one group, the irrigant was also activated by ultrasound. Ten to 19 months after treatment, the teeth were examined by using periapical radiography (PA) and cone-beam computed tomography (CBCT). The area and volume of the periapical lesions were measured, and the outcome was presented in four categories: absence, reduction, or enlargement of the radiolucency, or uncertain. Lesions were classified as reduced or enlarged when the radiolucency changed in size by 20% or more. 

Results: The recall rate was 82%, and 84 teeth were analyzed. CBCT detected significantly more postoperative lesions than PA (P = .038), but the percentages of absence and reduction of the radiolucency together revealed by CBCT and PA were similar (P = .383). The CBCT results showed that absence of the radiolucency was observed in 16 of 84 teeth (19%) and reduction of the radiolucency in 61 of 84 teeth (72.6%), but there was no significant difference between the results of the two groups (P = .470). Absence and reduction of the radiolucency together were observed in the ultrasonic group in 39 of 41 teeth (95.1%) and in the syringe group in 38 of 43 teeth (88.4%). 

Conclusions: Root canal treatments with and without additional ultrasonic activation of the irrigant contributed equally to periapical healing. 

Retrospective follow-up assess-ment of prognostic variables associated with the outcome of periradicular surgery 

Villa-Machado PA, Botero-Ramirez X, Tobon-Arroyave SI International Endodontic Journal (2013) 46(11): 1063-76 


Aim: To investigate, retrospectively over a 1- to 16-year follow-up period, the strength and independence of the association of different patient-, tooth- and surgery-related prognostic variables with the outcome of periradicular surgery. 

Methodology: The study cohort included 171 teeth in 154 subjects. Clinical and radiographic measures along with the follow-up period were used to determine the healing outcome. For statistical analysis, results were dichotomized into healed/healing versus asymptomatic function/persistent disease cases. The association between candidate prognostic variables and asymptomatic function/persistent disease was analyzed individually and adjusted for confounding using a multivariate binary logistic regression model. 

Results: The percentage of success (healed/healing cases) was found to be 83.6%, whereas the percentage of failure (asymptomatic function/persistent disease cases) was found to be 16.4%. While univariate analysis revealed a positive association of the presence of preoperative signs/symptoms, unsatisfactory quality of the coronal restoration, pronounced root-end resection bevel, and inadequate quality of root-end filling with asymptomatic function/persistent disease, after multivariate binary logistic regression analysis only the unsatisfactory quality of the coronal restoration and inadequate quality of root-end filling were strongly and independently associated with disease status. Confounding and interaction effects between candidate prognostic variables were noted. 

Conclusion: The findings of this study suggest that while the quality of both the coronal restoration and the root-end filling might be the foremost prognostic variables in periradicular surgery, there are synergistic biological interactive and mutually confounding effects with respect to root-end resection bevel and preoperative signs and/or symptoms that may be also associated with an increased proportion of failures after periradicular surgery. 


Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: a longitudinal trend analysis 

Shah AC, Leong KK, Lee MK, Allareddy V Journal of Endodontics (2013) 39(9): 1104-10 


Aim: Root canal therapy is a highly successful in-surgery treatment and preventive measure against periapical abscesses. Left untreated, periapical abscesses can have serious consequences that can lead to hospitalization. This study observes the trends of hospitalizations attributed to periapical abscesses. 

Methodology: A retrospective analysis of the Nationwide Inpatient Sample (years 2000-2008) was used; we selected cases with a primary diagnosis of a periapical abscess with/without sinus involvement. The demographic characteristics and outcomes were examined. Each individual hospitalization was the unit of analysis. 

Results: During the 9-year study period, a total of 61,439 hospitalizations were primarily attributed to periapical abscesses in the United States. The average age was 37 years, and 89% of all hospitalizations occurred on an emergency/urgent basis. The mean length of stay was 2.96 days, and a total of 66 patients died in hospitals. Medicare, Medicaid, and private insurance plans paid for 18.7%, 25.2%, and 33.4% of hospitalizations, respectively. Uninsured patients accounted for 18.5% of hospitalizations. Significant predictors that influenced both hospital charges and length of stay included age, race, insurance status, a periapical abscess with sinus involvement, geographic region of country, the Charlson comorbidity index, and the year of study (P < .05). 

Conclusion: The current study highlights the increasing burden of hospitalization of patients with periapical abscesses over a 9-year study period from 2000 to 2008. The high-risk groups likely to seek a hospital setting for the treatment of periapical abscesses were identified as were groups associated with higher hospital charges and a longer length of stay. 


The influence of bone tissue deficiency on the outcome of endodontic microsurgery: a prospective study 

Song M, Kim SG, Shin SJ, Kim HC, Kim E Journal of Endodontics (2013) 39(11): 1341-5 


Aim: This study assessed the influence of deficiencies of the periapical and marginal bone tissue on clinical outcomes after endodontic microsurgery. 

Methodology: Data were collected from the Microscope Center of the Department of Conservative Dentistry at the Dental College of Yonsei University, Seoul, South Korea, between August 2004 and March 2011. In total, 199 teeth that required endodontic surgery were included in the study. During the surgical procedure, deficiencies of the periapical and marginal bone tissue were measured immediately before the flap was repositioned. The patients were recalled 6 months and 1 year after the surgical procedure to assess the clinical and radiographic signs of healing. The Student’s t-test or the Mann-Whitney U test and logistic regression were performed to evaluate the parameters. Significant associations between the outcome and all the evaluation parameters were analyzed using the Pearson chi-square test or the Fisher’s exact test with a significance level of 0.05. 

Results: A recall rate of 67.8% (135/199 teeth) was obtained. The height of the buccal bone plate was the only significant predictor (P = .040) of the healing outcome, suggesting that teeth with a buccal bone plate > 3 mm presented a higher success rate than teeth with a buccal bone plate that was 3 mm high (94.3% versus 68.8%, P < .001) 

Conclusion: These data suggest that a favorable prognosis can be expected when teeth are covered with a buccal bone plate that is > 3mm in height regardless of the amount of marginal bone loss. 


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