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Dental Tribune Pakistan Edition No. 6, 2015

12 DENTAL TRIBUNE Pakistan Edition November 2015 ONTE DA CAPARICA, Portugal: Menopause is associated with a number of oral changes, including a higher risk of inflammation, a lower salivary flow rate, as well as alteration of salivary composition and primary osteoporosis affecting the jawbones. By comparing periodontitis in pre- and postmenopausal women, a team of researchers has now evaluated how menopausal changes affect the severity of periodontal disease and tooth loss. In order to measure the impact of menopause on women's oral health, researchers from the Center for Interdisciplinary Research Egas Moniz in Monte da Caparica, together with colleagues from the University of Granada in Spain, studied 68 menopausal women and 34 premenopausal women, all suffering from chronic periodontitis. Oral and periodontal parameters, such as number of teeth, plaque index, presence of calculus, probing depth, bleeding on probing, gingival recession and attachment loss, were recorded in a clinical examination conducted by a periodontologist. The researchers further collected demographic data, medical and gynaecological history, and oral health habits of the participants. When comparing pre- and postmenopausal women, the scientists did not find significant differences for periodontal parameters and tooth loss. Although the analyses showed that the number of teeth was significantly lower in postmenopausal women, the difference was not statistically significant after adjusting the results for age, smoking and plaque index. Against this background, the researchers concluded that menopause does not appear to influence the severity of periodontal disease and tooth loss significantly. Instead, other factors may exert a greater influence on the progression of periodontal disease rather than menopause itself. Owing to the multitude of factors involved, they further reasoned that that the relationship between menopause and periodontal disease is difficult to establish because any relationship found would always be less significant than other well-known risk factors of periodontal disease. Study evaluates impact of menopause on periodontal disease and tooth loss M Menopause is associated with a number of oral changes. Researchers have now investigated how the condition affects the severity of periodontal disease and tooth loss DT International Photoacoustic shockwave with irrigant debrides areas files can't reach uccessful endodontic treatment depends upon maximal debridement and disinfection of the entire root canal system. The root canal system must be shaped to a convenience form that permits adequate cleaning and disinfection by elimination of microbes.1 The literature is clear that as much as 35 percent or more of the root canal sys- tem remains untouched by any instrumentation technique. Essentially no filing technique allows instruments to sculpt all canal walls and remove infected dentin.2 To decrease the bacterial load and achieve better debridement, irrigation protocols are used prior to obturation. The efficacy of the irrigants to decontaminate canal walls has seen significant improvements recently. Both negative and positive apical pressure irrigation techniques have been surpassed by ultrasonically activated irrigants, photo-activated disinfection and laser-activated irrigants in their ability to improve cleanliness of the canal system.3,4 In particular, the Er:YAG (Lightwalker Er:YAG& Nd:YAG dental laser, National Dental Inc., Barrie, Ontario) has shown to be effective at removing debris and the smear layer from canal walls.3,4 A final ap- plication of the Er:YAG laser to the sodium hypochlorite already present within the canal, after standardized instrumentation, can result in improved cleaning of the canal walls with a higher quantity of open tubules (Fig. 1) compared with results without the use of the laser. 3,4 A new applicationoflaser-activated irrigation (LAI), Photon Induced Photoacoustic Streaming (PIPS™), uses an Erbium 2,940 laser to pulse extremely low energy levels of laser light to generate a photoacous- tic shockwave, which streams irrigants throughout the entire root canal system.5 Using extremely short bursts of peak power, laser energy is directed down into the canal and the action actively pumps the tissue debris out of the canals while cleaning, disinfecting and sterilizing each main canal, lateral canals, dentinal tubules and canal anastomoses to the apex. This movement of irrigant is achieved without the need to place the radial and stripped laser tip (PIPS tip, Fig. 2) into the canal itself, unlike with other conven- tional hand and ultrasonic systems. The tip is held stationary in the coronal aspectof theaccess prepara- tion only. With the irrigant occupy- ing the entire root canal system, the shockwave travels in all directions during activation and effectively debrides and removes organic tis- sue remnants. Through this laser- activated turbulent flow phenomenon, clinicians following the PIPS protocol are not required to place the tip into each canal, thus eliminating the need to en- large and remove more tooth structure to deliver standard needle irrigation to the smaller and more delicate apical anatomy, commonly seen in the apical one third. The results are canal convenience forms that are more conservative, minimally invasive and biomimetic (Fig. 3). Unlike other laser-activated irrigant techniques, PIPS is not a thermal event, but rather subablative. Properly executed, PIPS creates turbulent photoacoustic agi- tation of irrigants that move fluids three dimensionally throughout the root canal system even as far as the apical terminus, distant from the radial stripped tip location. By activating the tip in the access cavity and outside the root canal system, the extremely low energy needed to activate the unique PIPS tip (20 mJs or less) is below the threshold of ablation for dentin. Ledg- ing and thermal effects that have plagued the widespread use of other laser systems is completely avoided at the energy levels used by the PIPS technique.5,6 Recent testing, performed at the Uni- versity of Tennessee by Dr. Adam Lloyd, chairman of the department for endodon- tics, objectively confirmed the improved cleaning and debridement of organic and inorganic tissue left by instrumentation. Microcomputed tomography scans were used to assess before-and-after volumet- ric change in the internal intaglio of lower first molars treated with PIPS protocol (Fig. 4). Sequential slicing beginning at 6 mm from the apex and moving down to the last 2 mm demonstrated that all slice images showed significant improvements after PIPS. Because PIPS is a less technique- sensitive, minimally invasive and time-reducing method - and has Continued on page 14 Fig. 1: Left, apical third of root treated with PIPS shows clean surfaces, no thermal damage. Right, SEM of apical third shows clean dentin tubules post PIPS with no thermal damage. Photos/Provided by Enrico Divito, DDS Fig. 2: Left, tapered and stripped PIPS tip used for laser-activated irrigation. Right, position of laser tip in PIPS technique: in the pulp chamber and not in canal Fig. 3: Left, pre-treatment. Right, post-treatment obturation after PIPS. Tooth instrumented to a #25/06 taper. Note theconservative convenience form maintaining more original anatomy of root canal system and reducing the need to use larger file sizes, conserving more dentin tooth structure. Fig. 4: Left, mandibular molar canal system shows isthmus before (A, red canal) PIPS laser-activated irrigation. Areas of organic tissue and debris from instrumentation completely eliminated, as highlighted by post-PIPS image (B, green canal). Right, mandibular molar with canal preparation to a size 30/.04 (A, green canal) obturated with nano-particle BC Sealer (Brasseler USA, Savannah, Ga.) and single cone obturation (B, blue). S By Enrico Divito, DDS

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