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Dental Tribune Middle East & Africa No.1, 2017

Dental Tribune Middle East & Africa Edition | 1/2017 ENDO TRIBUNE A2 The canal lengths were determined electronically with an Apex NRG apex locator (Medic NRG) using a size10k-flexfile(Dentsply-Maillefer) and shaped with BioRace (FKG Den- taire) BRO, BR1, BR2, BR3 and BR4 se- quentially to length irrigating with 3ml3%NaOClbetweeneachfile. After shaping, the root canals were cleaned with the Irrisafe Passive Ul- trasonicIrrigatingtip(ActeonUK)for 3 cycles of 20 seconds per canal re- plenishingtheirrigantbetweeneach cycle (Figure 4). Following which a soak was performed with 17 % EDTA (FKG) for 60 seconds delivered as before, and the final flush was made with3%NaOCl. Obturation was performed with To- talFill BC Sealer (FKG Dentaire) and size 35/.04 TotalFill BC Points, gutta percha cones impregnated with bi- oceramic. The cones were sized to fit each individual canal with good tug back in canals still wet with 3% sodium hypochlorite. The canals were dried with 35/.04 paper points (FKG), the cones coated with Total- Fill BC Sealer (Figure 5) and seated into the canals, withdrawn half way and reseated. The coronal portion of the cones were then removed with a heated instrument and packed gen- tly into the canal orifices (Figure 6 and Figure 7), and the access cavity cleaned by washing with a 3-in-1 tri- plesyringe. AnamalgamNayyarcorewasplaced, the dam removed and the occlusion checked. A final radiograph was taken (Figure 8) showing a well-con- densed root canal filling in all 3 ca- nals extending to length with a well- adaptedcoronalrestoration. Discussion The diagnosis of acute symptomatic irreversible pulpitis can sometimes be difficult, however by repeating the patients’ sensitivity to cold it soon became apparent which tooth was causing the trouble. The best way to treat a pulpitis is to remove theinflamedtissueasquicklyaspos- sible; antibiotics have no place, as thereisn’taninfection. Thenarrownessofthecanalsandthe severe curvature on the mesial root can make instrumentation challeng- ing. Sclerosis of canals takes place as a result of deposition of secondary dentine and progressive deposition of calcified masses that originate in the root pulp (Bernick & Nedelman 1975), and true pulp stones are made ofdentineandlinedbyodontoblasts (Johnson&Bevelander1956). Pulp stones are common, ranging from 4% of first molars Chandler et al. 2003 to 78% of primary molars Arys et al. 1993, and vary in size from 50 μm in diameter to several milli- metres when they may occlude the entire pulp chamber (Sayegh & Reed 1968). Therefore if the pulp stone is not removed, the natural canal anatomy may be obscured making shaping and disinfection difficult or impossible. Shaping canals is essential to endo- dontic success (Schilder 1974), but nickel titanium files are prone to cy- clic fatigue fracture and torsional tip fracture (Bergmans et al. 2001). Glide pathcreationisessentialwhenshap- ing with rotary Nickel-Titanium in- strumentstopreventthesefractures (Patiño et al. 2005) and mechanical glide path preparation with Scou- tRace files has been shown to be su- perior to stainless steel hand files in maintaining the canal shape (Ajuz et al.2013). As always, shaping is only part of the process of canal debridement (Byström & Sundqvist 1981), shap- ing and irrigating with 0.5% NaOCl significantly reduced bacterial load compared to shaping and irrigating with saline (Byström & Sundqvist 1983) and irrigation with NaOCl and EDTA has been demonstrated to cre- ate cleaner canal walls (Baumgartner & Mader 1987). Additionally, the use of ultrasonic irrigant activation re- movesmoredebrisfromcanalsthan syringe irrigation alone. (Burleson et al.2007). Root canal preparation to a size 35 allows better irrigant flow and ex- change (Boutsioukis et al. 2010), creates space for the ultrasonic tip to vibrate thereby reducing con- tact dampening (Ahmad et al. 1992) which in turn improves the acoustic micro-streaming (Ahmad et al. 1987) and increases the reduction in bacte- rial load (Bhuva et al. 2010; Carver et al.2007). Bioceramics (tricalcium silicates) have many uses in endodontics, taking advantage of their ability to form an apatite layer (bioactiv- ity) and penetrate dentine tubules. Mineral Trioxide Aggregate (the first bioceramic) is currently employed for several endodontic techniques including root-end filling, direct pulp capping, repair of perforations and providing an apical seal in teeth with open apices (Parirokh & Tora- binejad 2010). The literature reports several favourable properties of re- cently developed bioceramic sealers as root canal filling materials includ- ing good sealing ability (Zhang et al. 2009a,b), biocompatibility (Zhang et al. 2010,), antibacterial activity (Zhang et al. 2009a,b) and adhesion todentine(Nagasetal.2012).Itissup- plied in premixed, injectable form and sets in the presence of natural canalmoisture(Loushineetal.2011). When sealer is placed on the cone and initially seated the canal walls are coated, withdrawing it and re- seating it then allows more sealer to be placed and dispersed within the complex canal ramifications. It is imperative that the cones fit well with tug back or are customized to improve apical control (van Zyl 2005)andthathydraulicpumpingis not employed. With this technique, the GP cone acts as a carrier and the sealer is employed to fill the entire canal space, thus providing the de- sired three-dimensional seal (Schil- der1967). Conclusions Pulp stones are a common occur- rence and act as a barrier to suc- cessful endodontic treatment Me- chanical glide path preparation with ScoutRace files allows predictable canalpreparation. Single cone obturation is possible withthissealer. - Further information on these tech- niques, instruments and materials is availableonwww.fkg.ch References Ahmad M, Pitt Ford TR, Crum LA (1987). Ultrasonic debridement of root canals: acoustic streaming and its possible role. Journal of Endodon- tics14,486-93. Ahmad M, Roy RA, Kamarudin AG Observations of acoustic streaming fields around an oscillating ultrason- icfile.EndododonticDentalTrauma- tology19928,189-94 Ajuz NC1, Armada L, Gonçalves LS, Debelian G, Siqueira JF Jr Glide path preparation in S-shaped canals with rotary pathfinding nickel-titanium instruments. Journal of Endodontics. 2013 Apr;39(4):534-7. doi: 10.1016/j. joen.2012.12.025.Epub2013Feb12. ArysA,PhilippartC,DourovNMicro- radiography and light microscopy of mineralization in the pulp of un- demineralized human primary mo- lars. 1993 Journal of Oral Pathology andMedicine22,49–53. Baumgartner JC, Mader CL. A scan- ning electron microscopic evalua- tionoffourrootcanalirrigationregi- mens. Journal of Enododontics 1987 Apr;13(4):147-57. Bergmans L, Van Cleynenbreugel J, WeversM,LambrechtsP.Mechanical root canal preparation with NiTi ro- tary instruments: rationale, perfor- mance and safety. Status report for the American Journal of Dentistry. American Journal of Dentistry. 2001 Oct;14(5):324-33. BernickS,NedelmanCEffectofaging onthehumanpulp.Journalof Endo- dontics1975(1),88–94. Bhuva B, Patel S, Wilson R, Niazi S, Beighton D, Mannocci F (2010). The effectiveness of passive ultrasonic irrigation on intraradicular Entro- coccus faecalis biofilms in extracted single rooted human teeth. Interna- tional Endodontic Journal 43, 241- 250. BoutsioukisC,GogosC,VerhaagenB, VersluisM,kastrinakisE,vanderSlu- isL(2010).Theeffectofapicalsizeon irrigant flow in root canals evaluated using an unsteady Computational FluidDynamicsModel.International EndodonticJournal,43,874-881. BurlesonA,NussteinJ,ReaderA,Beck M (2007). The in-vivo evaluation of hand/rotary/ultrasound instrumen- tation in necrotic, human mandibu- lar molars. Journal of Endodontics. 33, 782-7 Byström A, Sundqvist G (1981). Bacteriological evaluation of the efficacy of mechanical root canal instrumentationinendodonticther- apy. Scandinavian Journal of Dental Research89,321-8. ByströmA,SundqvistG(1983).Bacte- riologicevaluationoftheeffectof0.5 percent sodium hypochlorite in en- dodontic therapy. Oral Surgery Oral Medicine Oral Pathology 55(3):307-12 CarverK,NussteinJ,ReaderA,BeckM (2007). In-vivo antibacterial efficacy of ultrasound after hand and rotary instrumentation in human mandib- ular molars. Journal of Endodontics. 33,1038-43 Chandler NP, Pitt Ford TR, Monteith BD Coronal pulp size in molars: a study of bitewing radiographs. Inter- nationalEndodonticJournal200336, 757–63. Johnson PL, Bevelander G Histogenesis and histo- chemistry of pulpalcalcification.JournalofDental Research195635,714–22. Loushine BA, Bryan TE, Looney SW et al. (2011) Setting properties and cy- totoxicity evaluation of a premixed bioceramic root canal sealer. Journal ofEndodontics37,673–7. Nagas E, Uyanik MO, Eymirli A. et al. (2012) Dentine moisture conditions affecttheadhesionofrootcanalseal- ers.JournalofEndodontics38,240–4. Parirokh M, Torabinejad M Mineral trioxide aggregate: a comprehensive literature review – Part III: clinical applications, drawbacks, and mecha- nism of action. Journal of Endodon- tics201036,400–13. Sayegh FS, Reed AJ Calcification in the dental pulp. Oral Surgery, Oral Medicine, Oral Pathology 1968 25, 873–82. Schilder H (1967). Filling root canals in three dimensions. Journal of En- dodontics32,281-90. Schilder H Cleaning and Shapinng the Root Canal Dental Clinical of NorthAmerica1974Vol18No.2 Schnieder S A comparison of ca- nal preparations in straight and curved root canals 1971 Aug Vol 32 (2), 271–275 van Zyl SP, Gulabivala K, Ng YL. Effect of customization of master gutta-percha cone on apical control of root filling using different techniques: an ex vivo study. Inter- national endodontic Journal 2005 Sep;38(9):658-66. ZhangH,ShenY,RuseND,Haapasalo M Antibacterial activity of endodon- tic sealers by modified direct contact test against Enterococcus faecalis. Journal of Endodontics 2009a 35, 1051–5. ZhangW,LiZ,PengBAssessmentofa new root canal sealer’s apical sealing ability. Oral Surgery Oral Medicine Oral Pathology Oral Radiology & En- dodontology2009b107,79–82. Zhang W, Li Z, Peng B Ex vivo cyto- toxicity of a new calcium silicate- based canal filling material. 2010 International Endodontic Journal 43, 769–74. Fig.2a Fig.2b Fig.4 Fig.5 Fig.6(Buccals) Fig.7(Palatal) Fig.8 Fig.3 ◊PageA1 Prof.JamesPrichard,UK BDS(ULond);MSc(ULond);LDSRCS(Eng;MF GDP(UK);FIADFE(USA); FHEA(UK); FBARD (UK) VisitingProfessorandProgrammeLeader, MClinDent in Endodontology at BPP Uni- versity working with the City of London DentalSchool. Professor Prichard is a renowned teacher in Endodontics, delivering hands on courses, lectures and seminars through- out the UK and overseas. He has held the postsofAssociateClinicalTeacher,Clinical TeachingFellowandClinicalSupervisorin Endodontics on the Masters Programme atTheUniversityofWarwickpriortojoin- ing BPP University in London as Visiting Professor and Programme leader for the MClinDent in Endodontology. He has supervised postgraduate students in En- dodontics including several dissertations and theses. He has published in the scien- tific journals including the International Endodontic Journal, The British Dental Journal and Endodontic Practice. He has lecturedat conferencesincluding theBrit- ish Dental Association annual meeting and the British Academy of Restorative Dentistry. He is a Key Opinion Leader for several endodontic companies and has demonstrated the latest advances in endodontic technology for Schottlander and FKG Dentaire at the Dental Show- cases and Dentistry Show in the UK since 2004. He gained his Masters Degree (MSc) in Restorative Dental Practice with distinction for his dissertation which he completed at The Eastman Dental Insti- tute in London. He is a Fellow of the In- ternational Academy of Dental Facial Es- theticsinNewYork,aFellowoftheHigher Education Academy and a Fellow of the BiritishAcademyofRestorativeDentistry. FKGDentaireSA AlexandreMULHAUSER MiddleEast,AfricaandIndiaDirector a.mulhauser@fkg.ch M+971527658888 SkypeIDmulhauser.alexandre Medicine, Oral Pathology 196825,

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