PUBLISHED IN DUBAI www.dental-tribune.me November-December 2018 | No. 6, Vol. 8 Direct pulp capping as a conservative procedure to maintain pulp vitality By Dr. Jenner Argueta, Guatemala From a completely optimistic point of view, the ultimate goal for every dentist performing a restora- tive and/or endodontic procedure should be to maintain the pulp vi- tality and functionality of the tooth without any discomfort for the pa- tient. The pulp tissue is needed to provide nutrition, innervation and immunocompetence, with these acting as a defence mechanism and alerting to the presence of any exter- nal aggression.1 The pulp tissue may be exposed to the oral environment as a result of dental caries or by mechanical means when performing restorative or prosthetic procedures. Two possi- ble treatment options in these types of cases are root canal therapy and tooth extraction; the former proce- dure is a good choice, whereas the latter should be avoided at all costs in order to maintain the patient’s oral health and natural function.2–4 A third alternative in the case of pulp exposure is to use conservative vital pulp therapy procedures, which in- clude direct pulp capping, indirect pulp capping where the pulp is not fully exposed, and partial or total pulpotomies; this way, it is possible to maintain the vitality of the tooth, the nociceptive function and the body’s self-defence system. Thanks to the points mentioned previously, among others, it has been shown that teeth with no root canal therapy survive longer than those that have been treated endodontically.2, 5, 6 Next, we present two clinical cases in which the pulp tissue was exposed mechanically when carious tissue was removed. In both cases, it was managed to maintain the pulp vital- ity of the affected teeth by means of direct pulp capping. The vital pulp capping protocol suggested in this article is presented in the ﬁrst case. The second case describes a treat- ment performed with long-term follow-up, where full formation of calciﬁed tissue below the capping material could be observed by means of radiography. The treatment pro- tocol was similar in both cases. Clinical Case 1 The 24-year-old patient attended the dental clinic with transient pro- voked pain in tooth #19 (Fig. 1). The diagnosis was reversible pulpitis. The carious tissue was removed under complete isolation, producing two incidences of pulp exposure, with minimal bleeding (Fig. 2). Bleeding was stopped by applying pressure for 10 seconds using a cotton swab dampened with a sterile saline so- lution. The cavity was disinfected with 2.5% sodium hypochlorite (Fig. SUBSCRIBE NOW https://me.dental-tribune.com/e-paper/ issn 2193-4673 • Vol. 14 • Issue 4/2018 roots 4/18 international magazine of endodontics opinion 3-D endodontic instrumentation: Revision of a historical protocol industry report Strategies for the treatment of extremely curved root canals case report Management of referred pain 3), and then white mineral trioxide aggregate (MTA, Produits Dentaires) was placed as a direct pulp capping material (Fig. 4). To ensure that the MTA was placed accurately, the MAP System micro-applicator for den- tal materials (Produits Dentaires) ÿPage A2 AD Adapted to Nature Sing-e-fi-e system Shape memory a--oy Adaptive Core Preserves dentine, easy and safe ENDO DONE ! Discover our products on Swiss Pavi-ion, Ha-- 8, Booth 8E17-8F10 www.fkg.ch
A2 ◊Page A1 ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 6/2018 Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13 Fig. 16 Fig. 14 was used. This system allows the clinician to place the mate- rial exactly on exposure the site, and this avoids staining dentinal the walls, which could over time show pigmenta- tion due to the material used (Figs. 5 & 6). Once the MTA was placed on Fig. 15 the sites of pulp exposure and the deep parts of the pulp chamber roof, a light-curing calcium hydroxide paste was applied. This was used to protect the mate- rial (Fig. 7) and to be able to proceed to the bonding procedure, to put the ﬁ nal restoration of the tooth in place during the same session (Figs. 8 & 9). Seven days after the procedure, the patient was completely asympto- matic and the tooth responded nor- mally to sensitivity tests. In clinical situations like this, it is expected that there will be radiographic evidence of mineralised tissue formation be- low the cap between six and nine months after the procedure.7 Clinical Case 2 The 35-year-old patient attended the dental clinic with transient provoked pain in tooth #4. The diagnosis was reversible pulpitis. The same vital pulp therapy protocol described in the ﬁ rst case (Figs. 10–12) was fol- lowed, except that in this case, the permanent restoration was not put in place during the same ses- sion. In its place, a temporary non- radiopaque restorative material was placed. This made it possible to ascertain the suitable thickness of the pulp capping material and its precise po- sitioning at perforation level, while keeping the dental margin clear for a good bonding protocol (Figs. 13–15). It has been reported that the success rate of vital pulp therapy procedures may drop when the ﬁ nal restora- tion is put in place two days after the initial procedure.8 The MAP System is very useful for precise and stable placement of the capping material in direct procedures, indirect pro- cedures, and partial and total pul- ÿPage A3
Dental Tribune Middle East & Africa Edition | 6/2018 ◊Page A2 ENDO TRIBUNE A3 potomies. Here, the ﬁnal restoration was placed 15 days after the initial procedure and the patient was com- pletely asymptomatic. Nine months later, full formation of calciﬁed tis- sue could be seen at the level of the pulp capping, the tooth remained vital and the patient was completely asymptomatic (Fig. 16). Obtaining the right diagnosis is key to the success of conservative pulp therapy. An ideal case is a diagnosis of reversible pulpitis with no previ- ous history of spontaneous or pro- longed dental pain.9 It is generally ac- cepted that a history of spontaneous pain or pain at night is associated with the existence of an irreversible pulp inﬂammation process.10, 11 In these cases, the success of direct pulp capping may be questionable,12 al- though there are studies indicating that vital pulp therapy can be suc- cessful even in these situations.2, 13 –15 When it comes to the long-term success of conservative pulp proce- dures, it is extremely important to provide a ﬁnal permanent restora- tion for the tooth that ensures a suit- able marginal seal. The reason is that this last factor, in conjunction with the absence of bacterial contamina- tion during the procedure, is among the most important factors to con- sider in order to avoid subsequent pulp inﬂammation.4, 16 The success rate reported for vital pulp therapy procedures using MTA with a follow- up period of up to ten years is greater than 80%17 — a fairly high percent- age for a dental procedure within that functional period. Editorial note: A list of references is available from the publisher. This ar- ticle was published in the 3/2018 issue of roots_international magazine of endodontics. A contemporary endodontic approach using bioceramic cement By Prof. Dr Leandro A. P. Pereira Endodontics is the specialty of den- tistry which prevents or treats pa- thologies of pulpal and periaplical origins. The ultimate goal is to cure the endodontic disease and allow the affected tooth to reestablish its aes- thetic/functional functions through a complementary restorative treat- ment. Obturation of the root canal system is an important step in endodontic treatment and its function is to ﬁll and seal the canals to prevent their recontamination. With the evolution in intracanal microbiological knowl- edge and the impact of new canal modeling instruments with continu- ous or alternating rotation, we know that it is not possible to completely eliminate the microorganisms in- side the endodontic microanatomy. However, we also know that this is not necessary for success, and that the signiﬁcant reduction in the lev- els of intracanal infection, in most cases, is sufﬁcient to achieve success (SIQUEIRA). Thus, at the time of ob- turation, it is necessary to create an intercanal environment which is un- favourable to the population growth of the remaining bacteria. Therefore, another function of obturation is to prevent or hinder the growth of re- sidual bacteria not eliminated dur- ing the cleaning and disinfection process. To achieve the desired objectives, obturation cements must have es- sential properties in order to be used clinically. These are: capacity to ﬁll, seal, and present dimensional stabil- ity; not being soluble in the organic tissue ﬂuids; having a ﬁlm thickness or no more than 50 micrometers; being radiopaque; having good drainage; not producing chromatic alterations; having suitable working time; to set and be easy to manipu- late and easy to remove if necessary; to promote cementogenesis; to be biocompatible and non-irritating to the tissues of the periapex (Kenneth M. Hargreaves 2001). However, with the development of new materials and rehabilita- tive concepts in the era of adhesive dentistry, the search for two other characteristics has become increas- ingly important in the development of new endodontic cements. One of them is the absence of eugenol, which interferes in the strength of the bond of the resin systems (VANO et al 2006). The other characteristic is bioactivity. Bioactivity is the ca- pacity of a material to be integrated with the tissues and structures of the organism with which it is in contact. responsible for the superior adapta- tion of this material to the dentin (Torabinejad 1995 Reyes-Carmona 2009). Bioactivity of the MTA is known as biomineralization and was ﬁrst described by Reyes and Carmona in 2009. In one in vitro study, the authors used scanning electron mi- croscopy images to observe the in- tegration of the MTA with the dentin through deposition of numerous ap- atite groups on the dental collagen ﬁ- brils throughout the dentinal tubule surface in contact with the MTA. An- other very interesting factor is that the authors observed that the more contact time the material had with the dentin, the more extensive the mineralizations were. These miner- alizations took place, integrating the material with the dentin, and may be However, the low drainage capac- ity of MTA does not allow for its use as an obturating cement. Thus, to get the beneﬁt of this material’s biocompatibility, a new class of ob- turating endodontic cement was created, known as silicate-based ce- ments. This designation is derived from the components which make up the MTA and which are present in these cements. They are: Tricalcium silicate, Dicalcium silicate, Calcium Oxide and Tricalcium aluminate. The clinical case below shows the ÿPage A4 AD More than biocompatible, bioactive! 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A4 ◊Page A3 ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 6/2018 Fig 1: Initial X-ray Fig. 2: Initial clinical condition Fig. 3: Clinical aspect after removal of the provisional restoration Fig. 4: Access to the pulp chamber and location of the canals Fig. 5: Modeles and disinfected canals Fig. 6: Canals obturated with Gutta Percha and Fillapex MTA After the modeling of the canals, the system of canals was dried and ﬁlled with EDTA-T 17% and an Irrisonic ultrasound tip (Helse) was used to passively activate the substance for 3 cycles of 15 seconds with renewal of the substance for each cycle. After the ultrasound passive activation, the canals were again irrigated with 5ml of Sodium Hypochlorite at 2.5%. The main gutta percha cones were tested and adjusted. After this, the system of canals was dried with aspi- ration micro-cannulas connected to a vacuum suctor. The Fillapex MTA cement (Angelus) was prepared and introduced into the canals using the main gutta per- cha cones. The excess from the cones was cut using a heat transfer system (Touch’n Heat Sybron Endo) and cold-compressed vertically. The pulp chamber was sealed with photopo- lymerizable composite resin and the patient was sent to her dentist for deﬁnitive restoration of the den- tal element to be performed. After 17 months, the patient came in for a control consultation, and on the X- ray, it was possible to observe endo- dontic success characterized by the absence of signs and symptoms, the tooth functioning physiologically, normality of the periapex, and reab- sorption of the surplus Fillapex MTA. References 1. José F. Siqueira Jr and Isabela N. Rôças. Clinical Implications and Mi- crobiology of Bacterial Persistence after Treatment Procedures. J Endod. 2008 Nov; 34(11):1291-1301. 2. Torabinejad M1, Hong CU, Mc- Donald F, Pitt Ford TR. Physical and chemical properties of a new root- end ﬁlling material. J Endod. 1995 Jul;21(7):349-53. 3. Kenneth M. Hargreaves, Stephen Cohen, Louis H. Berman. Cohen’s Pathways of the Pulp. Ed 10; Mosby Elsevier, 2011 4. Vano M, Cury AH, Goracci C, Chi- efﬁ N, Gabriele M, Tay FR, Ferrari M. The effect of immediate versus delayed cementation on the reten- tion of different types of ﬁber post in canals obturated using a eugenol sealer. J Endod 2006; 32(9):882-5. 5. Reyes-Carmona JF1, Felippe MS, Fe- lippe WT. Biomineralization ability and interaction of mineral trioxide aggregate and white portland ce- ment with dentin in a phosphate- containing ﬂuid. J Endod. 2009 May;35(5):731-6 6.AAE Consensus Conference on Di- agnostic Terminology: background and perspectives. 7. Glickman GN. J Endod. 2009 Dec;35(12):1619-20 Fig. 7: Final X-ray Fig. 8: Control X-ray after 17 months use of the Fillapex MTA cement (An- gelus) associated with gutta-percha cones for endodontic obturation of a case of endodontic treatment per- formed in a single session. A 56-year-old female Caucasian pa- tient came to the ofﬁce complaining of spontaneous, pulsing pain which did not cease with the use of anal- gesics and anti-inﬂammatories in the left mandible region. She had a negative response to the test of api- cal palpation and vertical and lateral percussion on all the teeth of this quadrant. Thermal tests showed an exacerbated, long-duration positive response both the long-term to both cold and heat on tooth 37. On the other teeth of the quadrant, a slight, short-duration positive response shown to cold, with a negative re- sponse to heat. According to the classiﬁcation of the American Endodontics Association, tooth 36 had a pulpal and periapical diagnosis of irreversible inﬂamma- tory pulpitis with normal periapex. The treatment indicated was endo- dontic treatment. The treatment was conducted in its entirety with the use of an Operative Microscope, varying the magniﬁca- tion between 2.5 and 12.5X. Access the pulp chamber was done with a 1013 spherical diamond bit followed by a 3082 conical-truck diamond bit and the ﬁnishing was done with a conical-truck diamond ultrasonic tip (E7D Helse). After location of the canals, a type-K #10 ﬁle was slowly introduced until reaching 2/3 of the initial X-ray length of the tooth. This was followed by a reciprocating in- strument #25.06 (Reciproc -VDW) with apical progression in sequences of 3 movements around 1 mm in am- plitude in the apical direction. With each sequence of 3 movements with the reciprocating instrument, irriga- tion was done with 5 ml of sodium hypochlorite at 2.5% and a type-K #10 ﬁle was take to 2/3 of the X-ray length of the tooth. This procedure was repeated until the Reciproc 25 instruments would reach this pre- established length. The next step was to conduct elec- tronic odontometry with a foramen locator and to establish the real work length. On the work length, the di- ameter of the region was veriﬁed through introduction of different calibers of manual type-K ﬁles until one of them is observed to adapt to the lateral walls of the canals. In the mesial canals, the instrument which adapted to this region was the #30, and in the distal canal, #40. In this way, and in the same initial opera- tive sequence or preparation, mod- eling, and irrigation, the mesial ca- nals were prepared for the Reciproc 40 (VDW) instrument, and the distal was prepared for the Reciproc 50 (VDW) instrument. Dr Jenner Argueta, Guatemala Master in Endodontics Senior Lecturer in Endodontie at Universi- dad Mariano Gálvez de Guatemala Board member of Academia de Endodon- cia de Guatemala Prof. Dr Leandro A. P. Pereira Endodontics Professor of São Leopoldo Mandic Faculty Dental Master and PhD in Pharmacol- ogy, Anesthesiology and Drug Therapy UNICAMP Endodontics Specialist - Surgical Micros- copy - Sedation Inhalation
Dental Tribune Middle East & Africa Edition | 6/2018 ENDO TRIBUNE A5 Top performance Flexible NiTi ﬁle HyFlex EDM performs well internationally Full control in the dental practice As an established Endo provider, COLTENE has been working closely with leading dentists, universities and endo experts for many years. The multitude of sophisticated treatment aids, ranging from spe- cially hardened instruments to bio- active obturation materials, reﬂects the self-image of the Swiss innova- tion leader. True to the company’s motto “Upgrade Dentistry”, the COLTENE service team regularly asks practice owners and endodon- tic specialists about their wishes for even more conﬁdent work in virtu- ally all situations. This also formed the basis for the development of the production process called “Electri- cal Discharge Machining” (EDM for short) by the dental manufacturer’s renowned R&D department, which ultimately gave the exceptionally break-resistant ﬁles their name. The practice-oriented Endo offer is com- plemented by a large number of ap- plication-related workshops, train- ing materials and personal services. Further product information: https://hyﬂex.coltene.com/ HyFlex EDM File Sequence By Coltene In the course of two major interna- tional events in the dental industry, Swiss dental specialist COLTENE interviewed over 130 dentists and Endo experts about their experi- ences with its latest NiTi ﬁle system. The results of the product tests are more than impressive: 98% of the participants would continue to use the HyFlex EDM for the treatment of their endodontic cases, even after the tough test. The necessary cutting edge Every two years, both the Interna- tional Dental Show in Cologne (IDS for short) and the Congress of the Eu- ropean Society for Endodontics (ESE Congress) serve as an international platform for professionals with an interest in endodontics to exchange experiences between colleagues. Thus, both events in 2017 provided the ideal occasion for a large-scale test campaign for the latest NiTi ﬁle generation from COLTENE. Selected dentists and joint practices through- out Europe were given the oppor- tunity to put the ﬂexible HyFlex EDM’s ﬁle system through its paces. 76% of the participants particularly praised the high ﬂexibility that leads to good adaptation in the canal. The pre-bendable ﬁles work reliably in all the lengths and sizes currently available on the market without dis- placing the centre of the canal. Like the proven HyFlex™ CM ﬁles, the HyFlex™ EDM ﬁles also possess the so-called “Controlled Memory“ ef- fect and are distinguished by their high level of ﬂexibility. In contrast to classic NiTi ﬁles, they have almost no recovery effect and can be pre- bent. As a result, the ﬁles move per- fectly through the centre of the ca- nal, which signiﬁcantly reduces the risk of ledging, transportation and perforation. During autoclaving, they recover their original shape so that they can be reused safely until a visible break in their spiral struc- ture clearly indicates the end of their service life. At the same time, the in- novative manufacturing process by means of spark erosion contributes to the high breakage resistance of the HyFlex EDM ﬁles, particularly under heavy-duty use. In fact, Hy- Flex EDM ﬁles are up to 700% more resistant to cyclic fatigue compared to traditional NiTi ﬁles. A special combination of material surface and tapering allows a signiﬁcant reduction in the number of ﬁles used without compromising the preservation of the natural root ca- nal anatomy. These smart features were also evaluated positively in the test and the dentists use the robust high-performance instruments pri- marily for cases where they want to produce reliable results quickly with a reduced number of ﬁles. Additional ﬁles sizes allow- ing more ﬂexible application Due to limited access endo experts often want more ﬂexibility from their instruments. Pre-bendable tools can extend the horizon into new dimensions. Particularly in a limited working space, modular nickel-titanium systems display their full strength. With a total of seven highly ﬂexible ﬁle variants, COLTENE offers a wide-ranging Hy- Flex NiTi program. In addition to the usual lengths of 25 mm, all prepara- tion ﬁles of the popular EDM series are also available in 21 mm working length. The application of the more agile, shorter models is particularly recommended in of the posterior molars and in patients with cranio- mandibular problems. The new HyFlex EDM 20/.05 prepa- ration ﬁle augments the existing HyFley EDM line. The additional ﬁle enables fans of the ﬂexible NiTi range to treat curved channels only with the efﬁcient EDM ﬁles. After creating a glide path with the Glide- pathﬁle 10/.05, the new ﬁle with the same taper allows minimally inva- sive, fast preparation of the canal. Subsequently the actual shaping can be done in the usual manner with the universal ﬁle HyFlex EDM One- File, size 25. Depending on the chan- nel anatomy, apical preparation can be ﬁnished with EDM ﬁles up to ISO size 60. Even in these large sizes the ﬁles work safely and without trans- portation of the canal centre.
A6 ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 6/2018 The pathway to perfect endodontics Julian Webber introduces the latest glide path ﬁle from Dentsply Sirona that completes the WaveOne Gold reciprocating system. By Julian Webber, UK “The endodontic glide path is a smooth, radicular tunnel from canal oriﬁce to physiologic terminus. Its minimal size should be a ‘super loose No. 10’ endodontic ﬁle.” John West DDS, endodontist, Tacoma, Washing- ton, USA and key opinion leader for Dentsply Sirona. The glide path is the starting point for all endodontic shaping proce- dures. It fulﬁls a biological require- ment indicating that we can get from the oriﬁce of the canal to the termi- nus, giving us a road map for all other shaping instruments to follow. Whilst some endodontists do not be- lieve a glide path is necessary prior to starting the shaping procedure with mechanical endodontic shaping in- struments the literature is unequiv- ocal that without a glide path ledges, blockages, perforations and instru- ment fracture can easily occur. In my opinion, if there is no glide path, we should not be attempting to use any nickel titanium rotary or nickel tita- nium reciprocating shaping ﬁles. Hand ﬁles or dedicated mechanical ÿPage A8 Julian Webber, UK AD AD Endo non-surgical and surgical retreatment (Management of Endodontic Failure) Endo Micro Surgical Retreatment (Management of Endodontic Failure) HANDS-ON COURSE HANDS-ON COURSE 17-18 April 2019 Wednesday-Thursday CAPP Training Institute Dubai | UAE Area of interest: Endodontics AED 4,400 $ 1,200 19-20 April 2019 Friday-Saturday CAPP Training Institute Dubai | UAE Area of interest: Endodontics AED 4,400 $ 1,200 Dr. Antonis Chaniotis, Greece He currently serves as an active member of the Hellenic Society of Endodontology and the Academy of Microscope Enhanced Dentistry and is a certiﬁed member of the European Society of Endodontology. Prof. James Prichard, UK Visiting Professor and Programme Leader, MClinDent in Endodon- tology at BPP University. Course Objectives DAY 1 - Delegates will be able to: • • • • Remove guttapercha obturations from root canals. Remove Carrier based obturations from the root canals. Remove paste obturations and remove ﬁber posts. Have the oportunity to use most of the current technology used during retreatment procedures. DAY 2 - Delegates will be able to: Bypass and remove broken endodontic ﬁles. Understand all the preventive measures to avoid complications during endodontic instrumentation. Repair a pulp ﬂoor perforation. Obtutrate an internal resorption defect. Perform apical plugs with biocompatible materials. • • • • • Course Objectives DAY 1 - By the end of the course delegates will understand: Outcomes of endodontic microsurgery vs traditional apicectomy. The science behind eﬀective local anaesthesia in endodontic microsurgery. The use of a dental operating microscope in endodontic microsurgery. Flap design and tissue handling to improve post-surgical healing. How to eﬀectively prepare an osteotomy. Correct methods of ultrasonic root-end preparation and how to identify anatomical markers. Which equipment is appropriate for use in micro-surgical techniques. Eﬀective suturing and postoperative care including analgesia. DAY 2 - By the endo of the course delegates will have: Been calibrated to a dental operating microscope. Have identiﬁed cases where surgical intervention is appropriate. Have raised a ﬂap with microsurgical instruments. Created an osteotomy and identiﬁed anatomical markers. Performed root end resection and retrograde preparation of the root canal space. Performed microsurgical suturing. Developed a post-operative care strategy to minimize complications and improve healing. • • • • • • • • • • • • • • • www.cappmea.com/courses www.cappmea.com/courses CONTACT CAPP EVENTS Onyx Tower 2 | Oﬃce P204 & P205 The Greens | Dubai | UAE Mob/WhatsApp: +971502793711 Tel: +971 4 347 6747 E-mail: firstname.lastname@example.org Web: www.cappmea.com ACCREDITATION Est. DOH-Abu Dhabi 14 CME | Est. DHA 12 CME CAPP designates this activity for 14 CE Credits CONTACT CAPP EVENTS Onyx Tower 2 | Oﬃce P204 & P205 The Greens | Dubai | UAE Mob/WhatsApp: +971502793711 Tel: +971 4 347 6747 E-mail: email@example.com Web: www.cappmea.com ACCREDITATION Est. DOH-Abu Dhabi 14 CME | Est. DHA 12 CME CAPP designates this activity for 14 CE Credits
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