N L Y A L S O N F E S SI O O R T A L P N E D PUBLISHED IN DUBAI www.dental-tribune.me September-October 2019 | No. 5, Vol. 9 Novel applications of a bioactive resin in perforations, root resorption and endodontic-periodontic lesions By Dr Marta Maciak, Poland During the last decade, a consider- able amount of attention has been directed towards the development of so-called bioactive materials. To understand this phenomenon bet- ter and to avoid misinterpretation, a condensed review of the literature and an assessment of various deﬁni- tions need to be considered. There are already several commer- cially available dental materials that can be deﬁned as bioactive. For instance, any ﬂuoride-releasing ma- terial, calcium silicate- and calcium aluminate-based cements, and cal- cium-based or calcium-containing materials. Biomaterial scientists in the ﬁeld of implantology have adopted the word “bioactive” to mean materials that are bound to each other through a biomineralised interface. There appears to be confu- sion within the dental profession, in- cluding among scientists, clinicians and industry persons, to what extent biomineralisation can be achieved with dental materials and which ma- terials can be appropriately termed “bioactive” or “biomineralising”.1 Bioactivity has been deﬁned and can be interpreted in various ways. A broad deﬁnition that has several meanings is the following: a material that is able to have a biological ef- fect or a material that is biologically active and forms a bond between the tissue and the material.2 In the ﬁeld of tissue engineering, the term “bioactivity” is related to the cellu- lar effects induced by the release of biologically active substances and ions from the biomaterial, for ex- ample from bioactive glasses both in soft- and hard- tissue engineering applications.3, 4 In addition, its activ- ity has been demonstrated in pulp capping experiments in non-human primates.5 Thus, in medicine, bioactivity cov- ers all interaction of materials with living cells and tissue, including the effects of pharmaceuticals. In bio- material science, with bioceramics and bioactive glasses, bioactivity of a material usually denotes that the material is capable of forming hy- droxyapatite minerals on its surface in vitro and in vivo.6 The following theoretical question should be asked: can a material that releases ions for biomineralisation be considered bioactive or is the substrate on which the biominerali- sation occurs bioactive? Thus, bioac- tivity of dental materials relates to their potential to induce speciﬁc and ÿPage A2 AD EXPAND YOUR MIND ADAPTIVE. EASY. SAFE. EFFICIENT. www.fkg.ch/xpendo
A2 ◊Page A1 ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 5/2019 Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 intentional mineral attachment to the dentine substrate.7 Another deﬁnition has been pre- sented in an article by Lööf et al.: “Bioactivity of a ceramic material is a surface property that provides a bond between the material and liv- ing tissues without ﬁbrous encap- sulation.”8 In yet another deﬁnition, bioactivity is described as follows: “A bioactive material is one that forms a surface layer of an apatite-like ma- terial in the presence of an inorganic phosphate solution.”9 ACTIVA BioACTIVE-RESTORATIVE and ACTIVA BioACTIVE-BASE/LINER (Pulpdent) have been shown to ex- hibit bioactive properties based on this last deﬁnition. ACTIVA BioAC- TIVE products are the ﬁrst dental resins with a bioactive ionic resin matrix. They have a shock-absorbing rubberised resin component and reactive ionomer glass ﬁllers that mimic the physical and chemical properties of natural teeth. These bi- oactive materials actively participate in the cycles of ion exchange that regulate the natural chemistry of the teeth and saliva and contribute to the maintenance of tooth structure and oral health. ACTIVA has the strength, aesthetics and physical properties of resin composites and is more bioac- tive than glass ionomer cements.10 ACTIVA seals teeth against mi crole- akage11, 12 and its continuous release and recharge of signiﬁcant amounts of calcium, phosphate and ﬂuoride ions provide patients with long-term beneﬁts. In the US, the bioactivity claim for ACTIVA, being the ﬁrst bioactive resin material, has been accepted. Based on its strength and durability due to a patented rubberised resin molecule that absorbs stress and resists fracture, the author has used ACTIVA BioACTIVE-RESTORATIVE and ACTIVA BioACTIVE-BASE/LINER in lieu of mineral trioxide aggregate (MTA) and Biodentine (Septodont) for selected endodontic and other procedures. The cases presented here are off- label treatments using ACTIVA Bi- oACTIVE-BASE/LINER in cases with a poor prognosis and in which ex- traction (and an implant) may have seemed a more obvious choice of therapy. These procedures are not listed in the company’s indications for use and were carried out by the author after explaining the possible potential beneﬁts, as well as the risks to the patient. All of the patients agreed to the treatment and signed an informed consent form for endo- dontic treatment. Case 1 A 28-year-old female patient was referred and presented with pain of tooth #46. The referral letter stated that endodontic retreatment was needed and the perforation had been closed with MTA. The patient was in considerable pain when eating and when closing her mouth. Her medi- cal history did not present any con- traindications to dental treatment. The clinical examination showed a temporary ﬁlling in tooth #46. A ra- diograph taken on 20 October 2015 showed extrusion of MTA into the furcation, as well as a bony defect (Fig. 1). Perforation of the ﬂoor of the pulp chamber was diagnosed. Upon removal of the temporary ﬁlling, a large amount of purulent exudate ﬁlled the pulp chamber and was evacuated. After the MTA had been removed, the furcation was ﬂushed with metronidazole (liquid; Polpharma) and 2% chlorhexidine (Cerkamed). The borders of the perfo- ration were refreshed with a carbide bur, and then the pulp chamber was etched with 37% orthophosphoric acid for 10 seconds, followed by a thorough rinse. Through the perfo- ration, a collagen sponge (ANTEMA, Molteni Dental) was applied to sup- port the ACTIVA Bio-ACTIVE-BASE/ LINER and to protect the underly- ing bone defect. The sponge was not visible on the radiograph. The canal oriﬁces were protected with cotton pellets and the entire pulp chamber was treated with a dentine bonding agent (DenTASTIC UNO, Pulpdent), which was light-cured, and then cov- ered with ACTIVA BioACTIVE-BASE/ LINER, covering the ﬂoor of the pulp chamber (Fig. 2). The tooth was closed with GIZ glass ionomer (Ihde Dental) as a tempo- rary ﬁlling. The patient was pain- free within two days. A follow-up ra- diograph taken on 3 November 2015 (14 days postoperatively) showed the beginning of the healing of the bone in the furcation area (Fig. 3). Case 2 A 16-year-old patient was referred with root resorption of tooth #21. A CBCT scan and radiograph (Figs. 4 & 5) taken on 30 March 2017 clearly demonstrated the root resorption. Note the temporary ﬁlling in the pulp chamber. The patient’s medical history was non-contributory. The diagnosis was mixed internal and external root resorption. After removal of the temporary ﬁll- ing, inﬂamed granulation tissue was seen inside the canal. In spite of the fact that the apical portion of the ca- nal was calciﬁed, it was located. The canal was shaped and cleaned with the Self-Adjusting File (SAF) System (ReDent NOVA) and XP-endo Finish- er (FKG Dentaire), and ﬂushed with 5.25 % sodium hypochlorite (NaClO), 17% EDTA (Cerkamed) and metroni- dazole (Polpharma). As a ﬁrst tem- porary canal ﬁling, Dexadent (Che- ma-Elektromet) was applied for one week to treat the inﬂammatory tis- sue in the canal. During subsequent visits, the canal was rinsed with 40% citric acid (Cerkamed) and 2 % chlorhexidine (Cerkamed) using the SAF System and XP-endo Finisher. A temporary ﬁlling of Multi-Cal (Pulp- dent) mixed with 2% chlorhexidine (liquid) was inserted into the canal. Initially, the temporary dressing was replaced every two weeks to accom- plish removal of granulation tissue and to stimulate bone regenera- tion. Over the course of about seven months, a reduction of the bone le- sion was observed, as evidenced by radiographs (Fig. 6) and CBCT and under high mag- niﬁcation. The ﬁnal treatment after approxi- mately 11 months (Fig. 7) consisted of cleaning the canal with the XP-endo Finisher and EDTA and 2% chlorhex- idine irrigation. The resorption area was plugged with a collagen sponge (Antema) to provide support for ACTIVA BioACTIVE CEMENT and to prevent it from ﬂowing beyond the root structure. A dentine bonding agent (All-Bond Universal, Bisco) was applied to the canal space, but not polymerised, just slightly air-dried, and the root was ﬁlled from the apex to the pulp chamber with ACTIVA BioACTIVE-BASE/ LINER. A ﬁbre post (Cytec blanco, Hahnenkratt) was im- mediately placed, following which the pulp chamber was ﬁlled with AC- TIVA. After 20 seconds, the restora- tion was light-cured from three dif- ferent directions for 20 seconds each. The ﬁnal result can be seen on a ra- diograph from 13 February 2018. Complete bone healing adjacent to the resorption area was observed (Fig. 8). While the radiograph shows the ﬁbre post, the collagen sponge and ACTIVA BioACTIVE CEMENT do not possess sufﬁcient radiopacity to be seen on a radiograph. Case 3 A 63-year-old female patient pre- sented for dental treatment. A pano- ramic radiograph (Fig. 9) revealed a heavily restored dentition with single crowns, a three-unit bridge and multiple missing teeth in both arches. She complained of pain in the mandibular right premolar area. Her medical history did not present any contra-indications to dental treatment. When the patient was informed that tooth #45 would have to be extracted, she objected and asked if anything could be done to save it, even if only on a temporary basis, as she was reluctant to commit to wear- ing a removable partial denture. She thus consented to a treatment that offered no guarantee of success. Clinical examination showed third- stage luxation and pus in the gin- gival pocket. A radiograph showed a three-wall infrabony pocket (Fig. 10A) reaching the apex of the root. The diagnosis was periapical peri- odontitis with purulent exudate and root caries on the mesial aspect. The treatment consisted of endodontic and periodontal treatment after a panoramic radiograph and realtime polymerase chain reaction (PET test, PET Plus, MIP Pharma) were per- formed. Endodontic treatment was per- formed on 2 July 2014 with a HyFlex ﬁle of size 25.04 (COLTENE) and the SAF System. The pus was evacuated from the root canal and the canal was ﬂushed with 5.25% NaClO and met- ÿPage A3
Dental Tribune Middle East & Africa Edition | 5/2019 ◊Page A2 ENDO TRIBUNE A3 ronidazole, and Dexadent ointment was applied and left for one week. To avoid extra expenses, no bone graft- ing material was used; only a deep curettage was performed. An occlusal cavity was prepared and ﬁlled with ACTIVA BioACTIVE- RESTORATIVE, and the tooth was splinted to the adjacent premolar with ﬁbreglass and ACTIVA (Fig. 10B). The purpose of the splint was to lend support to the tooth, which presented with a Class III mobility, thus promoting healing. After a few days, the patient reported being free of pain, and no exudate in the canal was observed. period of two weeks. Two weeks later, the Multi-Cal was removed with the SAF System using 40 % citric acid and distilled water. Then the canal was rinsed with 2% chlorhexidine and dried with suction. GuttaFlow (COLTENE) was used as a sealer, and a master cone was softened in chlo- roform and placed in the canal. Verti- cal hot condensation was carried out in the apical part. The remainder of the root canal was ﬁlled with a con- tinuous wave of gutta-percha. The period until the next appointment determined whether the treatment would be successful or not. Healing of the infrabony lesion continued during this period (Fig. 11). On 10 July 2014, the canal dressing was changed to Multi-Cal mixed with 2% chlorhexidine and left for a Three months later, the gutta-percha was partially removed from the ca- nal, which was etched and rinsed, fol- lowed by application of the dentine bonding agent (All-Bond Universal). The canal was ﬁlled with ACTIVA CE- MENT and a ﬁbre post was placed, and after 20 seconds, it was light- cured (Fig. 12). After three years, a radiograph showed complete bone healing and periodontal attachment (Fig. 13). Conclusion Based on the available published research and after early favourable results had established the effective- ness of ACTIVA BioACTIVE materials, and based on the pH, release of calci- um and phosphate ions and apatite formation in the presence of saliva, the decision was made to expand the number of suitable cases. Although a favourable outcome could not be guaranteed, clinical cases followed over a period of three and more years presented with positive results and provided evidence that the bio- active properties of ACTIVA BioAC- TIVE materials through their ability to stimulate apatite formation and osteoblasts provided a viable treat- ment option. The evidence has been presented here with radiographs and CBCT scans showing new bone formation. Although histopathologi- cal evidence has not been provided, a periodontal evaluation demon- strated periodontal attachment in the cases presented here. Editorial note: A list of references is available from the publisher. This article was originally published in roots-international magazine of endodontics, Issue 4/2018. About the author Dr Marta Maciak, Poland PhD, graduated with a DDS from the Medical University of Białystok in Poland in 1999. In 2007, she graduated with a specialty in conservative dentistry and endodontics from the university’s Depart- ment of Restorative Dentistry. From 2004 to 2009, she was an assistant in the same department. In 2009, she received a PhD in medical sciences in dermatology. She is a member of the Polish Dental Associa- tion and Polish Endodontic Association. She has authored many publications, and since 2005, she has lectured in Poland and numerous other countries, in addition to presenting practical training in the ﬁelds of endodontics and aesthetic dentistry. Her main interests are aesthetic dentistry, endodontics and prosthetics. She can be contacted at martamaciak2012@gmail. com. Five quick questions with Dr Jorge Vera By Dental Tribune International Dental Tribune International asked Dr Jorge Vera ﬁve quickﬁre questions about his background in dentistry and what inspires him to practice endodontics every day. In the inter- view, Vera also shed some light on his favourite products that he uses in his private practice and provided some useful tips for aspiring endo- dontists. Dr Vera, what is your background in endodontics? After ﬁnishing my DDS in Mexico, I did my postdoctoral programme in endodontics at Tufts University School of Dental Medicine in Boston in Massachusetts in the US, from 1991 to 1993, helping to teach in the undergraduate clinic and doing many research projects under a great team consisting of Drs Joseph Tenca, Robert White and Melvin Goldman. Once I got my certiﬁcate, I returned to practising and teaching in Mexico. What are your three favourite things about endodontics? Firstly, I like the challenge of prop- erly diagnosing and treating orofa- cial and dental pain, and, of course, relieving the affected patients. And then being able to treat sympto- matic and previously endodonti- cally treated teeth with retreatment techniques using CBCT, the micro- scope or endodontic microsurgery, and returning them to functionality. Lastly, the tremendous load of basic science that endodontists must carry requires continuous study to better perform clinically in ﬁelds like phar- macology, physiology and others. Which endo products couldn’t you do without and why? I would not be able to work without a microscope and ultrasonic tips be- cause they change the approach to removing interferences like calciﬁca- tions and previously placed materi- als from the root canal system in a conservative way. Also, the use of rotary/reciprocating instruments is essential in my everyday practice— their evolution is making root canal preparation easier while maintain- ing more dentine—and, ﬁnally, the use of hydraulic calcium silicate/ bioceramic cements and CBCT for many cases. What inspires you in your day-to- day work? Being able to bring new techniques, devices and materials into my prac- tice about which I have learnt in lectures and courses. Document- ing their use and eventually seeing those patients on which they were used, heal and remain functional for a long time. I also enjoy preparing lectures for students and peers on those same topics. What is one piece of advice that you would like to share with aspir- ing endodontists? To be both open and critical about new techniques and devices arriv- ing on the market; to always bring basic science into everyday practice because therein lies the foundation of our profession, so that whatever we use on patients helps both them and us; to study every single day; to revise old notes from school and to read the journals. Finally, it is advis- able to take new courses every year. Thank you very much for the interview. Endo Non-surgical and Surgical Retreatment (Management of Endodontic Failure) Endo Micro Surgical Retreatment (Management of Endodontic Failure) AD AD HANDS-ON COURSE 26-27 March 2020 Thursday-Friday 09:00 - 18:00 CAPP Training Institute Dubai | UAE Area of interest: Endodontics AED 4,400 $ 1,200 HANDS-ON COURSE 28-29 March 2020 Saturday-Sunday 09:00 - 18:00 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. 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. www.cappmea.com/courses CAPP Training Institute Dubai | UAE Area of interest: Endodontics AED 4,400 $ 1,200 Prof. James Prichard, UK Visiting Professor and Programme Leader, MClinDent in Endodon- tology at BPP University. 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 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. 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. DHA 12 CME CAPP designates this activity for 14 CE Credits
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