A2 ◊Page A1 ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 6/2020 required no further treatment or intervention after palliative care at a follow-up rate of 96%. In the second part, 31 teeth had received partial or full root canal debridement before the statewide shutdown. The mean time for com- pletion of treatment was 13 weeks. At a recall rate of 100%, 77% of the teeth did not experience any ad- verse events resulting from delays in treatment completion. The most common adverse event was a frac- tured provisional restoration (13.0%), followed by a painful and/or infec- tious flare-up (6.4%). These events were managed appropriately and therefore deemed successful. Only one tooth was fractured and nonre- storable (3%), leading to the failed outcome of tooth extraction. The re- maining four outcome failures (13%) were due to patient unwillingness to undergo school-mandated SARS- CoV-2 testing or patient unwilling- ness to continue treatment because of perceived risk of SARS-CoV-2 in- fection. In an interview with Dental Tribune International, study co-author Dr. Biraj Patel explained the reason- ing behind this study: “The school decided to defer aerosol-generating procedures in accordance with the state guidelines. We managed cases very differently to what we would have routinely done and were inter- ested to see how successful we were. Furthermore, the literature has lim- ited data on the effect of delaying treatment in endodontics and the outcomes of the palliative manage- ment of endodontic disease. Our report on the management of endo- dontic emergencies has important clinical implications for the dental community worldwide and aims to provide an insight into the effect of conservative management of endo- dontic emergencies without the use of aerosol-generating procedures.” As results have shown, palliative care proved successful for the UT re- searchers, but it is important to note that this level of endodontic emer- gency management is only a tempo- rary solution and aerosol-generating procedures cannot be avoided forev- er. “The state witnessed a lock- down from 23 March to 20 May 2020, and palliative care was successful in managing patient symptoms during this time. However, if this lockdown had been longer, we may have had to reevaluate patients if they became symptomatic and potentially inter- vene with aerosol-generating proce- dures,” said Patel. What is the long-term solution? “At present, our school reduces the risk of transmission by testing all pa- tients for SARS-CoV-2 using reverse transcription-polymerase chain re- action (RT-PCR) prior to aerosol-gen- erating procedures,” the endodontist added. “We make sure to follow the state and CDC guidelines, especially with regard to social distancing measures and personal protective equipment. We hope that a better understanding of the transmission of SARS-CoV-2, along with develop- ments in rapid testing, will eventu- ally reduce the risk to healthcare professionals. This will hopefully result in a reduced need for clinics to stay closed. The expectation is that we will see further lockdowns if cases of COVID-19 become uncontrolled. Hopefully, the findings of our study will help dentists manage patients without aerosol-generating proce- dures during periods of lockdown.” Editorial note: The study, titled “To drill or not to drill: Management of en- dodontic emergencies and in-process patients during the COVID-19 pan- demic,” was published on 22 August 2020 in the Journal of Endodontics. The importance of irrigation in challenging cases By Dr Marco Martignoni, Italy Introduction Irrigation of root canals is key to improving the removal of bacte- ria, pulp tissue, the smear layer and debris from the root canal system,1 reducing the risk of post-treatment disease. In fact, it is well known that mechanical instrumentation leaves untreated canal areas ranging from 10 to 50% in individual canals.2–6 In these areas, there is the possibility for bacteria to replicate, leading to the failure of the treatment.7 A re- cent article showed that the bacterial persistence at the time of filling has a significant influence on the outcome of the treatment, regardless of the ir- rigating solution and the medication used,8 thus stressing the importance of eradicating as many microorgan- isms as possible from the root canal system. The synergy between me- chanical preparation and irrigation is influenced by several factors, such as the fluid properties and the vol- ume of the irrigant, the irrigant de- livery system and its depth of place- ment, and the anatomy of the root canal system.9 Conventional needle irrigation is un- able to provide good disinfection10 because of the risk of the vapour lock effect11 and because needles can have difficulty penetrating into narrow spaces;12 as a consequence, the difficulty in reaching the most apical region of the canal with large volumes of fresh irrigant may re- sult in insufficient replacement and fluid exchange beyond the tip of the needle.13 In order to increase the effi- ciency of the irrigation, the literature suggests the use of preheated solu- tions14 or activation of irrigants1 by means of ultrasonic/sonic devices15 or negative pressure devices.16 The closer the needle is to the work- ing length, the greater the irrigation is. For this reason, using products that follow the anatomy of the pre- pared root canal can help in this clinical step. However, the flux must not be violent, in order to decrease the risk of extruding debris into the periapical tissue.17 Several articles have described the use of a novel poly-propylene nee- dle (IrriFlex, Produits Dentaires) characterised by a back-to-back side vent design that helps the clinician irrigate the root canal space effi- ciently and safely. This product, with its 30-gauge tip, has the advantages of reaching the working length ef- fortlessly and of bringing a high volume of irrigant close to the apex. The product has been shown to be effective in curved canals, but what about challenging cases? The follow- ing case reports demonstrate the use of IrriFlex in two different scenarios: a retreatment and a primary treat- ment of a calcified canal. Case 1 A 62-year-old patient was referred to our clinic for endodontic retreat- ment. The patient reported swelling of the maxillary left gingiva. The radiographic examination revealed the results of a previous endodontic therapy and the presence of periapi- cal radiolucencies (Fig. 1). Since the results of the previous therapy could be improved, we decided to retreat the tooth, passing through the exist- ing crown. After positioning of the dental dam (Fig. 2), the existing composite filling in the centre of the crown was re- moved using a diamond-coated bur driven by a high-speed handpiece. In this way, the access cavity was cre- ated and refined in order to see the pulp chamber (Fig. 3). The existing root canal filling was removed us- ing rotary instruments specifically designed for retreatment, and then ultrasonic tips were used to remove the remnants on the pulp chamber floor. The chamber was filled with 5% sodium hypochlorite (Fig. 4), and the second mesiobuccal canal, which had not been shaped, cleaned or filled during the initial treatment, was located and shaped according to the standard protocol. Considering the presence of an en- dodontic lesion and swelling, a great deal of time was dedicated to decon- tamination of the root canal system Fig. 1 (Fig. 5).18 The device chosen to deliver the irrigating solution to the work- ing length was IrriFlex (Fig. 6 & 7) because, thanks to its flexibility, it would be able to deliver the irrigant to the apical third of each root, with- out any effort, without stopping in case of curvatures. The irrigant was then activated by means of ultra- sonic inserts19 according to the indi- cations given by Tonini and Cerutti.12 After ensuring that the root canals were dry, they were filled according to the warm gutta-percha compac- tion technique (Figs. 8–10). After that, the access cavity was filled by means of a direct composite restoration (Fig. 11) and a postoperative radio- graph was taken in order to check the final result (Fig. 12). Case 2 A 50-year-old patient came to our of- fice because of an emergency: while eating, he had broken tooth #22 and he was not able to find the fragment (Fig. 13). The fracture had exposed the pulp and the patient reported spon- taneous and acute pain. The preop- erative radiograph showed that the tooth had a very thin canal lumen (Fig. 14) and sufficient bone support. It was thus decided to do an endo- ÿPage A3 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7