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Moisture's effect on apical sealing
INQUIRY Anesthesiology Extraction without palatal injection Background.—The pain of palatal injections stems from the tight binding of the palatal mucosa to its underlying periosteum and the abundant nervous supply to the area. In attempting to minimize the discomfort, dentists have applied topical anesthetics, topical cooling, computerized injection systems, pressure administration, eutectic mixture of local anesthetics, and transcutaneous electronic nerve stimulation. Articaine has been praised for its ability to diffuse through soft and hard tissues more reliably than other local anesthetics and its ability to provide palatal soft tissue anesthesia via a maxillary buccal infiltration so palatal injection is not needed. This latter claim was tested. Methods.—Fifty-three patients ranging in age from 18 to 48 years took part in the study. Twenty-three had bilateral and 30 unilateral extractions. Twenty-six subjects were given injections of 2 mL of 4% articaine hydrochloride with 1:100,000 epinephrine into the buccal vestibule of the tooth 5 minutes before the tooth was extracted. Twenty-seven subjects served as controls who underwent the same protocol plus a palatal injection. A Faces Pain Scale and a 100-mm visual analog scale were completed after the extractions. Results.—The 23 patients with bilateral extractions noted no statistically significant difference in the extraction experience between having the palatal injection (97.5%) and not having the palatal injection (96.8%). Statistical analysis demonstrated no significant differences between the control and study groups (Table), although some variations were noted. Discussion.—Depositing the local anesthetic in the buccal vestibule and waiting 5 minutes was as effective in providing anesthesia as giving a palatal injection. Thus in permanent maxillary tooth extraction, giving a local anesthetic injection and observing a protracted latency period was better than all other techniques for minimizing pain.
Table.—Reason for Extraction, Number of Teeth Extracted, and Success Rate
Extraction reason
Orthodontic treatment Profound caries Apical lesion Periodontitis Profilactic extractions Total
Number of teeth
Success rate (%) (with palatal injection)
Success rate (%) (without additional palatal injection)
13 12 13 28 10 76
100 90 93 97 97 95.4
100 87 90 96 95 93.6
(This article was published in Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 102, Uckan S, Dayangac E, Araz K, Is permanent maxillary tooth removal without palatal injection possible?, 733-735, Copyright American Academy of Oral and Maxillofacial Radiology (2006).
Clinical Significance.—Palatal injections hurt. No one likes getting them. While some variation was noted, depending on the reason for extraction, minimal statistical difference was found between buccal injection of articaine alone compared with inclusion of palatal anesthesia.
Uckan S, Dayangac E, Araz K: Is permanent maxillary tooth removal without palatal injection possible? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102:733-735, 2006 Reprints available from E Dayangac, Baskent Univ, Faculty of Dentistry, 11 sok No 26, 06490 Bahcelievler, Ankara, Turkey; e-mail: [email protected]
Dental Materials Moisture’s effect on apical sealing Background.—Root canal systems are filled to prevent reinfection of the periapex, but the ability of the filling material to seal can be adversely affected by moisture and
liquids. With time, fluid can penetrate through the dentinal tubules and contaminate the surface of the root canal dentin. The quality of the apical seal obtained using various
Volume 52
Issue 5
2007
281
Table 1.—Experimental Groups Group
1a 1b 2a 2b 3a 3b 4a 4b 5a 5b 6a Negative control Positive control
Sealer
Number of teeth
AH Plus AH Plus Apexit Apexit Ketac-Endo Ketac-Endo RoekoSeal RoekoSeal Tubli-Seal Tubli-Seal AH Plus AH Plus —
n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n=5 n=5
Condition
Obturation technique
Dry Moist Dry Moist Dry Moist Dry Moist Dry Moist Dry Dry Dry
Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Lateral condensation Single-cone technique —
(This article was published in J Endod, 33, Roggendorf MJ, Ebert J, Petschelt A, et al, Influence of moisture on the apical seal of root canal fillings with five different types of sealer, 31-33, Copyright American Association of Endodontics (2007).)
sealing materials in dry or moisture-contaminated root canals was assessed. The null hypothesis was that the apical microleakage of root canal fillings would not be affected by type of sealer or contamination with moisture. Methods.—The 5 classes of sealers were epoxy-resin (AH Plus), calcium salicylate (Apexit), glass-ionomer cement (Ketac-Endo), polyvinylsiloxane (RoekoSeal Automix), and zinc oxide-eugenol sealer (Tubli-Seal). One hundred twenty single-rooted teeth were instrumented and then assigned randomly to 10 groups of 10 each plus a negative and a positive control group (Table 1). The teeth were thoroughly dried, then recontaminated with moisture. Obturation of the experimental groups was accomplished with a sealer and a single gutta-percha cone. The teeth were then centrifuged in 5% methylene blue and the linear dye penetration was measured using a stereomicroscope. The 10 teeth in 1 control group were dried and filled with AH Plus with use of the lateral condensation technique. Five positive controls were not obturated. Five negative controls were filled and coated completely with nail varnish. Results.—In the presence of moisture, Tubli-Seal, Apexit, and RoekoSeal Automix had less leakage but AH Plus and Ketac-Endo showed poorer apical seal (Table 2). The moisture did not affect apical microleakage statistically, but analysis showed that the sealer type and the combination of sealer and moisture significantly influenced the presence of microleakage. Linear dye penetration differed significantly between the groups. The absence of moisture in the RoekoSeal and Tubli-Seal groups had a negative effect. Discussion.—The leakage that occurred with the various sealing combinations revealed that moisture had varying effects. For sealers such as RoekoSeal and Tubli-Seal, the moisture may serve as a lubricant, permitting better
282
Dental Abstracts
Table 2.—Dye Penetration Scores Group
1a 1b 2a 2b 3a 3b 4a 4b 5a 5b 6a
Dye penetration [mm] (SD)
1.4 (0.7) 2.3 (1.8) 2.5 (0.7) 1.7 (1.1) 3.6 (1.1) 6.1 (2.9) 2.2 (2.4) 1.3 (0.7) 4.2 (2.1) 2.8 (1.1) 3.0 (2.3)
(This article was published in J Endod, 33, Roggendorf MJ, Ebert J, Petschelt A, et al, Influence of moisture on the apical seal of root canal fillings with five different types of sealer, 31-33, Copyright American Association of Endodontics (2007).)
attachment to the canal wall. Completely drying the root canal dentin of these samples seemed to adversely affect linear dye penetration. Calcium salicylate sealers showed faster setting but less effective sealing with moist conditions. The glass-ionomer cement sealer Ketac-Endo had significantly more apical leakage than Apexit and Diaket under moist conditions in other studies. The overall mechanical properties of these sealers declined with moisture contamination. Zinc oxide-eugenol and lateral condensation technique sealers demonstrated no increased apical seal leakage with moisture. Silicone-based and epoxy resinbased sealers seal the root canal effectively, perhaps as a function of the slight expansion that occurs in the setting reactions. Traces of moisture seem to benefit silicones but adversely affect epoxy resins. Overall, it appears that the sealer is the most significant factor in whether apical microleakage develops.
Clinical Significance.—Conventional wisdom suggests moisture should degrade the degree of apical sealing for sealers of all composition. In this study moisture (not wet) was shown to affect different materials differently, silicones benefiting while epoxies suffered. The tables tell the tale.
Roggendorf MJ, Ebert J, Petschelt A, et al: Influence of moisture on the apical seal of root canal fillings with five different types of sealer. J Endod 33:31-33, 2007 Reprints available from MJ Roggendorf, Dental Clinic 1–Operative Dentistry and Periodontology, Univ Erlangen-Nuremberg, Glu¨ckstr 11, D-91054 Erlangen, Germany; e-mail: [email protected]
Devices Interface media for electric pulp testers Background.—Electric pulp testers (EPT) are excellent tools to diagnose disorders of endodontic origin, but they have some limitations. For example, false-positive or falsenegative responses are obtained in 10% to 20% of cases. A medium is required to conduct and concentrate the electric field created at the tip of the EPT, but no single material is recognized as the best conducting medium that yields a reliable result. The conductance of an EPTcurrent through an extracted premolar was measured with a voltmeter to determine the performance of various interface media. Methods.—The premolar was extracted, then the cathode of a voltmeter was placed into the tissue of the pulp chamber. The anode was coupled to the EPT handpiece, and a measurement of 0 V was obtained for a negative control with no interface medium present. A positive control was measured with the EPT tip directly touching the cathode, yielding a value of 3.9 V. Media that are readily available in a dental office were tested, including materials that were wax- or petroleum-based, water-based gels, toothpastes, and liquids. Results.—Liquid media permitted more electric current to flow to the cathode, whereas wax- or petroleumbased materials did not conduct the electrical stimulus. Of the water-based media, K-Y jelly conducted the most current to the cathode, with values statistically greater than for the other nonliquid media. Crest Baking Soda & Peroxide Whitening Tartar Control toothpaste conducted significantly more current to the cathode than the other dentifrices, which were similar in their conductance. The best transmission of the electrical stimulus to the pulp chamber occurred with K-Y jelly (Table 1). Discussion.—Compared with all the nonliquid media, K-Y lubricating gel and Crest Baking Soda & Peroxide Whitening Tartar Control toothpaste permitted higher electrical impulses to be conducted to the cathode. Liquid media had the highest ratings, but it is difficult to control liquid media and they could give false-positive readings if they contact adjacent gingival tissues. Salivary contamination can also affect liquid media readings. Thus liquid interface media are not recommended.
Table 1.—Average Voltmeter Readings of Interface Media Used Measurements of Current Recorded on the Voltmeter (average)
Media Tested
Dry K-Y gel (K-Y brand lubricating jelly) Wax Lipstick Sallne (0.9% irrigating solution) White petroleum jelly (Fougera) Topical LA (20% benzocaine; Sultan) Triple ABX (Neosporin) Lip balm (Blistex Lip Medex) Lavender oil (Young Living Essential Oils) Duraflor (sodium fluoride) Hand soap Chlorhexidine (0.12% Peridex rinse) Scope Lotion Extra whitening paste (Crest) Regular paste (Crest) Crest Baking Soda & Peroxide Whitening Tartar Control Regular gel (Crest) Sensitivity protection Purnice (Whip Mix Preppies) Ultracal (Ultradent) Eye drops (Refresh Plus) Gel-Kam (0.4% stannous fluoride) Topical fluoride gel (Henry Schein) EndoGel (EDTA preparation) RC-Prep (Premier) Glyde (File Prep) Cavit (Henry Schein) Saliva
0 1.4 0 0 3.2 0 0.7 0 0 0 0.3 0.2 1.4 3.3 0.8 0.7 0.7 1.4 0.6 0.6 0.5 0.5 0.6 0.7 0.9 0.4 0.3 0.3 0 1.6
(Reprinted from J Endod, 32, Mickel AK, Lindquist KAD, Chogle S, et al, Electric pulp tester conductance through various interface media, 1178-1180, Copyright American Association of Endodontics, Copyright (2006).)
Volume 52
Issue 5
2007
283
Table.—Reason for Extraction, Number of Teeth Extracted, and Success Rate
Extraction reason
Orthodontic treatment Profound caries Apical lesion Periodontitis Profilactic extractions Total
Number of teeth
Success rate (%) (with palatal injection)
Success rate (%) (without additional palatal injection)
13 12 13 28 10 76
100 90 93 97 97 95.4
100 87 90 96 95 93.6
(This article was published in Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 102, Uckan S, Dayangac E, Araz K, Is permanent maxillary tooth removal without palatal injection possible?, 733-735, Copyright American Academy of Oral and Maxillofacial Radiology (2006).
Clinical Significance.—Palatal injections hurt. No one likes getting them. While some variation was noted, depending on the reason for extraction, minimal statistical difference was found between buccal injection of articaine alone compared with inclusion of palatal anesthesia.
Uckan S, Dayangac E, Araz K: Is permanent maxillary tooth removal without palatal injection possible? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102:733-735, 2006 Reprints available from E Dayangac, Baskent Univ, Faculty of Dentistry, 11 sok No 26, 06490 Bahcelievler, Ankara, Turkey; e-mail: [email protected]
Dental Materials Moisture’s effect on apical sealing Background.—Root canal systems are filled to prevent reinfection of the periapex, but the ability of the filling material to seal can be adversely affected by moisture and
liquids. With time, fluid can penetrate through the dentinal tubules and contaminate the surface of the root canal dentin. The quality of the apical seal obtained using various
Volume 52
Issue 5
2007
281
Table 1.—Experimental Groups Group
1a 1b 2a 2b 3a 3b 4a 4b 5a 5b 6a Negative control Positive control
Sealer
Number of teeth
AH Plus AH Plus Apexit Apexit Ketac-Endo Ketac-Endo RoekoSeal RoekoSeal Tubli-Seal Tubli-Seal AH Plus AH Plus —
n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n = 10 n=5 n=5
Condition
Obturation technique
Dry Moist Dry Moist Dry Moist Dry Moist Dry Moist Dry Dry Dry
Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Single-cone technique Lateral condensation Single-cone technique —
(This article was published in J Endod, 33, Roggendorf MJ, Ebert J, Petschelt A, et al, Influence of moisture on the apical seal of root canal fillings with five different types of sealer, 31-33, Copyright American Association of Endodontics (2007).)
sealing materials in dry or moisture-contaminated root canals was assessed. The null hypothesis was that the apical microleakage of root canal fillings would not be affected by type of sealer or contamination with moisture. Methods.—The 5 classes of sealers were epoxy-resin (AH Plus), calcium salicylate (Apexit), glass-ionomer cement (Ketac-Endo), polyvinylsiloxane (RoekoSeal Automix), and zinc oxide-eugenol sealer (Tubli-Seal). One hundred twenty single-rooted teeth were instrumented and then assigned randomly to 10 groups of 10 each plus a negative and a positive control group (Table 1). The teeth were thoroughly dried, then recontaminated with moisture. Obturation of the experimental groups was accomplished with a sealer and a single gutta-percha cone. The teeth were then centrifuged in 5% methylene blue and the linear dye penetration was measured using a stereomicroscope. The 10 teeth in 1 control group were dried and filled with AH Plus with use of the lateral condensation technique. Five positive controls were not obturated. Five negative controls were filled and coated completely with nail varnish. Results.—In the presence of moisture, Tubli-Seal, Apexit, and RoekoSeal Automix had less leakage but AH Plus and Ketac-Endo showed poorer apical seal (Table 2). The moisture did not affect apical microleakage statistically, but analysis showed that the sealer type and the combination of sealer and moisture significantly influenced the presence of microleakage. Linear dye penetration differed significantly between the groups. The absence of moisture in the RoekoSeal and Tubli-Seal groups had a negative effect. Discussion.—The leakage that occurred with the various sealing combinations revealed that moisture had varying effects. For sealers such as RoekoSeal and Tubli-Seal, the moisture may serve as a lubricant, permitting better
282
Dental Abstracts
Table 2.—Dye Penetration Scores Group
1a 1b 2a 2b 3a 3b 4a 4b 5a 5b 6a
Dye penetration [mm] (SD)
1.4 (0.7) 2.3 (1.8) 2.5 (0.7) 1.7 (1.1) 3.6 (1.1) 6.1 (2.9) 2.2 (2.4) 1.3 (0.7) 4.2 (2.1) 2.8 (1.1) 3.0 (2.3)
(This article was published in J Endod, 33, Roggendorf MJ, Ebert J, Petschelt A, et al, Influence of moisture on the apical seal of root canal fillings with five different types of sealer, 31-33, Copyright American Association of Endodontics (2007).)
attachment to the canal wall. Completely drying the root canal dentin of these samples seemed to adversely affect linear dye penetration. Calcium salicylate sealers showed faster setting but less effective sealing with moist conditions. The glass-ionomer cement sealer Ketac-Endo had significantly more apical leakage than Apexit and Diaket under moist conditions in other studies. The overall mechanical properties of these sealers declined with moisture contamination. Zinc oxide-eugenol and lateral condensation technique sealers demonstrated no increased apical seal leakage with moisture. Silicone-based and epoxy resinbased sealers seal the root canal effectively, perhaps as a function of the slight expansion that occurs in the setting reactions. Traces of moisture seem to benefit silicones but adversely affect epoxy resins. Overall, it appears that the sealer is the most significant factor in whether apical microleakage develops.
Clinical Significance.—Conventional wisdom suggests moisture should degrade the degree of apical sealing for sealers of all composition. In this study moisture (not wet) was shown to affect different materials differently, silicones benefiting while epoxies suffered. The tables tell the tale.
Roggendorf MJ, Ebert J, Petschelt A, et al: Influence of moisture on the apical seal of root canal fillings with five different types of sealer. J Endod 33:31-33, 2007 Reprints available from MJ Roggendorf, Dental Clinic 1–Operative Dentistry and Periodontology, Univ Erlangen-Nuremberg, Glu¨ckstr 11, D-91054 Erlangen, Germany; e-mail: [email protected]
Devices Interface media for electric pulp testers Background.—Electric pulp testers (EPT) are excellent tools to diagnose disorders of endodontic origin, but they have some limitations. For example, false-positive or falsenegative responses are obtained in 10% to 20% of cases. A medium is required to conduct and concentrate the electric field created at the tip of the EPT, but no single material is recognized as the best conducting medium that yields a reliable result. The conductance of an EPTcurrent through an extracted premolar was measured with a voltmeter to determine the performance of various interface media. Methods.—The premolar was extracted, then the cathode of a voltmeter was placed into the tissue of the pulp chamber. The anode was coupled to the EPT handpiece, and a measurement of 0 V was obtained for a negative control with no interface medium present. A positive control was measured with the EPT tip directly touching the cathode, yielding a value of 3.9 V. Media that are readily available in a dental office were tested, including materials that were wax- or petroleum-based, water-based gels, toothpastes, and liquids. Results.—Liquid media permitted more electric current to flow to the cathode, whereas wax- or petroleumbased materials did not conduct the electrical stimulus. Of the water-based media, K-Y jelly conducted the most current to the cathode, with values statistically greater than for the other nonliquid media. Crest Baking Soda & Peroxide Whitening Tartar Control toothpaste conducted significantly more current to the cathode than the other dentifrices, which were similar in their conductance. The best transmission of the electrical stimulus to the pulp chamber occurred with K-Y jelly (Table 1). Discussion.—Compared with all the nonliquid media, K-Y lubricating gel and Crest Baking Soda & Peroxide Whitening Tartar Control toothpaste permitted higher electrical impulses to be conducted to the cathode. Liquid media had the highest ratings, but it is difficult to control liquid media and they could give false-positive readings if they contact adjacent gingival tissues. Salivary contamination can also affect liquid media readings. Thus liquid interface media are not recommended.
Table 1.—Average Voltmeter Readings of Interface Media Used Measurements of Current Recorded on the Voltmeter (average)
Media Tested
Dry K-Y gel (K-Y brand lubricating jelly) Wax Lipstick Sallne (0.9% irrigating solution) White petroleum jelly (Fougera) Topical LA (20% benzocaine; Sultan) Triple ABX (Neosporin) Lip balm (Blistex Lip Medex) Lavender oil (Young Living Essential Oils) Duraflor (sodium fluoride) Hand soap Chlorhexidine (0.12% Peridex rinse) Scope Lotion Extra whitening paste (Crest) Regular paste (Crest) Crest Baking Soda & Peroxide Whitening Tartar Control Regular gel (Crest) Sensitivity protection Purnice (Whip Mix Preppies) Ultracal (Ultradent) Eye drops (Refresh Plus) Gel-Kam (0.4% stannous fluoride) Topical fluoride gel (Henry Schein) EndoGel (EDTA preparation) RC-Prep (Premier) Glyde (File Prep) Cavit (Henry Schein) Saliva
0 1.4 0 0 3.2 0 0.7 0 0 0 0.3 0.2 1.4 3.3 0.8 0.7 0.7 1.4 0.6 0.6 0.5 0.5 0.6 0.7 0.9 0.4 0.3 0.3 0 1.6
(Reprinted from J Endod, 32, Mickel AK, Lindquist KAD, Chogle S, et al, Electric pulp tester conductance through various interface media, 1178-1180, Copyright American Association of Endodontics, Copyright (2006).)
Volume 52
Issue 5
2007
283