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Endo tips    Better Endo    Endo abstracts    Endo discussions

  crown fracture of tooth # 11 and # 21

The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. - photographs courtesy: Marga Ree
From: Marga Ree
Sent: Friday, February 25, 2005 4:52 AM
Subject: [roots] Rico, my favourite patient

Today I finished an endodontic treatment on Rico, a 7 year old sweetie. 
He had an accident 10 months ago with a uncomplicated crown fracture of 
teeth # 11 and # 21 and an intrusion of tooth # 11. Within 1 hour his 
dentist had repositioned # 11 and applied a semi-rigid splint. He took 
some pics, unfortunately they are a bit out of focus, and made
2 composite restorations on both central incisors.

A few months after the accident a sinus tract appeared, and he was 
referred to me. I tried the triple antibiotic soup of Hoshino, but without 
succes, the sinus tract didn't disappear. So I decided to do an apical 
closure with MTA, and after application of Ca(OH)2 for 1 month the sinus 
tract did disappear, but there was still a lot of bleeding and draining from
the periapical tissues, so I reapplied the Ca(OH)2 and decided to wait. 
After 3 more months I was able to make an apical plug of MTA. The remaining 
part of the canal was filled with composite. Because of the greyish 
discoloration of the crown, I applied some sodium perborate. Today it was
his day, I could finally make a definitive restoration. He was very happy
with the result. All together, it took us 7 sessions. I will miss him - Marga

accident case
accident case
accident case
accident case Surprising to see that Hoshino’s soup is not working as he claims 100% success (if I interpret the table correctly) in his article although on primary teeth. Are we dealing here with a main difference between primary teeth and permanent teeth or a research project carried out by the inventor of the soup? In that situation you see that the inventor-researcher often gets the results he wants. Another argument not to use a product or material till independent research has shown that it may work. Do not go by the results of the inventor. I cannot see myself work for years on developing a product and then spend the years thereafter my precious time to proof that my invention does not work. The lesson to be learned again is: be careful in trusting the results of the inventor!! - Paul Wesselink Hi Paul, I for one believe Hoshino to be an honest scientist. And I am also "happy" to see that Ca(OH)2 worked so beautifully when properly placed by a skilled clinician such as Marga. Besides the antimicrobial effectiveness of Ca(OH)2, its ability to necrotize remaining tissue within the root canal system will help in the debridement upon the subsequent NaOCl rinse. So a synergistic effect can be expected to enhance the debridement and disinfection procedure. As such, I am always surprised by the poor results that some show with Ca(OH)2. I would recommend that before any paper testing Ca(OH)2 gets published, a proper determination of the material's pH be tested against known controls. - Fred Paul, I agree with Fred's remark about Hoshino being an honest scientist. I have no indication of the oppposite, he is neither a salesman, nor does he want to promote a product in which he has financial interest. Second remark: what do you loose by trying this triple antibiotic paste to work? Worst case scenario is that it doesn't work, in which case you can switch to another approach, like I showed with this case. Suppose it did work? I think that you gain a lot when this immature root will continue to develop in the apical part. I would try this again in a similar situation, and that has nothing to do with uncritically trusting the results of the inventor. - Marga Marga and Fred I have no reason not believe that Dr Hoshino is an honest researcher but I suggest not to rely on the results of the inventor as no matter how honest they try to be there is always some bias. Wait for independent research before you start using these kind of things! Why did the soup not work in Marga's case while it worked 100% in Hoshino's study. You may wonder if it is very sensible to expose a child to three antibiotics running the risk to senstize the patient or contribute to the development of resistant bacteria while you are may be missing a good scientific foundation for your treatment. What I hate to see is this magic believe in cocktails, drugs and medications in endodontic treatment hoping that it will help but what is the evidence for their use? No wonder other people start to make up strong antibacterial cocktails and sell them as a root canal sealer. With this attitude we invite people to do so.If we keep having this approach in endodontics we remain being hooked up to dressings and medications where the most important part is to remove that biofilm that is inside the root canal and is probably hardly affected by drugs. - Paul Wesselink Bravo!!!!! Profesor Wesselink, words of wisdom based in very profound thoughts of somebody who really understands and has read critically the biology of endodontic therapy., and produced a lot of knowledge in our field. I salute you again. - Ben Paul, Concerns about microbial resistance and sensitization are of course valid. However, the biofilm was not eradicated by instrumentation and NaOCl. So what else is to be done? Certainly not surgery! I am sure you would agree that bleach is a strong cocktail as well, no? In the perio literature, as far as I remember, doxycycline has not yet created havoc with resistant strains and allergic reactions. Controlled release delivery of antimicrobials is especially effective in reducing/preventing such complications. - Fred Paul, I share your concerns with regard to microbial resistance and sensitization, and in general I agree that there is very limited indication for its use in endodontics. However, after reading the below mentioned papers, and especially the paper of Banchs, I thought my patient might benefit from this treatment protocol. Marga 1: Takushige T, Cruz EV, Asgor Moral A, Hoshino E. Endodontic treatment of primary teeth using a combination of antibacterial drugs. Int Endod J. 2004 Feb;37(2):132-8. PMID: 14871180 [PubMed - indexed for MEDLINE] 2: Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, Iwaku M. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J. 1996 Mar;29(2):125-30. PMID: 9206436 [PubMed - indexed for MEDLINE] 3: Sato I, Ando-Kurihara N, Kota K, Iwaku M, Hoshino E. Sterilization of infected root-canal dentine by topical application of a mixture of ciprofloxacin, metronidazole and minocycline in situ. Int Endod J. 1996 Mar;29(2):118-24. PMID: 9206435 [PubMed - indexed for MEDLINE] 4: Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod. 2004 Apr;30(4):196-200. PMID: 15085044 [PubMed - indexed for MEDLINE] - Marga I apologize for this VERY long posting, but antibiotics are being used in the treatment of periodontal disease: - Fred 1: J Int Acad Periodontol. 2004 Oct;6(4 Suppl):143-9. The microbiological case for adjunctive therapy for periodontitis. Page RC. Regional Clinical Dental Research Center, Health Sciences Bldg., Rm. B-530, University of Washington, Seattle, WA 98195, USA. That chronic periodontitis is an infectious disease is now firmly established, and the primary role of Porphyromonas gingivalis, Tannerella forsythensis and Treponema denticola is generally accepted. Treatment by mechanical means such as scaling and root planing or surgery generally results in significant clinical improvement but may not arrest the progress or recurrence of disease. Several studies have shown that the probability of achieving lasting stability as measured by the arrest of progressive attachment loss and bone loss by primary mechanical therapy is a function, in major part, of whether pathogenic microorganisms are still present at local subgingival sites at the completion of active therapy. The infecting bacterial species are susceptible to killing by several antibiotics including, among others, tetracycline-class drugs, amoxicillin and metronidazole as well as by local exposure to chlorhexidine. Randomized clinical trials have shown that use of systemically administered antibiotics as an adjunct to mechanical therapies significantly enhances clinical outcomes and stability. Several slow-release devices that deliver anti-microbial drugs directly into periodontal pockets have been developed and are now on the market. Use of these devices permits local delivery of long-lasting, high concentrations of doxycycline (Atridox) minocycline (Arestin), and chlorhexidine (PerioChip) directly into periodontal pockets. Although these devices differ with regard to ease of use, concentration of drug delivered and length of time high drug concentrations can be maintained, randomized clinical trials have shown that their use as an adjunctive treatment to scaling and root planing results in a significantly greater reduction of periodontal pocket depth and an average increase in clinical periodontal attachment level of about 0.8 mm. Gain in clinical attachment is greater in deeper pockets than in shallower pockets. Locally delivered adjunctive anti-microbial therapy is an effective means to enhance therapeutic outcomes. 2: Ann Periodontol. 2003 Dec;8(1):79-98. Local anti-infective therapy: pharmacological agents. A systematic review. Hanes PJ, Purvis JP. Department of Periodontics, Medical College of Georgia, School of Dentistry, Augusta, GA 30912-1220, USA. BACKGROUND: It is well recognized that periodontal diseases are bacterial in nature. An essential component of therapy is to eliminate or control these pathogens. This has been traditionally accomplished through mechanical means (scaling and root planing [SRP]), which is time-consuming, difficult, and sometimes ineffective. Over the past 20 years, locally delivered, anti-infective pharmacological agents, most recently employing sustained-release vehicles, have been introduced to achieve this goal. RATIONALE: This systematic review evaluates literature-based evidence in an effort to determine the efficacy of currently available anti-infective agents, with and without concurrent SRP, in controlling chronic periodontitis. FOCUSED QUESTION: In patients with chronic periodontitis, what is the effect of local controlled-release anti-infective drug therapy with or without SRP compared to SRP alone on changes in clinical, patient-centered, and adverse outcomes? SEARCH PROTOCOL: MEDLINE, the Cochrane Central Trials Register, and Web of Science were searched. Hand searches were performed of the Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. Searches were performed for articles published through April 2002. In addition, investigators contacted editors of the above-mentioned journals and companies sponsoring research on these agents for related unpublished data and studies in progress. SELECTION CRITERIA: INCLUSION CRITERIA: Studies included randomized controlled clinical trials (RCT), and case-controlled and cohort studies at least 3 months long. Therapeutic interventions had to include 1) SRP alone; 2) local anti-infective drug therapy and SRP; or 3) local anti-infective drug therapy alone. Included studies had to report patient-based mean values and measures of variation for probing depth (PD) and/or clinical attachment levels (CAL) for both test and control groups. EXCLUSION CRITERIA: Studies were excluded if they: 1) included data from a previously published article; 2) included daily rinsing with chlorhexidine (CHX); or 3) had unclear descriptions of randomization procedures, examiner masking, or concomitant therapies. DATA COLLECTION AND ANALYSIS: For the meta-analysis, PD and CAL were expressed as summary mean effects with 95% confidence intervals (CI) for the effect, and analyzed using a standardized difference between SRP alone and experimental agent groups. The results were assessed with both fixed-effects and random-effects models. Studies were ranked according to the York system. MAIN RESULTS: 1. Thirty-two studies were included (28 RCT, 2 cohort, and 2 case-control), incorporating a total patient population of 3,705 subjects. 2. Essentially all studies reported substantial reductions in gingival inflammation and bleeding indices, which were similar in both control and experimental groups. 3. A meta-analysis completed on 19 studies that included SRP and local sustained-release agents compared with SRP alone indicated significant adjunctive PD reduction or CAL gain for minocycline (MINO) gel, microencapsulated MINO, CHX chip and doxycycline (DOXY) gel during SRP compared to SRP alone. 4. Use of antimicrobial irrigants or anti-infective sustained-release systems as an adjunct to SRP does not result in significant patient-centered adverse events. REVIEWERS' CONCLUSIONS: 1. In some populations, anti-infective agents in a sustained-release vehicle alone can reduce PD and bleeding on probing (BOP) equivalent to that achieved by SRP alone. 2. No evidence was found for an adjunctive effect on reduction of PD and BOP of therapist-delivered CHX irrigation during SRP compared to SRP alone. 3. Additional RCTs are needed which evaluate the effectiveness of these therapies in all forms of periodontitis. 4. The study protocol for future RCTs should include appropriate statistical analyses and complete data sets to facilitate future evidence-based reviews. 5. Alternative surrogate parameters to PD and CAL need to be identified and validated such as microbial, inflammatory, or tissue-destructive markers that could be used in conjunction with clinical parameters to help determine the patient's response to emerging technologies that target the infectious and/or inflammatory aspects of periodontitis. 6. Future Phase IV clinical trials should be designed that evaluate local anti-infective therapies in conjunction with SRP in a manner consistent with current standards of care and evaluate cost-effectiveness. 7. The use of local anti-infective agents in at-risk patient populations and for the treatment of at-risk disease sites needs to be validated in randomized controlled clinical trials. 8. Several local anti-infective agents combined with SRP appear to provide additional benefits in PD reduction and CAL gain compared to SRP alone. The decision to use local anti-infective adjunctive therapy remains a matter of individual clinical judgment, the phase of treatment, and the patient's status and preferences. 3: Ann Periodontol. 2003 Dec;8(1):115-81. Systemic anti-infective periodontal therapy. A systematic review. Haffajee AD, Socransky SS, Gunsolley JC. Department of Periodontology, Forsyth Institute, Boston, Massachusetts, USA. BACKGROUND: Periodontal diseases are infections and thus systemically administered antibiotics are often employed as adjuncts for their control. There are conflicting reports as to whether these agents provide a therapeutic benefit. RATIONALE: The purpose of this systematic review is to determine whether systemically administered antibiotics improve a primary clinical outcome measure, periodontal attachment level change. FOCUSED QUESTION: In patients with periodontitis, what is the effect of systemically administered antibiotics as compared to controls on clinical measures of attachment level? SEARCH PROTOCOL: The Pub/Med database was searched from 1966 to May 2002. Searches were limited to human studies published in English. Hand searches were performed on the Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. References in relevant papers and review articles were also examined. SELECTION CRITERIA: INCLUSION CRITERIA: Trials were selected if they met the following criteria: randomized controlled clinical trials, quasi-experimental studies, and cohort studies of > 1 month duration with a comparison group; subjects with aggressive, chronic, or recurrent periodontitis and periodontal abscess; use of a single or a combination of systemically administered antibiotics(s) versus non-antibiotic therapy; and a primary outcome of mean attachment level change (AL). EXCLUSION CRITERIA: Studies involving the use of low-dose doxycycline, combinations of locally plus systemic antibiotics, or where the control group included a systemically administered antibiotic were excluded. DATA COLLECTION AND ANALYSIS: A mean difference in AL between groups was available for all papers used in the meta-analysis. A standard deviation (SD) for the difference was used if provided or calculated from the SD or standard error of the mean (SEM) when provided for single measurements. Data were subset by antibiotic employed, type of adjunctive therapy, and disease type. Results were assessed with both fixed-effects and random-effects models. MAIN RESULTS: 1. Twenty-nine studies, 26 RCTs and 3 quasi-experimental (36 comparisons), met the entry criteria. Total study population, both control and test groups, was estimated at over 1,200. 2. Twenty-two studies (27 comparisons) were used in the meta-analysis, evaluating if the antibiotics provided a consistent benefit in mean AL change for different patient populations, for different therapies, and for different antibiotics. 3. For the majority of the comparisons, systemically administered antibiotics exhibited a more positive attachment level change than the control group in the study. The combined results were statistically significant (P < 0.001). 4. The systemic antibiotics were uniformly beneficial in providing an improvement in AL when used as adjuncts to scaling and root planing (SRP) and were consistently beneficial, although of borderline significance, when used as adjuncts to SRP plus surgery or as a stand alone therapy. 5. When examining the effects of individual or combinations of antibiotics, it was found that there were statistically significant improvements in AL for tetracycline, metronidazole, and an effect of borderline statistical significance for the combination of amoxicillin plus metronidazole. 6. Improvements in mean AL were consistent for both chronic and aggressive periodontitis subjects, although the aggressive periodontitis patients benefited more from the antibiotics. REVIEWERS CONCLUSIONS: 1. The use of systemically administered adjunctive antibiotics with and without SRP and/or surgery appeared to provide a greater clinical improvement in AL than therapies not employing these agents. 2. The data supported similar effect sizes for the majority of the antibiotics; therefore, the selection for an individual patient has to be made based on other factors. 3. Due to a lack of sufficient sample size for many of the antibiotics tested, it is difficult to provide guidance as to the more effective ones. 4: J Clin Periodontol. 1998 May;25(5):354-62. The use of metronidazole and amoxicillin in the treatment of advanced periodontal disease. A prospective, controlled clinical trial. Berglundh T, Krok L, Liljenberg B, Westfelt E, Serino G, Lindhe J. Department of Periodontology, Faculty of Odontology, Goteborg University, Sweden. The present clinical trial was performed to study the effect of systemic administration of metronidazole and amoxicillin as an adjunct to mechanical therapy in patients with advanced periodontal disease. 16 individuals, 10 female and 6 male, aged 35-58 years, with advanced periodontal disease were recruited. A baseline examination included assessment of clinical, radiographical, microbiological and histopathological characteristics of periodontal disease. The 16 patients were randomly distributed into 2 different samples of 8 subjects each. One sample of subjects received during the first 2 weeks of active periodontal therapy, antibiotics administered via the systemic route (metronidazole and amoxicillin). During the corresponding period, the 2nd sample of subjects received a placebo drug (placebo sample). In each of the 16 patients, 2 quadrants (1 in the maxilla and 1 in the mandible) were exposed to non-surgical subgingival scaling and root planing. The contralateral quadrants were left without subgingival instrumentation. Thus, 4 different treatment groups were formed; group 1: antibiotic therapy but no scaling, group 2: antibiotic therapy plus scaling, group 3: placebo therapy but no scaling, group 4: placebo therapy plus scaling. Re-examinations regarding the clinical parameters were performed, samples of the subgingival microbiota harvested and 1 soft tissue biopsy from 1 scaled and 1 non-scaled quadrant obtained 2 months and 12 months after the completion of active therapy. The teeth included in groups 1 and 3 were following the 12-month examination exposed to non-surgical periodontal therapy, and subsequently exited from the study. Groups 2 and 4 were also re-examined 24 months after baseline. The findings demonstrated that in patients with advanced periodontal disease, systemic administration of metronidazole plus amoxicillin resulted in (i) an improvement of the periodontal conditions, (ii) elimination/suppression of putative periodontal pathogens such as A. actinomycetemcomitans, P. gingivalis, P. intermedia and (iii) reduction of the size of the inflammatory lesion. The antibiotic regimen alone, however, was less effective than mechanical therapy with respect to reduction of BoP - positive sites, probing pocket depth reduction, probing attachment gain. The combined mechanical and systemic antibiotic therapy (group 2) was more effective than mechanical therapy alone in terms of improvement of clinical and microbiological features of periodontal disease. 5: J Clin Periodontol. 2004 Oct;31(10):869-77. Clinical and microbiological changes associated with the use of combined antimicrobial therapies to treat "refractory" periodontitis. Haffajee AD, Uzel NG, Arguello EI, Torresyap G, Guerrero DM, Socransky SS. Department of Periodontology, The Forsyth Institute, Boston, MA, USA. BACKGROUND: The present investigation examined clinical and microbial changes after a combined aggressive antimicrobial therapy in subjects identified as "refractory" to conventional periodontal therapy. METHOD: Fourteen subjects were identified as "refractory" based on full-mouth mean attachment loss and/or >3 sites with attachment loss > or =3 mm following scaling and root planing (SRP), periodontal surgery and systemic antibiotics. After baseline monitoring, subjects received SRP, locally delivered tetracycline at pockets > or =4 mm, systemically administered amoxicillin (500 mg, t.i.d. for 14 days)+metronidazole (250 mg, t.i.d. for 14 days) and professional removal of supragingival plaque weekly for 3 months. Subjects were monitored clinically every 3 months post-therapy for 2 years. Subgingival plaque samples were taken at the same time points from the mesial aspect of each tooth and the levels of 40 subgingival taxa were determined using checkerboard DNA-DNA hybridization. Mean levels of each species were averaged within a subject at each visit. Significance of changes in clinical and microbiological parameters over time were evaluated using the Friedman or Wilcoxon signed ranks test. RESULTS: On average, subjects showed significant improvements in all clinical parameters after therapy. Mean (+/-SEM) full-mouth pocket depth reduction was 0.83+/-0.13 mm and mean attachment level "gain" was 0.44+/-0.12 at 24 months. Clinical improvement was accompanied by major reductions in multiple subgingival species during the first 3 months of active therapy that were maintained for most species to the last monitoring visit. Reductions occurred for three Actinomyces species, "orange complex" species including Campylobacter showae, Eubacterium nodatum, three Fusobacterium nucleatum subspecies, Peptostreptococcus micros, Prevotella intermedia as well as the "Streptococcus milleri" group, Streptococcus anginosus, Streptococcus constellatus and Streptococcus intermedus. Subjects differed in their response to therapy; six modest response subjects exhibited less attachment level gain and were characterized by reductions in the microbiota from baseline to 3 months, but re-growth of many species thereafter. CONCLUSIONS: The combined antibacterial therapy was successful in controlling disease progression in 14 "refractory" periodontitis subjects for 2 years. Copyright Blackwell Munksgaard, 2004 Dear Paul, have a question! Somebody approached me telling me the story of the PCR checkerboard test in Perio. He than asked me why not doing the same in Endo. I asked him: where would the great benefit be? Who can pay for? His answer: You will know when the root canal filling is indicated! Let me just put this short conversation in the air and wait for suggestions, comments, of course critique and please lots of advises! - Liviu Dear Liviu. Do you mean this type of work? I glanced over it last night. It seems as certain strains can grow in the presence of calcium hydroxide? Or at least ther was a moderate increase in the prevalence of A actinomycetemcomitans, E corrodens and E nodatum. Where have I seen increased prevalence or growth of mico-organisms in the presence of calcium hydroxide before? . At least E. faecalis was gone after treatment in primary endodontic infections with sodium hypochlorite and calcium hydroxide. But may be I should take the time to read it better. I hope this information helps you and is what you were asking for - Paul Wesselink Honesty has nothing to do with bias when you are the inventor. Actually Dr. Hoshino is not the clinician in the reported studies with almost 100%.success.. He is certainly the world expert in Carious Dentin and therefore of bacteria in the tubules. The use for revascularization came later, he was looking for a mix to disinfect dentin. I certainly have been fascinited with his work. as it was an area of research interest for me. Below are abstract of some of the studies not about re-vascularization but disinfection of dentin, including the one on "anti-freeze" polypropilen glycol. Glicol de propileno in Spanish ... I did some pilot work 25 years ago mixing an acetate salt of Chlorexidine (not gluconate but acetate) in carious dentin, we also mixed CHX with polycarboxilate, there was a paper by Schwartzman, Caputo on this in J. Prost. dentistry.Boris worked in our lab in Mexico as an undergrad. and took the idea to UCLA where he studied for his Prsth. specialty, he got Dr. Caputo a materials science man into the idea. Schwartzman, B., A. A. Caputo, et al. (1980). "Antimicrobial action of dental cements." J Prosthet Dent 43(3): 309-12. It was observed that some of the cements tested had bacteriostatic and/or bactericidal action. The cements listed in decreasing order of effectiveness are (1) zinc oxide-eugenol, (2) silicophosphate, (3) zinc phosphate, and (4) silicate. The two newer cements, polycarboxylate and composite resin, exhibited no measurable antimicrobial action. Schwartzman B, Caputo AA Enhancement of antimicrobial action of polycarboxylate cement. In: J Prosthet Dent (1982 Aug) 48(2):171-3 Hoshino, E., N. Kurihara-Ando, et al. (1996). "In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline." Int Endod J 29(2): 125-30. The aim of this study was to clarify the antibacterial effect of a mixture of ciprofloxacin, metronidazole and minocycline, with and without the addition of rifampicin, on bacteria taken from infected dentine of root canal walls. The efficacy was also determined against bacteria of carious dentine and infected pulps which may the precursory bacteria of infected root dentine. This efficacy was estimated in vitro by measuring bacterial recovery on BHI-blood agar plates in the presence or absence of the drug combination. Bacteria ranging in number from 10(2) to 10(6) occurred in samples of infected root dentine (27 cases). However, none was recovered from the samples in the presence of the drug combination at concentrations of 25 micrograms ml-1 each. The respective drug alone (10, 25, 50 and 75 micrograms ml-1) substantially decreased the bacterial recovery, but could not kill all the bacteria. Bacteria taken from carious dentine (25 cases) and infected pulps (12 cases) were also sensitive to the drug combination. These results may indicate that the bactericidal efficacy of the drug combination is sufficiently potent to eradicate bacteria from the infected dentine of root canals. Hori, R., S. Kohno, et al. (1997). "Bactericidal eradication from carious lesions of prepared abutments by an antibacterial temporary cement." J Prosthet Dent 77(4): 348-52. PURPOSE: The aim of this study was to observe the antibacterial potential of polycarboxylate temporary cement containing a mixture of metronidazole, ciprofloxacin, and cefaclor on carious lesions of prepared abutments that were designed to leave caries on the abutments. MATERIAL AND METHODS: Antibacterial efficacy was estimated in vitro and in vivo by measuring bacterial recovery from the lesions. Bacteria counts ranged from 10(4) to 10(7) both in vitro (nine samples) and in vivo (five samples) in time-zero samples, just before the application of the antibacterial cement. RESULTS: No bacteria were recovered from carious lesions in vitro (six samples) or in vivo (four samples) after the lesions were covered by the antibacterial temporary cement. For the remaining samples, some bacteria (5 to 80 counts per sample) were recovered, with one notable exception in which marginal leakage provided a bacteria count of 10(3). Bacteria counts ranging from 10(3) to 10(5) occurred in carious lesions covered by temporary cement without antibacterial agents, which indicated that temporary cement alone was not a potent disinfectant. CONCLUSIONS: The results of this study indicated that the antibacterial temporary cement can be useful for eradicating bacteria from carious lesions of prepared abutments. Cruz, E. V., K. Kota, et al. (2002). "Penetration of propylene glycol into dentine." Int Endod J 35(4): 330-6. AIM: This study aimed to evaluate penetration of propylene glycol into root dentine. METHODOLOGY: Safranin O in propylene glycol and in distilled water were introduced into root canals with and without artificial smear layer. Dye diffusion through dentinal tubules was determined spectrophotometrically. The time required for dye to exit through the apical foramen using propylene glycol and distilled water as vehicles was also determined. The extent and areas of dye penetration on the split surfaces of roots were assessed using Adobe Photoshop and NIH Image Software. RESULTS: Propylene glycol allowed dye to exit faster through the apical foramen. The area and depth of dye penetration with propylene glycol was significantly greater than with distilled water (P < 0.0001). Smear layer significantly delayed the penetration of dye. CONCLUSION: Propylene glycol delivered dye through the root canal system rapidly and more effectively indicating its potential use in delivering intracanal medicaments. Ben posted this abstract bt Hoshino's group previously: Int Endod J. 1998 Jul;31(4):242-50. Bacterial eradication from root dentine by ultrasonic irrigation with sodium hypochlorite. Huque J, Kota K, Yamaga M, Iwaku M, Hoshino E. Department of Operative Dentistry and Endodontics, Niigata University School of Dentistry, Japan. The study aimed to evaluate intracanal irrigation procedures in eradicating bacteria from surface, shallow and deep layers of root dentine using extracted human teeth. Artificial bacterial smear layer was successfully produced by rubbing a mixture of dental plaque and artificially decalcified dentine or carious dentine on root canal walls. The reservoir holes were 3.5 mm in depth, 1 mm in diameter prepared 1.5 mm apart and parallel to the root canals on the decrowned planes, in which five separate bacterial species were placed (Actinomyces israelii, Fusobacterium nucleatum, Propionibacterium acnes, Streptococcus mutans and Streptococcus sanguis). Bacterial eradication after irrigation of the prepared canals was determined by bacterial recovery (i) from the root canal surfaces and shallow layers where bacteria were smeared artificially and (ii) from deeper layers of root canal dentine reservoir holes. Ultrasonic irrigation with 5.5% and 12% NaOCl eradicated bacteria from artificial smear layer (P < 0.0001), whilst 12% NaOCl irrigation with a syringe was insufficient. Ultrasonic irrigation with water or 15% EDTA-failed to eradicate bacteria from smeared surfaces. Ultrasonic irrigation with 12% NaOCl killed A. israelii, F. nucleatum, P. acnes, S. mutans, and S. sanguis placed in reservoir channels, although for F. nucleatum, a very small number of bacteria remained in five samples out of 12. Ultrasonic irrigation with less concentrated NaOCl failed to eliminate bacteria completely from reservoir channels in most samples. Ultrasonic irrigation with 12% NaOCl appeared to eliminate bacteria efficiently from surface, shallow and deep layers of root dentine. Fred, My first time posting to this group although I have appreciated what I have read so far. I graduated from dental school in 1997, and at that point, what we were taught in the endo clinic was mix the calcium hydroxide powder with "pretty much any sterile liquid" ...we used sterile water, sterile saline or even lidocaine. And now you are saying, maybe the pH is important??? :) Well, that's going to change if you are using these different liquids. It would also change depending on the viscosity of the mix, true? i.e., more or less calcium hydrox:water ratio? Could this explain why it works so well for some, but not for others? You mean everything I learned in dental school isn't engraved in stone? - CATHERINE JOHNSON MINCY, DDS If you mix Ca(OH)2 USP powder with local anesthetic, the pH is still very high; and works clinically.How do I know.......I have used it that way for years......see, clinical empiricism ;-)) Same goes for CHX. The high pH accounts for the antimicrobial effectiveness as most of the canal bugs are not alkalinophilic. Of course, E. faecalis, the famous bug, can survive in a pH of at least 10. This bug can neutralize its cytoplasm via proton pumps. See papers by David Figdor et al. - Fred Hi Fred , abpout 15 years ago, I started to use Ca(OH)2 because the lit suggested to do so and because Ledermix/Aphaline was not considered chemically correct although it worked fine. As a consequence, I had a lot of flareups and went back to my old L/A. It was several years later that I took a course with Oliver Pontius who showed single visit endo in necrotic teeth using lots of NaOCl for irrigation and emphasizing the importance of patency (a term I had never heard of before) and suggesting Ca(OH)2 as a dressing. I retried with higher concentrations of NaOCl and longer rinsing and patency and Ca(OH)2 as an interdediate dressing and - big surprise - Ca(OH)2worked fine all of a sudden. I did not need the L/A any more. My gut feeling from these experiences is that you have to clean the canal to the foramen, dissolve the tissue with NaOCl and then and only then Ca(OH)2 will work predictably in necrotic cases. Vital cases are a different story. Back in those early L/A days, my problem were vital teeth with pulps bleeding like hell and widened pdl. Necrotic cases with big translucencies worked a lot better. Looking back I interpret this problem as lack of dissolving the tissue with NaOCl, giving neither Ca(OH)2 nor L/A a chance to reach the problem. Does that make sense to you? - Winfried Winfied, Exactly! You get it. Nonspecific agents, bleach, CH, and Chlorhexidine work just fine and the most clinically significant and variable part of the process is the mechanical debridement that allows access of these agents. The obsession with specific antimicrobial concoctions like Ledermix fails to address the weakest link of the treatment process contributing to success or failure which is the variable operator level and ability to skillfully "clean and shape". - Terry It certainly makes sense to me, Winfried. CaOH is a cauterizing agent. It works on contact. The only reliable Tx is C&S to completion, plus CaOH which will then make contact where "the rubber meets the road". DougR Hi Winfried, Yes, it does make some sense to me. The Ca(OH)2 has to get to the problem area to work best. Minimal debridement of a canal, and then trying to get the white stuff down there and expecting good results does not work. I did a study at Penn on 2000 teeth, looking at flare-ups (never published but presented at the IADR). 1000 teeth were from the postdoc clinic and 1000 teeth were from my practice over a period of time. We did NOT practice patency, but, the canal was COMPLETELY DEBRIDED to 0.5 to 1mm short of radiographic apex with diluted NaOCl, and then filled with Ca(OH)2 powder mixed with either sterile water or LA solution. Asymptomatic teeth had a flare-up rate of about 2.5%. Silver point retreatments : ~10%. - Fred
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