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The aim of this case report was to show the concept of guided endodontics in a maxillary first molar with limited interocclusal space. Guided endodontics involves merging cone-beam computed tomographic imaging and a surface scan of the tooth in order to create a guide to perform a drill path into the seemingly obliterated root canal. In the molar region, the interocclusal space is often too small to accommodate the guide, bur, and handpiece at once, and, therefore, a modified approach is presented. A 52-year-old man was referred because the dentist had failed to localize the distobuccal root canal of a maxillary molar (#3) associated with apical pathosis. After reopening and rubber dam placement, a glide path was established for both the palatal first mesiobuccal root canal and the second mesiobuccal using a size 10 hand file and coronal flaring. Further instrumentation to the working length was achieved by reciprocating file size 25. All 3 canals were temporarily filled with calcium hydroxide. For the distobuccal root canal, guided endodontics was chosen in order to avoid further impairment of the tooth because negotiation of the canal failed even with the use of the operating microscope. Following the merged data obtained from the cone-beam computed tomographic and surface scans, a translucent SICAT Optiguide (SICAT, Bonn, Germany) was constructed containing a sleeve representing the proper direction of a drill path in order to reach the distobuccal root canal. The access cavity was temporarily filled with a composite material made for light-curing. Before light curing, the Optiguide was replaced on the teeth, and a steel pin was pressed through the sleeve and the composite whereby the proper drill path direction was transferred into the composite. After polymerization and removal of the Optiguide and pin from the composite base sleeve, the guided drilling could be performed. This case report is the first on guided access preparation in a molar with pulp canal obliteration and limited interocclusal space. The demand for more interocclusal space was solved by transforming the virtual drill path into a composite-based intracoronal guide. The use of digital technology was essential. [ABSTRACT FROM AUTHOR]

Introduction The aim was to present a case report of a full-length extrusion of an obturator's core carrier into the maxillary sinus, causing clinical symptoms from the nose region with differential diagnostics aspects, which, in turn, led to several surgical treatments of the nostrils before diagnosis and correct endodontic retreatment of a maxillary right first molar. A 36-year-old man presented in 2012 with complaints from the right nostril region. Medical treatment with antibiotics and surgical procedures because of nasal stenosis resulted only in partial improvement. Five years earlier, a root canal treatment was performed on the maxillary right first molar. Intraoral radiographs revealed 10-mm overfilling of root filling material into the maxillary sinus from the palatal root of tooth #3. Methods Before surgical removal of the excess root filling material, orthograde revision was performed. Cone-beam computed tomographic imaging was used to localize the position of the root filling material, which protruded through the maxillary sinus and reached the inferior nasal wall. Results Surgical removal from the palatal aspect revealed that the root filling material was a core carrier of an obturator. Scanning electron microscopy and transmission electron microscopy showed evidence of microbial biofilm on the core carrier as well as remnants of sinus mucosa. At the long-term follow-ups, the tooth had healed apically, and symptoms of nasal stenosis were markedly reduced. Conclusions This case report represents a challenging differential diagnostic topic urging the importance of a medical and dental interdisciplinary dialogue. The use of cone-beam computed tomographic imaging was crucial for the surgical retreatment. [ABSTRACT FROM AUTHOR]

Introduction The aim was to assess survival in the Swedish population of teeth treated by nonsurgical root canal treatment during 2009. Methods Data from the Swedish Social Insurance Agency were analyzed by Kaplan-Meier analysis to assess cumulative tooth survival during a period of 5–6 years of all teeth that were root-filled during 2009. Results In 2009, 248,299 teeth were reported as root-filled. The average age of the patients at the time of the root filling was 55 years (range, 20–102 years). The teeth most frequently root-filled were the maxillary and mandibular first molars. During the 5- to 6-year period 25,228 of the root-filled teeth (10.2%) were reported to have been extracted; thus 223,071 teeth (89.8%) survived. Tooth survival was highest in the youngest age group (93.2%). The highest survival (93.0%) was for the mandibular premolars, and the lowest (87.5%) was for the mandibular molars. Teeth restored with indirect restorations within 6 months of the root filling had higher survival rates (93.1%) than those restored with a direct filling (89.6%). Conclusions In the adult population of Sweden, teeth that are root-filled by general practitioners under the tax-funded Swedish Social Insurance Agency have a 5- to 6-year survival rate of approximately 90%. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to analyze cases of liability claims related to persistent altered sensation following endodontic treatments so as to characterize the medico-legal aspects of this complication. Study design: A comprehensive search of an Israeli professional liability insurance database was conducted to retrospectively identify and analyze cases of persistent altered sensation following endodontic treatment. Results: Sixteen claims of persistent altered sensation following endodontic treatments were identified and analyzed. The typical profile of a claim was a female patient who underwent an endodontic treatment at a second mandibular molar, which was associated with overfilling. A significant correlation between the tooth location and the suggested cause of nerve injury was found. None of the claims were reported by the practitioners, and all cases were identified as a result of the patient''s demand for financial compensation, either directly or by legal actions. Conclusions: When a nerve injury is diagnosed, the treating practitioner should be encouraged to seek medical and legal assistance so as to prevent permanent damage and to enable a better medico-legal response. [Copyright &y& Elsevier]

Objective: This investigation explored the hypothesis that among general dental practitioners (GDPs), the performance of root fillings of substandard quality might be associated with deficient knowledge of factors important to the outcome of endodontic treatment. Study design: A questionnaire was mailed to 600 randomly selected GDPs. The influence of 24 factors on treatment outcome was assessed on 100 mm visual analog scales. A gold standard (GS) was established by an external group of researchers. Comparisons between the GDP response and the GS were analyzed using Wilcoxon tests. Results: Despite large variation, the responses were significantly associated with sex, year of education, and exposure to endodontic treatment. Compared with the GS, the GDPs emphasized factors associated with clinical symptoms and underevaluated factors related to the microbial situation in the root canal. Conclusions: The GDPs seemed to regard endodontics mainly to be a procedure to keep a patient free of symptoms. [Copyright &y& Elsevier]

Article Title and Bibliographic Information: Ways of enhancing pulp preservation by stepwise excavation—a systematic review. Hayashi M, Fujitani M, Yamaki C, Momoi Y. J Dent 2011;39(2):95-107. Epub 2010 Dec 3. Reviewer: Lars Bjørndal, DDS, PhD, Dr Odont Purpose/Question: To determine the clinical effectiveness of stepwise excavation for pulp preservation Source of Funding: Japanese Society of Conservative Dentistry Type of Study/Design: Systematic review Level of Evience: Level 2: Limited-quality patient-oriented evidence Strength of Recommendation Grade: Grade B: Limited-quality patient-oriented evidence [Copyright &y& Elsevier]

Studies on dental regeneration involving interventions for pulp therapy such as regeneration and revascularization procedures are promising for the injured tooth; however, a complete replication of the original pulp tissue does not seem to take place. In cases in which we wish to preserve or maintain parts of the pulp during treatment, it is apparent that the effectiveness of healing or biological regeneration is dependent on the degree of inflammation of the pulp tissue. Thus, the control or prevention of a pulp infection is still a major issue for the clinicians. Data indicate that the typical reason for performing endodontic treatment is deep caries. The biological concept of vital pulp therapy associated with deep caries takes the treatment and evaluation of the unexposed as well as the exposed pulp into account. Interestingly, the clinical diagnosis is typically the same. Deep caries with reversible pulpitis may receive differing treatments such as excavation procedures aiming to avoid pulp exposure or more pulp invasive treatments such as pulp capping or pulpotomy. This should not be the case. Consequently, huge treatment variation is noted among clinicians based on the same caries diagnosis. Which treatment should be selected? High-quality trials are needed, and it is important to obtain information on the actual lesion depth and an estimate of the lesion activity before treatment. These may be basic indicators for the regenerative potential of dental pulp. Recent clinical trials dealing with the treatment of deep caries lesion are discussed, including pulp invasive and noninvasive concepts, to attempt to solve the task of getting the best clinical outcome for adult patients. [ABSTRACT FROM AUTHOR]

Abstract: Various treatment concepts have been suggested to solve the deep carious lesion dilemma. Recent systematic reviews are presented. Their conclusions are based on very few studies, and the main message is that optimal randomized clinical studies are lacking. Observational studies on indirect pulp treatment and stepwise excavation demonstrate that these treatments avoid pulp exposures, but it cannot be said which approach is best. A less invasive modified stepwise excavation approach is described, focusing on changing an active lesion into an arrested lesion even without performing an excavation close to the pulp. In Denmark and Sweden a randomized clinical multi-center trial is currently taking place, the Caries and Pulp (CAP) trial. This trial is investigating the effects of stepwise excavation over 2 visits versus 1 complete excavation of deep caries in permanent teeth. Guidelines for treatment are presented. [Copyright &y& Elsevier]

Abstract: The understanding of the caries process and its effect on the pulp is presented in the context that caries does develop in various rates of progression. Early in the caries process, the pulp reflects changes within lesion activity. Thus, the early pulp response is reversible. Later, the rate of caries progression is reflected by the quality of the tertiary dentin. Slowly progressing lesions create tertiary dentin resembling normal tubular dentin. Rapidly progressing lesions lead to the production of atubular dentin or complete absence of tertiary dentin, as well as pulp necrosis and apical pathology. Finally, the nature of the untreated deep carious lesion is an ecosystem that might undergo significant changes. The untreated lesion is temporarily converted from an active and closed lesion environment into one that is open and slowly progressing. The analysis of untreated carious lesions has transformed the treatment philosophy of deep carious lesions. [Copyright &y& Elsevier]