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Asepsis is Everything!! The Seal is the Deal Everything Eventually Leaks Slide 2 11 week Recall Eric M. Rivera, DDS, MS Slide 3 Where to Sear Root Canal Filling Material Flush With Orifice Level Below Orifice Level VS Slide 4 Where to Place Restorative Material Flush With Orifice Level Below Orifice Level Amalgam Plug Not Needed(?) VS Amalgam as Final Restoratuion - Sufficient Remaining Tooth Structure Slide 5 Where to Place Restorative Material Flush With Orifice Level Below Orifice Level Amalgam Plug Needed(?) VS Amalgam as Final Restoratuion - Insufficient Remaining Tooth Structure Slide 6 IntraCoronal Amalgam Use With respect to depth of amalgam in the canal space, it is speculated that it is not necessary to use amalgam as a coronal-radicular core material if adequate volume of chamber exists. If minimal chamber volume exists, may gain additional retention and seal. Nayyar A, Walton RE, and Leonard LA. An amalgam coronal-radicular dowel and core technique for endodontically treated posterior teeth. J Prosthet Dent, 1980. 43(5): p. 511-5. Ulusoy N, Nayyar A, Morris CF, Fairhurst CW. Fracture durability of restored functional cusps on maxillary nonvital premolar teeth. J Prosthet Dent, 1991. 66(3): p. 330-5. Slide 7 Coronal Restoration Just as important and many times more important than Root Canal Filling due to coronal microleakage Ray, H.A. and M. Trope, Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J, 1995. 28(1): p. 12-8. The purpose of this study was to evaluate the relationship of the quality of the coronal restoration and of the root canal obturation on the radiographic periapical status of endodontically treated teeth. Full-mouth radiographs from randomly selected new patient folders at Temple University Dental School were examined. The first 1010 endodontically treated teeth restored with a permanent restoration were evaluated independently by two examiners. Post and core type restorations were excluded. According to a predetermined radiographic standard set of criteria, the technical quality of the root filling of each tooth was scored as either good (GE) or poor (PE), and the quality of the coronal restoration similarly good (GR) or poor (PR). The apical one-third of the root and surrounding structures were then evaluated radiographically and the periradicular status categorized as (a) absence of periradicular inflammation (API) or (b) presence of periradicular inflammation (PPI). The rate of API for all endodontically treated teeth was 61.07%. GR resulted in significantly more API cases than GE, 80% versus 75.7%. PR resulted in significantly more PPI cases than PE, 30.2% versus 48.6%. The combination of GR and GE had the highest API rate of 91.4%, significantly higher than PR and PE with a API rate of 18.1%. Slide 8 34mo Recall Eric M. Rivera, DDS, MS Slide 9 LuxaCore Blue Shade Resin Chlorhexidine Pellet Slide 10 Slide 11 PermaFlo Purple Whats the big deal about coronal seal? Slide 12 Flowable Composite Root Canal Filling Material (Resilon/Gutta Percha) Flowable Composite May provide added protection against bacterial contamination, especially if: Temporary restoration leaks or is lost Restorative procedures are not performed under rubber dam isolation Not recommended as build-up material due to strength and dimensional stability concerns Fills the difficult to access intracoronal space (due to magnification and illumination under Dental Operating Microscope) Slide 13 Intraorifice Barrier/Sealing Intraorifice barriers should be considered immediately after Root Canal filling as a secondary seal to prevent infection/reinfection by microleakage. Slide 14 NameYrType StudyAmt IO Barrier Results Roghanizad & Jones 1996Leakage Dye3.0 mmAmal w Varnish > Cavit = Term > Control Pisano et al1998Leakage Microbes3.5 mmCavit > IRM = Super EBA > Control (all leaked in < 49 days) Wolcott et al1999Leakage Microbes3.0 mmGI (Vitrebond=GC America=Ketac bond) > No Barrier Belli et al2001Leakage Fluid Filtration?Resins (ClearfilSEBond=OneStep=C&B Metabond) > IRM >GP No Sealer Galvan et al2002Leakage Fluid Filtration3.0 mmAmalgambond > C&B Metabond > (IRM = Eliteflo = Palfique) > Control Howdle et al2002Leakage Dye Transparency ?Bonded Tytin (Vitrebond=SuperbondD Liner II=Panavia 21) > Unbonded Tytin Shindo et al2004Leakage Dye4.0 mmAdvantageous sealing ability of Adhesive and Flowable Materials Shimada et al2004Histology Monkey?No necrosis in any groups. No bacterial penetration along cavity walls in Flowable Composite or Glass Ionomer Cement. Amalgam without Adhesive Liner showed slight bacterial penetration along wall Yamauchi et al2005 Abstract Histology Dog left open2.0 mmSignificant periapical inflammation in 90% of samples when plugs not placed. Reduced to 47% w Composite or 37% w IRM Plug. Slide 15 Intraorifice Barrier/Sealing Intraorifice barriers should be placed immediately after Root Canal filling as a secondary seal to prevent infection/reinfection by microleakage. Slide 16 Slide 17 Intraorifice Barrier/Sealing Roghanizad N and Jones JJ, Evaluation of coronal microleakage after endodontic treatment. J Endod, 1996. 22(9): p. 471-3. A new method is suggested for placing a coronal seal in the orifice of the root canal right after root canal therapy. Root canal therapy was done on 94 extracted human maxillary centrals. Three mm of the coronal gutta-percha was replaced by either Cavit, TERM, or amalgam with cavity varnish. After thermocycling and 2 wk of immersion in dye, the amount of dye penetration was measured. The results showed that amalgam with two coats of cavity varnish sealed significantly better than Cavit and TERM. However, Cavit and TERM were still significantly better than a positive control group. Slide 18 Intraorifice Barrier/Sealing Pisano DM, DiFiore PM, McClanahan SB, Lautenschlager EP, Duncan JL. Intraorifice sealing of gutta-percha obturated root canals to prevent coronal microleakage. J Endod, 1998. 24(10): p. 659-62. A study was conducted to evaluate Cavit, Intermediate Restorative Material, and Super-EBA as intraorifice filling materials to prevent coronal microleakage. Root canal instrumentation and obturation was done on 74 extracted single- rooted teeth. Three and one-half millimeters of the gutta-percha was removed from the coronal aspect of the root canal and replaced with one of the three filling materials. The teeth were suspended in scintillation vials containing trypticase soy broth, and human saliva was added to the pulp chambers. Microbial penetration was detected as an increase in turbidity of the broth corresponding to bacterial growth. At the end of 90 days, the results showed that 15% of the Cavit-filled orifices leaked, whereas 35% of the Intermediate Restorative Material and Super-EBA- filled orifices leaked. The gutta-percha obturated root canals that received an intraorifice filling material leaked significantly less than the obturated, unsealed control group--all of which leaked in < 49 days. Slide 19 Intraorifice Barrier/Sealing Wolcott JF, Hicks ML, Himel VT. Evaluation of pigmented intraorifice barriers in endodontically treated teeth. J Endod, 1999. 25(9): p. 589-92. The purpose of this study was to evaluate the effectiveness of three pigmented glass ionomer cements used as intraorifice barriers to prevent coronal microleakage. One hundred ten extracted mandibular human premolars were divided into four experimental groups of 25 teeth each and two control groups of 5 teeth each. The experimental teeth were instrumented and obturated using thermoplasticized gutta- percha and AH26 sealer. Group 1 teeth received no further treatment. Teeth in groups 2 through 4 had 1 of 3 pigmented glass ionomers (Vitrebond, GC America, and Ketac- Bond) placed as an intraorifice barrier. Positive control teeth were instrumented but not obturated. The negative control teeth were instrumented, obturated, and externally sealed with epoxy resin. The coronal 3 mm of each root was sealed into the lumen of an 18-mm segment of latex surgical tubing. After the apparatus was sterilized, 2.0 ml of a 24 h growth of Proteus vulgaris in trypticase soy broth (TSB) was placed in the coronal reservoir of the tooth. The inoculated apparatus was placed into a presterilized test tube containing 1.5 ml of TSB and incubated for 90 days at 37 degrees C. The TSB in the lower reservoir was observed daily for turbidity, which would indicate leakage along the full length of the obturated root canal. To determine if differences in microbial leakage occurred among the four experimental groups, Pearson's chi 2 and Fisher's exact tests were performed. The confidence level was set at 95%. The positive and negative controls validated the microbial testing method. The teeth without an intraorifice barrier leaked significantly more than teeth with Vitrebond intraorifice barriers (p 0.05). Slide 20 Intraorifice Barrier/Sealing Belli S, Zhang Y, Pereira PN, Pashley DH. Adhesive sealing of the pulp chamber. J Endod, 2001. 27(8): p. 521-6. The purpose of this in vitro study was to evaluate quantitatively the ability of four different filling materials to seal the orifices of root canals as a secondary seal after root canal therapy. Forty extracted human molar teeth were used. The top of pulp chambers and distal halves of the roots were removed using an Isomet saw. The canal orifices were temporarily sealed with a gutta-percha master cone without sealer. The pulp chambers were then treated with a self-etching primer adhesive system (Clearfil SE Bond), a wet bonding system (One-Step), a 4-methacryloyloxyethyl trimellitate anhydride adhesive system (C&B Metabond), or a reinforced zinc oxide-eugenol (IRM). The specimens were randomly divided into four groups of 10 each. A fluid filtration method was used for quantitative evaluation of leakage. Measurements of fluid movement were made at 2-min intervals for 8 min. The quality of the seal of each specimen was measured by fluid filtration immediately and after 1 day, 1 wk, and 1 month. Even after 1 month the resins showed an excellent seal. Zinc oxide-eugenol had significantly more leakage when compared with the resin systems (p < 0.05). Adhesive resins should be considered as a secondary seal to prevent intraorifice microleakage. Slide 21 Intraorifice Barrier/Sealing Galvan RR, West LA, Liewehr FR, Pashley DH. Coronal microleakage of five materials used to create an intracoronal seal in endodontically treated teeth. J Endod, 2002. 28(2): p. 59-56. The purpose of this study was to quantitatively compare the sealing effectiveness of five restorative materials that were used to create an intracoronal double seal. Fifty-two extracted mandibular molars were randomly divided into five groups of 10 teeth, and one positive and one negative control tooth. The crowns were removed and the pulpal floor and canal orifices were sealed with 3 mm of one of the following materials: Amalgabond, C&B Metabond, One-Step Dentin Adhesive with AEliteflo composite, One-Step with Palfique composite, or intermediate restorative material (IRM). Each tooth was affixed to a fluid filtration device and the seal was evaluated at 0, 1, 7, 30, and 90 days. The results showed a significant (p = 0.0001) difference in leakage between the materials. At 7 days, IRM, AEliteflo, and Palfique leaked significantly more than Amalgabond or C&B Metabond. Amalgabond consistently produced the best seal of all the materials throughout the duration of the study. Slide 22 Intraorifice Barrier/Sealing Howdle, M.D., K. Fox, and C.C. Youngson, An in vitro study of coronal microleakage around bonded amalgam coronal-radicular cores in endodontically treated molar teeth. Quintessence Int, 2002. 33(1): p. 22-9. OBJECTIVE: The aim of this study was to compare the coronal microleakage of conventional and bonded amalgam coronal-radicular (Nayyar) restorations on endodontically treated molar teeth, because coronal seal is a major factor in the long-term success of endodontic treatment. METHOD AND MATERIALS: Forty extracted human molar teeth were root-filled and prepared for coronal-radicular amalgam restorations. Four groups of 10 teeth were restored with Tytin amalgam and Vitrebond, Superbond D Liner II, Panavia 21, or no adhesive agent. The teeth were placed in India ink for 1 week, and then demineralized and rendered transparent. The ink penetration was assessed with a coded scoring system. RESULTS: The bonded amalgam groups produced significantly less leakage than did the nonbonded group. No statistically significant differences in leakage were detected among the bonded amalgam groups. CONCLUSION: To prevent the reinfection of the endodontically treated molar, it may be preferable to restore the tooth immediately after obturation by employing a bonded amalgam coronal- radicular technique. Slide 23 Intraorifice Barrier/Sealing Shindo K, Kakuma Y, Ishikawa H, Kobayashi C, Suda H. The influence of orifice sealing with various filling materials on coronal leakage. Dent Mater J, 2004. 23(3): p. 419-23. The aim of this study was to evaluate the sealing ability of materials filled in the orifice after root canal treatment. A total of 100 root canal-treated teeth were divided into six experimental groups: 1, Protect Liner F (PL); 2, Panavia F (PF); 3, DC core-Light cured (DCL); 4, DC core-Chemically cured (DCC); 5, Super-EBA (SE); 6, Ketac (KC). The materials were filled--to a depth of 4 mm--in the coronal part of the root canals, and evaluated for microleakage. The number of teeth that failed to stop dye penetration in the filled materials differed statistically between PL and DCL or SE or KC, PF and SE or KC, DCC and KC, DCL and KC. The mean distance of dye penetration differed significantly between PL and SE or DCC, PF and SE or DCC. Hence, these results indicated the advantageous sealing ability of adhesive and flowable materials. Slide 24 Intraorifice Barrier/Sealing Shimada Y, Seki Y, Sasafuchi Y, Arakawa M, Burrow MF, Otsuki M, Tagami J. Biocompatibility of a flowable composite bonded with a self-etching adhesive compared with a glass lonomer cement and a high copper amalgam. Oper Dent, 2004. 29(1): p. 23-8. This study evaluated the pulpal response and in-vivo microleakage of a flowable composite bonded with a self-etching adhesive and compared the results with a glass ionomer cement and amalgam. Cervical cavities were prepared in monkey teeth. The teeth were randomly divided into three groups. A self-etching primer system (Imperva FluoroBond, Shofu) was applied to the teeth in one of the experimental groups, and the cavities were filled with a flowable composite (SI-BF-2001-LF, Shofu). In the other groups, a glass ionomer cement (Fuji II, GC) or amalgam (Dispersalloy, Johnson & Johnson) filled the cavity. The teeth were then extracted after 3, 30 and 90 days, fixed in 10% buffered formalin solution and prepared according to routine histological techniques. Five micrometer sections were stained with hematoxylin and eosin or Brown and Brenn gram stain for bacterial observation. No serious inflammatory reaction of the pulp, such as necrosis or abscess formation, was observed in any of the experimental groups. Slight inflammatory cell infiltration was the main initial reaction, while deposition of reparative dentin was the major long-term reaction in all groups. No bacterial penetration along the cavity walls was detected in the flowable composite or glass ionomer cement except for one case at 30 days in the glass ionomer cement. The flowable composite bonded with self-etching adhesive showed an acceptable biological com- patibility to monkey pulp. The in vivo sealing ability of the flowable composite in combination with the self-etching adhesive was considered comparable to glass ionomer cement. Amalgam restorations without adhesive liners showed slight bacterial penetration along the cavity wall. Slide 25 Intraorifice Barrier/Sealing Yamauchi S, Shipper G, Buttke T, Yamauchi M, Trope M. Effect of Orifice Plugs on the Periapical Inflammation in Dogs. J Endod, 2005. Abstract. Gutta-percha and sealer do not resist coronal leakage thus placing the burden on the filling above it. The purpose of this study was to evaluate the effect of orifice plugs using dentin-bonding composite resin (C) (Clearfil SE Bond and Clearfil Photo Core:Kuraray Medical Inc) or IRM in resisting coronal leakage as assessed by periapical inflammation in vivo. 60 premolar roots in 3 beagle dogs were instrumented to at least size #40 and were filled with gutta-percha (GP) and AH26 Sealer (S) and the coronal 2mm was removed with a heated plugger. In group 1 and 2 C and IRM respectively were used as plugs in the prepared 2mm space. In group 3 no plugs were placed and served as control. The access cavities were kept open for 8 months after which the dogs were killed. The periapical regions of the roots were prepared for histologic examination. Significant periapical inflammation was observed in 90% of the samples where plugs were not placed (GP+S), but in those with plugs, the occurrence was decreased to 47% (GP+S+C) and 37% (GP+S+IRM), respectively. The poor seal of gutta-percha and sealer was confirmed in this study. The placement of an orifice plug with composite resin or IRM significantly improved resistance to coronal leakage but are still not sufficient to provide adequate resistance to bacterial penetration. Supported by Kuraray Medical Inc Slide 26 Experimental Procedure Instrumentation/ Obturation Removal of G/S Placement of Orifice Plug Plug (IRM or Composite) Histology ~2 mm 8 months Slide 27 Evaluation of periapical inflammation No inflammation Mild inflammation Severe inflammation Slide 28 Results: Periapical inflammation rate 58% (7/12) M=5, S=2 G + NS + Comp G + S + IRM 38% (5/13) M=5 G + S + Comp 39% (7/18) M=6, S=1 With Plug Without plug (G+S) 89% (16/18) M=7, S=9 M=mild S=severe Slide 29 Flowable Composite Root Canal Filling Material (Resilon/Gutta Percha) Flowable Composite Cotton Pellet IRM Glass Ionomer/Composite Amalgam Slide 30 Flowable Composite Flowable Composite Not Placed In Canals Where Post or Plug Needed Root Canal Filling Material (Resilon/Gutta Percha) Flowable Composite Cotton Pellet IRM Glass Ionomer/Composite Amalgam Slide 31 Flowable Composite Flowable Composite Not Placed In Canals Where Post Needed Post Space Preferably Created with Heated Plugger (do not allow to cool) May also use Rotary Instruments, Carefully!! Endodontist will provide Post Space if Requested Slide 32 We Strive To Please the Referring Dentist!! Communication Biological Principles Communication Asepsis Communication Literature Support Communication Placement of the Coronal Restoration After Completion of RC Fill is Variable, but Based mainly on Asepsis. Slide 33 Eric M. Rivera, DDS, MS 2mo Recall 34mo Recall Slide 34 Please Read Chart and/or Referral Letter Root Canal Filling Material Used Restoration Placed Cotton Pellet Placed Please Review Postoperative Radiograph Level of Root Canal Fill Space between Root Canal Fill and Restoration Returned to Restorative Dentist Slide 35 Root Canal Filling Material (Resilon/Gutta Percha) Flowable Composite Cotton Pellet IRM Glass Ionomer/Composite Amalgam Returned to Restorative Dentist Slide 36 Root Canal Filling Material (Resilon/Gutta Percha) Flowable Composite Cotton Pellet IRM Glass Ionomer/Composite Amalgam Returned to Restorative Dentist If it were possible to place a material to the anatomic apex that prevented leakage and had dimensional stability, we would use this material. Slide 37 Significant Loss of Tooth Structure Root Canal Filling Material (Resilon/Gutta Percha) Flowable Composite Cotton Pellet IRM Glass Ionomer/Composite Amalgam Returned to Restorative Dentist Slide 38 Significant Loss of Tooth Structure Root Canal Filling Material (Resilon/Gutta Percha) Flowable Composite Cotton Pellet IRM Glass Ionomer/Composite Amalgam Returned to Restorative Dentist Slide 39 Root Canal Filling Material (Resilon/Gutta Percha) Flowable Composite Cotton Pellet IRM Glass Ionomer/Composite Amalgam Amalgam placed when Access is through Intact Crown/Onlay Restoration Slide 40 8mm probing defect DL Eric M. Rivera, DDS, MS 6 week Re-Evaluation No probing > 3mm Slide 41 Thank You! Slide 42 I appreciate your feedback!! Slide 43 University of North Carolina School of Dentistry Department of Endodontics and Endodontic Dental Faculty Practice 1098 Old Dental Building, CB #7450 Chapel Hill, NC 27599-7450 919-966-2707 (Office) 919-966-6344 (Fax) 919-966-2115 (Dental Faculty Practice) first_last@dentistry.unc.edu How To Contact Us