ToothSOS for emergency care of traumatic dental injuries

Dental trauma is common and most prevalent in children and adolescents. The role of prevention, diagnosis, and treatment of dental trauma is of utmost importance for the survival of primary and permanent teeth. Therefore, both the public and the dental community should be educated on the management of traumatic dental injuries. Early intervention may significantly improve the prognosis of an injured tooth and therefore can restore function, proper development, and a patient’s smile to its original state. The first few hours following injury are critical in determining the prognosis of an injured tooth. Many studies have indicated that dental practitioners and the public lack education in proper trauma management.

An effective way to educate patients and professionals is through articles, lectures, and technology. The digitization of health care has shown a shift in the delivery of information from in-person to remote and patient-generated. The benefits of this shift include the following: increased patient education, reduced healthcare costs, improvement in general patient health, and better treatment outcomes. Mobile software technologies have already been used in many fields of medicine. As such, an accessible and easy-to-use mobile application could prove to be a valuable tool for sharing information on general medical issues as well as on dental trauma.

Incorporating technology into dental public health education may help share preventive strategies and improve treatment outcomes. Launched in April 2018 under the initiative and presidency of Dr. Nestor Cohenca, ToothSOS is a free service created, offered, and sponsored by the IADT. It aims to deliver information about traumatic tooth injuries to the public, including patients, parents, educators, and professionals. The ToothSOS is user-friendly and available for free download on both Apple and Android devices. In emergency and non-emergency situations, the app can be a useful resource for the lay person dealing with traumatic dental injuries as it provides step-by-step guidance for various dental injuries, such as knocked-out, displaced, pushed-in, loosened, and broken teeth, as well as injuries to the skin, lips, gums, jaws, and joints, before seeing a dentist (Figure 1). The app also contains information for dental professionals and provides the most current therapeutic guidelines for treatment of traumatic dental injuries.

In a recent study, the total number of ToothSOS downloads over the 2 years was 47,725. Europe was the territory with the greatest number of downloads followed by the United States and Canada, Asia, Latin America and the Caribbean, and Africa, the Middle East, and India. The study concluded that further attempts and public campaigns should be made in order to increase the visibility of the app. Dental professionals should encourage patients and communities to use the app in order to increase awareness for the prevention and proper emergency management of traumatic dental injuries.

Khehra A, Cohenca N, Cehreli ZC, Levin L. The International Association of Dental Traumatology

ToothSOS Mobile App: A Two-Year Report. Dent Traumatol. 2021

Feb;37(1):145-150.

Regeneration of necrotic pulps has become an alternative conservative treatment option for young permanent teeth with immature roots and is a subject of great interest in the field of endodontics. This novel procedure exploits the full potential of the pulp for dentin deposition and produces a stronger mature root that is better able to withstand the forces than can produce fracture.

Pulp revascularization of immature teeth with apical periodontitis depends mainly on: (a) disinfection of the canal; (b) placement of a matrix in the canal for tissue in-growth; and (c) a bacterial tight seal of the access opening. Since the infection of the root canal system is considered to be polymicrobial, a combination of drugs would be needed to treat the diverse flora. Thus, the recommended protocol combines the use of metronidazole, ciprofloxacin, and minocycline. Hoshino et al performed an in vitro study testing the antibacterial efficacy of these drugs alone and in combination against the bacteria of infected dentin, infected pulps, and periapical lesions (1). Alone, none of the drugs resulted in complete elimination of bacteria. However, in combination, these drugs were able to consistently sterilize all samples. In addition, a study by Sato et al. (2) found that this drug combination was very effective in killing bacteria in the deep layers of root canal dentin.

Unfortunately, intracanal bacteria could sturdily resist chemo-mechanical preparation and survive into remote and inaccessible areas of the root canal system, such as the apical part of root canals, isthmi, lateral canals, or dentinal tubules (3). Almutairi et al analyzed 28 studies that reported 67 failed cases of Regenerative Endodontic Therapy (RET) (4). A total of 37 failed RET cases reported the etiology that resulted in the initiation of RET; 59% of these cases were caused by dental trauma, and 30% were caused by dens evaginatus. A total of 26 (39%) failed RET cases were detected at least 2 years after the initiation of RET. A total of 53 (79%) failed RET cases were presented with signs and/or symptoms of persistent infection. Persistent infection was the main presentation in 79% of failed RET cases. Furthermore, 39% of failed RET cases were identi?ed after more than 2 years of follow-up.

References

1. Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996;29(2):125-30.

2. 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;29(2):118-24.

3.  Chaniotis A. Treatment Options for Failing Regenerative Endodontic Procedures: Report of 3 Cases. J Endod 2017 Sep;43(9):1472-1478

4. Almutairi W, Yassen GH, Aminoshariae A, Williams KA, Mickel A. Regenerative Endodontics: A Systematic Analysis of the Failed Cases. J Endod. 2019 May;45(5):567-577

9-year old boy presents with a chronic apical abscess, after a failing attempt for pulp regeneration.

CBCT showing apical bone destruction and fracture of cortical plates.

2-year follow-up after apexification with MTA as an apical plug.

Nestor Cohenca, D.D.S., FIADT

6/13/2024

The relationship between teeth and sinus abnormalities has been widely reported in the literature. This association is in part due to the close anatomic relationship between the floor of the maxillary sinus and the roots of the posterior maxillary teeth and may contribute to bacterial infection, toxins and products of pulpal necrosis spreading within the maxillary sinus. 

The normal mucosal lining within the maxillary sinus is <1 mm in thickness. Normal sinus mucosa is not visualized on radiographs. Sinus mucosal thickening more than 2 mm is an important indicator of pathology. CBCT imaging has proven to be a valuable resource to evaluate the correlation between apical periodontitis and the maxillary mucosa lining thickness (Fig 1).  

In a study we recently completed, scans of 1,200 patients were examined by two calibrated blinded examiners. The correlation between the proximity of teeth with endodontic treatment (ET) and the presence of maxillary abnormalities was recorded among patients from different ethnicities.  

A total of 1,043 patients were included in the study. Sinus abnormalities were found in 52.1% of the CBCT scans. The minimum and maximum thickness of sinus mucosa were measured at 0.9 and 38.9 mm respectively, with a mean thickness of 8.4 mm. The distance between the apex of teeth to the floor of the sinus was measured between 0 and 20.5 mm, with a mean distance of 1.5 mm. 

No statistical significance was found between endodontic therapy and abnormalities in maxillary sinus (p=0.4). No statistical significance was found in mucosal thickness between different populations (p=0.2). A statistically significant correlation was found between the distance from apex to sinus floor and thickness of sinus mucosa (p=0.001) (Fig 2).

Conclusions

1. Sinus abnormalities was a very common finding with a 52.1% prevalence of random collected CBCT. 

2. There is no correlation between the presence of sinus abnormalities and the presence or absence of RCT in the adjacent tooth. 

3. No difference in mucosa thickening was found between populations from USA, South Korea and Israel. 

4. Close spatial relationship between teeth and the sinus resulted in thicker sinus abnormalities.

5. Predictable and efficient root canal disinfection and treatment can heal sinus abnormalities (Fig 3).  

Root Canal Anatomy Of The Permanent Mandibular First Molar. Clinical Implications And Recommendations

The world of endodontics has incorporated new technologies, instruments and materials in the past decade. Among them, operating microscopes, digital radiography, cone beam computed tomography (CBCT), 3D nickel titanium files, sonic and ultrasonic instruments and new irrigation delivery systems. However, despite all these improvements, the overall outcome, especially of non-surgical endodontics, has not increased significantly. Why? If we think critically, there are two important factors directly related to prognosis on which our advancements were limited: predictable eradication of microorganisms and access to the full anatomy of the canal system in which they might be harbored.

The mandibular first molar is the more frequently endodontically treated tooth. In a study by Swartz et al, the success rate of endodontically treated teeth was 87.79%, demonstrating the mandibular firs molar a significant lower success rate of 81.48%. It is well accepted that a unique cleaning and shaping technique is not suitable for all cases. Therefore, the endodontist should be able to fully understand the tooth morphology and root canal configurations in order to select the most appropriate treatment modality for a particular case and increasing the healing rate.

Number of roots

Review of the literature revealed a strong correlation between the presence of a third root in 13% of teeth and the ethnicity of the patients, particularly Asians, Mongolians and Eskimos. This macrostructure was term radix entomolaris with high variation regarding the coronal, mesio-distal plane. When the position of this third root was buccal, it is called radix paramolaris. Its shape and curvature are highly variable. Several radiographic exposures are required to clearly observe the presence of additional roots. Treating a mandibular first molar without initial off-angle radiographs could lead to third roots go unnoticed (Fig 1). Initially, a file located in the extra root, may give the appearance of a perforation. To prevent mishaps, it is advisable to choose a small and highly flexible instrument when treating the apical portion.

Number of root canals

In a systematic review compiling data on 4,745 mandibular first molars, three canals were present in 61.3%, followed by 4 canals in 35.7% of cases and 5 canals in almost 1% (Fig 2). However, in vivo studies performed by endodontists demonstrated the presence of 4 canals in 45% of the treated cases. Five canals were found in 0.8% of the samples while case reports have demonstrated the possibility of six and even 7 root canals.

Conclusions

1. The number of roots in the first mandibular molar is directly related to the ethnicity of the population studied.
2. The instrumentation of the third root requires a different access and the use of small and flexible instruments, considering the curvature at the apical third.
3. Mesial roots present 2 canals on a regular basis, adopting 2-2 and 2-1 as the most frequent configurations. A third canal might be present in 2.6% of the population.
4. The most common configuration in the distal root is 1-1 (62.7%), followed by 2-1 (14.5%) and 2-2 (12.4%).
5. Access modifications are required in order to find extra roots and/or canals.
6. The presence of isthmuses reaches 55% in the mesial root and 20% in the distal. This anatomical configuration should be taken into consideration during endodontic treatment as well as during periapical surgery.

Nestor Cohenca, DDS, FIADT
Diplomate. American Board of Endodontics
PS. Full references available per request.

Based on a study published by Setzer et al., in 2017 at the Journal of Endodontics, 80.3% of endodontists have access to a CBCT; 50.69% have the technology on-site and 49.31% have access to the technology off-site. The technology has proven essential in many fields of dentistry and we’ve come a long way since large, complicated imaging systems were relegated to universities and reserved for only the most complicated cases. Today, systems are smaller and more capable of meeting the unique needs of endodontists than ever before, making a CBCT system something to consider for your practice and your patients.|

A Brief History of the CBCT and Endodontics

Most of the major changes in endodontics, both in concepts and technology, started in the early 2000s. The use of microscopes, biological materials and rotary instrumentations were some of the most significant advancements in endodontics in the 21st century. Then came CBCT imaging. Initially used in academic institutions—mostly for trauma, root resorptions and pre-surgical assessment—CBCT imaging revolutionized the field. Doctors acknowledged the advantages, but most were reluctant to implement the technology due to its size and cost. It took a few years, but around 2009, with incentives given to graduate programs which led to further development, research and clinical experience, the technology developed exponentially. Part of that was fueled by the introduction of systems that were more affordable and with a relatively small footprint.

Wow’ Imaging for More Confident Diagnosis and Patient Confidence

My first “wow” moment with CBCT was during the early years of the technology when scanning a patient after a traumatic dental injury that lead to lateral luxation of the maxillary left central incisor. The CBCT scan was able to produce images that previously had only ever been drawn or imagined. Those stunning 3D images have only gotten better over time. When indicated, 3D imaging provides critical information toward development of the best treatment plan. High-resolution images give endodontists the ability to change course and adapt quickly if needed to achieve better outcomes. Being able to diagnose a predictable failure also avoids unnecessary invasive procedures. For example, cases of root fractures or deep cracks (figure 1). For root canal retreatments understanding the etiology of the disease or failure is critical to obtain a positive outcome. CBCT also aids with enhanced visualization of traumatic injuries, particularly for crown, root fractures and luxation injuries (figure 2). Ultimately, the more accurate and realistic assessments of prognoses, the more predictable and positive outcome for my patients.

From the patient’s perspective, the “wow” moments happen daily when they can see their jaw and teeth moving three-dimensionally. More important, the fact that patients can now see exactly what’s the problem and understand the available treatment options is critically important to obtain an informed decision. Rather than trying different procedures with unpredictable results, CBCT imaging can save patients time, money and stress; for example, excluding unsavable teeth from the very start of the treatment plan. An additional benefit of CBCT imaging is differential diagnosis of chronic pain. Instead of prescribing medication to treat the symptoms, CBCT has the potential to instantly reveal the underlying problem allowing me to provide the correct treatment and relief.

Invest in Hardware, Reap the Benefit of Software

Today, CBCT imaging is driven by advanced software algorithms. That means that the software that powers these systems is just as important as the equipment itself. The quality of the 3D scans, the ease of use and the ability to share scans with referrals all come down to software. Ultimately, the hardware will not change much in the coming years; however, software updates and other new features and improvements must be pushed out by the manufacturer to ensure doctors are always practicing with the most advanced technology. Some examples of these updates can lead to improved image quality, digital measurements and reconstructions, metal artifact reduction (MAR) and therapeutic guides for surgical and non-surgical cases.

Spreading the Word about CBCT

If you’re still on fence about CBCT, why not experience it for yourself? Webinars, study clubs, trade shows and hands-on events give doctors every opportunity to explore their CBCT options. In fact, after setting up my new practice and installing a CS 8100 3D (Carestream Dental), I recently founded the Kirkland Study Club with the purpose of creating a multidisciplinary group of professionals willing to share and learn from each other. The first meeting covered a topic relevant to anyone looking to learn more about what CBCT could do for their patients and practice: “Clinical Applications of CBCT in Endodontics.” Upcoming meetings will cover topics such as advanced Invisalign concepts; immediate implant placement; non-invasive dentistry; keys to managing growth and eruption in the mixed dentition and more. Additionally, Carestream Dental makes it easy for doctors looking to get a sample of CBCT imaging at carestreamdental.com/3D with a digital library of 3D imaging resources. Studies and research show more and more the benefits of CBCT in endodontics, and 80% of the profession can’t be wrong. Join us on the other side with enhanced imaging, improved diagnosis and better patient care.

a-b. Periapical radiographs from different angles. Patient was referred for endodontic therapies on teeth 19 and 20 with apical lucencies consistent w

a-b. Periapical radiographs from different angles. Patient presented immediate after a traumatic
injury to maxillary anterior teeth. Clinical and radi

Conclusions: Endodontic retreatment in 1 or 2 visits exhibited equally favorable periapical healing at 18 months, with no statistically significant differences between groups. Cestari Toia et al. J Endod 2022;48:4–14

This randomized clinical trial aimed to compare the effectiveness of endodontic retreatment of teeth with post-treatment apical periodontitis (PTAP) performed in 1 visit versus 2 visits on the reduction of cultivable bacteria and the periapical lesion volume (mm3) after 18 months of follow-up. M & M: 40 patients diagnosed with PTAP were selected and randomly divided into the following 2 groups: 1-visit retreatment and 2-visit retreatment with the placement of calcium hydroxide medication for 14 days. Cone-beam computed tomographic scans were performed at 2 stages: preoperatively and after 18 months of follow-up. Samples were collected before and after root canal procedures. Results: A higher bacterial load was found in the 2-visit group after the retreatment protocol, with no statistical differences between the groups regarding endotoxin levels and periapical lesion volume (mm3) at the 18-month follow-up analyzed by cone-beam computed tomographic imaging. Conclusions: Endodontic retreatment in 1 or 2 visits exhibited equally favorable periapical healing at 18 months, with no statistically significant differences between groups.

Welcome to the first issue of Prime Endodontics’ Newsletter. I am very excited to launch this newsletter which will inform and inspire you on a quarterly basis with clinical information to keep you updated within the world of Endodontics.

Zahran et al. J Endod 2022;48:479–486 Assessing the Iatrogenic Contribution to Contamination During Root Canal Treatment

Asepsis in endodontics aims to control all potential sources of infection. Inadvertent introduction of bacteria into the root canal system may occur when the aseptic chain is breached during treatment. This study aimed to assess potential bacterial contamination and the potential risk of iatrogenic introduction from 7 sites comprising surfaces, instruments, and files acquired during the treatment of 30 vital teeth with irreversible pulpitis.

Materials & Methods: Bacterial samples were collected from access burs, files, endodontic rulers, rubber dam surfaces, gloves, and instruments. Genomic DNA was extracted and quantified by quantitative polymerase chain reaction. Bacterial types were determined using next generation sequencing.Results: Thirty-eight percent of the initial files introduced into the root canal had significant levels of bacteria at the point of obturation, including endodontic pathogens. Around half of the rubber dam surfaces were contaminated with substantial bacterial loads at the time of obturation, and bacteria were also detected in 20-30% of gloves, instruments and rulers before obturation. Conclusions: Gloves, rubber dams, instruments, and files acquire bacterial contamination during treatment at high frequencies and loads. This highlights the potential risk of iatrogenic contamination at the clinically vulnerable point of canal obturation. Measures to address these may improve clinical outcomes.