Asepsis is Everything!!

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Asepsis is Everything!!
The Seal is the Deal Everything Eventually
Leaks
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Eric M. Rivera, DDS, MS
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Where to Sear Root Canal Filling Material
VS
Flush With Orifice Level
Below Orifice Level
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Where to Place Restorative Material
Amalgam as Final Restoratuion - Sufficient
Remaining Tooth Structure
VS
Flush With Orifice Level
Below Orifice Level
Amalgam Plug Not Needed(?)
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Where to Place Restorative Material
Amalgam as Final Restoratuion - Insufficient
Remaining Tooth Structure
VS
Flush With Orifice Level
Below Orifice Level
Amalgam Plug Needed(?)
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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.

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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.

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Eric M. Rivera, DDS, MS
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Eric M. Rivera, DDS, MS
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PermaFlo Purple
Whats the big deal about coronal seal?
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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)

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Intraorifice Barrier/Sealing

• Intraorifice barriers should be considered
  immediately after
• Root Canal filling as a secondary seal to prevent
  infection/reinfection by microleakage.

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Name Yr Type Study Amt IO Barrier Results
Roghanizad Jones 1996 Leakage Dye 3.0 mm Amal w Varnish gt Cavit Term gt Control
Pisano et al 1998 Leakage Microbes 3.5 mm Cavit gt IRM Super EBA gt Control (all leaked in lt 49 days)
Wolcott et al 1999 Leakage Microbes 3.0 mm GI (VitrebondGC AmericaKetac bond) gt No Barrier
Belli et al 2001 Leakage Fluid Filtration ? Resins (ClearfilSEBondOneStepCB Metabond) gt IRM gtGP No Sealer
Galvan et al 2002 Leakage Fluid Filtration 3.0 mm Amalgambond gt CB Metabond gt (IRM Eliteflo Palfique) gt Control
Howdle et al 2002 Leakage Dye Transparency ? Bonded Tytin (VitrebondSuperbondD Liner IIPanavia 21) gt Unbonded Tytin
Shindo et al 2004 Leakage Dye 4.0 mm Advantageous sealing ability of Adhesive and Flowable Materials
Shimada et al 2004 Histology 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 al 2005 Abstract Histology Dog left open 2.0 mm Significant periapical inflammation in 90 of samples when plugs not placed. Reduced to 47 w Composite or 37 w IRM Plug.
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Intraorifice Barrier/Sealing

• Intraorifice barriers should be placed
  immediately after
• Root Canal filling as a secondary seal to prevent
  infection/reinfection by microleakage.

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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.

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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 lt 49 days.

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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 lt 0.05). The difference
  in leakage among the experimental glass ionomer
  barriers was not significant (p gt 0.05).

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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-methacryloyloxyethy
  l trimellitate anhydride adhesive system (CB
  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 lt
  0.05). Adhesive resins should be considered as a
  secondary seal to prevent intraorifice
  microleakage.

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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, CB
  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 CB
  Metabond. Amalgabond consistently produced the
  best seal of all the materials throughout the
  duration of the study.

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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.

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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.

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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.

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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 CoreKuraray 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
  (GPS), but in those with plugs, the occurrence
  was decreased to 47 (GPSC) and 37 (GPSIRM),
  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

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Experimental Procedure
Instrumentation/Obturation
Placement of Orifice Plug
Removal of G/S
Plug (IRM or Composite)
2 mm
8 months
Histology
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Evaluation of periapical inflammation
No inflammation
Mild inflammation
Severe inflammation
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Flowable Composite
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Flowable Composite
Flowable Composite Not Placed In Canals Where
Post or Plug Needed
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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
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We Strive To Please theReferring Dentist!!

• Communication
• Biological Principles
• Communication
• Asepsis
• Communication
• Literature Support
• Communication

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Eric M. Rivera, DDS, MS
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Returned to Restorative Dentist

• 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

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Returned to Restorative Dentist
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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.
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Returned to Restorative Dentist
Significant Loss of Tooth Structure
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Returned to Restorative Dentist
Significant Loss of Tooth Structure
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Returned to Restorative Dentist
Amalgam placed when Access is through Intact
Crown/Onlay Restoration
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Eric M. Rivera, DDS, MS
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Thank You!
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Questions??
I appreciate your feedback!!
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How To Contact Us
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_at_dentistry.unc.edu