Chronic kidney disease is associated with progressive deterioration of renal function resulting in reduced glomerular filtration rate. Multiple drugs used for its management invariably alter the common oral manifestations associated with the disease. The patients require special considerations for endodontic management because of increased tendency towards bleeding episodes, odontogenic infections and drug interactions. The present case report describes the comprehensive endodontic management in a patient of chronic renal disease taking plethora of medications.

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The aim of this work was to undertake a literature review on two different techniques of apical preparation of root canals e.g. apical patency and apical plug. Apical patency is a technique in which apical constriction and apical foramen are kept patent throughout the instrumentation of root canals. This technique prevents packing of debris at the apical area. It also helps to maintain working length. A small patent file 1mm longer than the working length is passed through the apical foramen passively. This technique is thought to ensure complete debridement of root canals. It is associated with less postoperative pain. The objections to this technique are the extrusion of debris, irrigating solutions, sealer and filling materials. It may also cause over instrumentation and foramen transportation. Enlargement of apical constriction or apical foramen through patency files is not supported by literature. Apical plug is the technique in which instrumentation is kept within working length of the root canals without using any patency file. This results in the formation of an apical plug composed of dentinal chips in the apical third of the root canal. Apical plug may be contaminated with micro flora and necrotic tissues leading to inflammatory reactions in the periapical tissues. This technique prevents the extrusion of debris, irrigating solution, sealers and thermoplastic gutta-percha. However, intentional packing with dentinal chips or biological compatible materials at the apical area is required in teeth with immature apices, root resorption, or when apical constriction is violated due to over instrumentation.

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Aim: The aim of our study is to elaborate a new cement based on Portland cement (PC), Modified Portland Cement (MPC) with modified chemical and physical properties that allow easier clinical manipulation and faster setting time than MTA^® and then to evaluate its cytotoxicity in vitro and its biocompatibility in vivo in comparison with MTA^® . Materials and Methods: Elaboration of MPC: Portland cement powder slenderly grinded to homogenize the particles, mixed with a radiopaque element and a setting time accelerator. A comparative in vitro study (MTS test) of the toxic effect of MTA^® and MPC with culture isolated from the calvaria of 18-day-old fetal Swiss OF1 mice are done. A comparative in vivo study of the biocompatibility of MTA^® and MPC: Under general anaesthesia, three holes (2.5 mm) were made in both the left and right femurs of six White New Zealand rabbits. In the first hole MPC is placed, in the second MTA^® and the third one is left empty (negative control group). Three weeks after implantation, two rabbits are sacrificed, then two other rabbits over six weeks and the last two after twelve weeks. The neck of the femur is trimmed and prepared for undecalcified histological studies. Mann-Whitney test was used to analyze the results. Results: The cell viability test according to the morphological observations suggested the biocompatibility of the two biomaterials tested. The in vivo test showed similar biocompatibility between MTA^® and MPC. Bone healing and minimal inflammatory response adjacent to MTA^® and MPC implants were observed at all experimental periods (3, 6 and 12 weeks), suggesting that both materials are well tolerated. Conclusion: This pilot comparative study of MTA^® and MPC showed no or very limited toxic effects of both cements in vitro and similar biocompatibility in vivo. However, additional in vivo and clinical studies should be done on MPC before it can be introduced in our clinical practice.

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Aim: To determine the prevalence of the number of root canals in permanent maxillary first and second premolars of a Saudi Arabian sub-population. Results will be compared to previous Asian studies. Materials and Methods: A total of 894 periapical radiographs of endodontically treated maxillary first and second premolars of 628 Saudi patients (268 males and 360 females) were viewed. The teeth were segregated into maxillary first premolars (463) and maxillary second premolars (431). The diagnostic, working length, master cone and final films with different angles were mounted, projected and, with the utilization of written clinical records, evaluated. Teeth with multiple canal systems were categorized according to whether the canals exited the root by common or separate apical foramen. Data was analyzed statistically using Chi-square test and professional t-test, by comparing pairs of groups with the significant level established at 5% (P < 0.05). Results: More than 90% of first maxillary premolar and more than 50% of the second maxillary premolar was found to have two canals. There was no significant difference between male (92%) and female (95%) in the distribution of the two root canals of the first maxillary premolar (t-test = 1.21, P value = 0.228), however, there was significant difference between the distributions of male (69.4%) and female (52.2%) of the two root canals within the second maxillary premolar (t-test = 3.75, P value = 0.000). Few teeth showed three canals. Conclusion: The number of root canals of the maxillary first premolar in Saudi population shows a higher incidence of two canals (93.6%) than previously reported. In addition, the figure is higher than most of the Asian countries.

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Introduction: Vertical root fractures (VRFs) of endodontically treated teeth are serious complications that are associated with a poor survival prognosis. The diagnosis of VRFs is difficult, because the clinical signs and symptoms are often obscure and periapical radiographs (PAs) provide limited diagnostic information. Recently, Cone Beam Computed Tomography (CBCT) has been used to address complicated cases of VRFs with an inconclusive diagnosis. Aim: To determine the clinical diagnostic accuracy of CBCT in detecting VRFs in complex failing cases of endodontically treated teeth, as an adjunct to PAs. Materials and Methods: Evaluating the diagnostic accuracy of CBCT in a series of clinical cases of suspected VRFs, presented via clinical photographs, PAs, and CBCT images. Results: CBCT imaging significantly aided the differential diagnosis in most cases. Conclusions: CBCT imaging provides a 3D image and information in many cases of VRF that 2-dimensional PAs fail to generate. The slice thickness and interslice interval of the CBCT image influence the perception of the normal anatomy and pathoses.

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Aim: To present the current situation of dental operating microscopy (DOM) training in the available Advance Specialty Education Programs in Endodontics in Arab Middle-Eastern countries. Materials and Methods: A web-based survey was sent to the electronic mail address of Advance Specialty Education programs of 15 Arab and middle east countries. The questions were limited to those who have an advanced specialty education program in Endodontics at their University if they are using an operating microscope? Results: Out of 15 countries, only 4 countries have microscopic technology in their Advance Education Programs in Endodontics. Conclusion: Few Arab Middle-Eastern countries have DOM in their advance education programs in endodontics. The highest authority in advancing endodontic education in the Arab Middle-East should consider in the near future the importance of this technology as standard care in teaching advance endodontics. An advance workshops should be organized regularly to provide enough knowledge about this standard educational technology.

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Aim: The purpose of this in vitro study was to assess the apical sealing ability of Epiphany/Resilon, AH Plus/gutta-percha and their cross combinations-AH Plus + Resilon and Epiphany+gutta-percha. Materials and Methods: Fifty eight extracted human single-rooted mandibular premolars were used and obturated with different combinations of core material and sealer using lateral compaction technique. The groups were as follows: Group-1: Epiphany + Resilon; Group-2: AH Plus + Gutta-percha; Group-3: AH Plus + Resilon; Group-4: Epiphany + Gutta-percha; Group-5: Negative control group. Apical microleakage was assessed with dye penetration method using stereomicroscope. Statistical analysis was performed using one-way ANOVA followed by post hoc test (Bonferroni test), with significance level set at P < 0.05. Results: Results indicated that AH Plus + Resilon had the least microleakage than all the other groups, followed by Epiphany + Gutta-percha group while Epiphany + Resilon group demonstrated the greatest amount of microleakage. Statistical analysis showed significant results (P < 0.05) except for comparison between Group 1-2 and Group 3-4 (P > 0.05). Conclusions: Resilon + AH Plus showed significantly least amount of microleakage and better apical sealing ability as compared to other groups.

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The main objective of performing root canal therapy is to eliminate bacteria from the infected root canal system or remove inflamed pulp tissue and close it with a biologically acceptable filling material. If this treatment managed well, regardless of the number of visits, it will create a favorable environment for healing. The recent advances in Endodontic technology, attracts the dental practitioners as well as the Endodontist to perform the root canal treatment in one visit. The question that we consider in this review article focuses on the long term prognosis of one-and multiple appointment endodontic therapy for teeth with vital pulp, necrotic pulp, and apical periodontitis .

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The aim of this study was to evaluate the apical seal obtained with four root canal sealers in conjunction with lateral condensation technique in apically perforated root canals. A total of 38 single rooted teeth stored in saline were utilized. The teeth were instrumented to their anatomical apices to a size #45 MAF using the step-back technique. An apical stop was developed 1 mm short of the working length with the help of a size #50 K-file. Based upon the mesio-distal and bucco-lingual widths of the apical foramen the teeth were stratified and randomly divided into four groups of 9 teeth each. Each of the four groups was obturated with either Sealapex, Ketac-Endo, AH26, or Tubli-Seal in conjunction with lateral condensation technique. The remaining two roots were used as controls: positive with gutta-percha and no sealer and negative with the apex sealed with nail varnish. The root apices were immersed in 1% methylene blue for 7 days and then sectioned longitudinally. Dye penetration was measured using a travelling microscope. The best seal was obtained using Sealapex cement, which differed significantly from Ketac-Endo, AH26, and Tubli-Seal. There was significant difference between the latter. It is recommended that Sealapex should be the sealer cement of choice, in conjunction with lateral condensation technique, when obturating apically perforated root canals.

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In the recent times no other field has shown so much growth in Endodontics as much as that of diagnosis. The human element in diagnosis is enriched by newer technologies available as adjuncts to the process of endodontic diagnosis. The trend of this development has been toward increasing objectivity sensitivity and reproducibility of the pulp tests while decreasing the patient discomfort. Methods like Pulse Oximetry, Laser Doppler Flowmetry, Ultrasound Doppler, Dual Wavelength Spectroscopy, Photoplethysmography besides the thermographic imaging and calorimetric pulp tests are being developed and evolved to suit the current clinical setting for the modern endodontist. A necessity arises here to keep abreast of all the new methods in order to be able to choose the best tools for the successful diagnostician. The aim of this review therefore was to assess the usefulness of some devices and techniques used in endodontic therapy to make the correct pulpal diagnosis.

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The aim of this study was to determine the prevalence of pulp stones in a group of patients using radiographs, and to assess any associations with age, gender, tooth type, jaw, caries, restorations, attrition and periodontal disease. A total of 600 patient charts (319 males and 281 females) were selected randomly amongst patients referred to the Oral Diagnosis and Radiology Department, College of Dentistry, king Saud University. Bitewing radiographs were examined. The age of the evaluated patients ranged from 16 to 56 years old. Both maxillary and mandibular premolars and molars were evaluated. Frequency and distribution of teeth with pulp stones was calculated and statistical analysis was performed with chi-square test. Pulp stones were identified in 10.2% of the teeth examined. Molars had statistically more pulp stones than premolars (P<0.001). Teeth with attrition, first molars and patients of old age showed statistically more pulp stones. It was concluded that the prevalence of pulp stones increased with age and was significantly higher in molar teeth than premolars. The features of pulp stones noted in this study may provide additional information about the dental morphological features of Saudis.

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Biomechanical preparation of the entire root canal system is one of the most important procedures in endodontic treatment. Separation of instruments while preparing root canals presents a compromised situation in which a biologically inert segment is left behind with potential contamination that has the ability to affect the healing process. Management of this procedural error is tedious and requires creativity as well as clinical knowledge and skills. In this report, we demonstrated two cases with separated instrument in which a combined technique of ultrasonic method with microtube tube method was used to retrieve the separated tips using a modified Vista dental tip.

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Objectives: To evaluate and compare the antibacterial efficiency of MTAD, Oxytetracycline, 5% NaOCl, and 2% chlorhexidine when used as root canal irrigants against Enterococcus faecalis. Materials and Methods: Fifty extracted human single rooted anterior teeth were selected. The decoronated sterilized root samples were infected with 10μl of 24 hours pure culture suspension of E. faecalis for 48 hours except for 10 teeth in negative control group (Group V). The test samples were divided into four groups (n = 10) as: Group I- 5% Sodium Hypochlorite, Group II- MTAD, Group III- Oxytetracycline and Group IV- 2% Chlorhexidine. The root canals were instrumented while using respective root canal irrigant solution. The bacterial cultures were taken from each root canal and colony forming units were counted on agar plates. The data was statistically analyzed. Results: It was observed that Group-III (Oxytetracycline) showed the maximum antibacterial efficacy against E. faecalis followed by Group II (MTAD), Group IV (2% Chlorhexidine), Group I (5% Sodium hypochlorite). Conclusion: Oxytetracycline has a great potential as a root canal irrigating agent because of its superior antimicrobial efficacy against E. faecalis, easy availability and cost effectiveness.

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Crown root fractures in the maxillary anterior region represent an intriguing challenge for clinicians. An interdisciplinary approach based on exposing fractured margins and the definitive prosthetic rehabilitation represent the standard modality of treatment for these conditions to restore the appropriate biologic dimension and esthetics. However, if the margins of the fragment and the tooth show perfect juxtaposition with no interfragmentary space and immediate esthetic replacement is needed, reattachment of the fractured segment using adhesives may be indicated. The aim of this case report is to describe the treatment of a crown root fracture at CEJ of an endodontically treated tooth having porcelain fused to metal crown by means of metal post placement and reattactment of the fragment using Glass ionomer cement with follow up of one year. Conclusion: Reattachment of a tooth fragment is a viable technique that restores function and aesthetics with a very conservative approach in a single visit and can be considered when treating patients with crown/root fractures of the anterior teeth.

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Background : The rubber dam is one of the best tools for tooth isolation and infection control in the dental field. Our aim is to evaluate the attitudes toward the use of rubber dams by dental interns in Riyadh Dental Colleges (RCsDP) and determine the barriers to their use. Materials and Methods: A self-administered questionnaire was designed and used for data collection. 150 questionnaires were distributed by hand to the dental interns of RCsDP over a period of two weeks. Information sought included the attitudes toward and difficulties for the use of the rubber dam, the time needed to apply the rubber dam, and the patients' allergic history of the rubber dam. Respondents were asked to state their preference on a five point Likert type scale ranging from "strongly dislike" to "strongly like". The information and data of the completed questionnaires were statistically analyzed using Mann-Whitney U test and Friedman test. Results: Of 150 questionnaires distributed, 150 were completed and returned (response rate = 100%). Of those, 46.7% were males and 53.3% were females. In general; (43.3%), interns strongly liked the use of the rubber dam and the rest (46.7%) liked the use of the rubber dam. The majority of respondents liked to use rubber dam in direct restorations more than in indirect restorations and 46.7% strongly liked to use it in posterior teeth for composite restoration. Most dental interns felt that they would strongly like to use a rubber dam for endodontic treatment whether in posterior teeth (73.3%) or anterior teeth (68.7%). 66.7% of interns asked their patients if they had an allergy to latex prior to the use of the rubber dam. Child behavior (mean rank about seven) is the most important reason for not using rubber dam. The time is taken to apply the rubber dam was less than five minutes in most cases. Conclusion: Most dental interns prefer to use rubber dams in the general dental field and are enthusiastic to use it in future.

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Aim: The purpose of this in vitro study is to provide clinical data on the presence of the second canal in mandibular incisor teeth of Saudi Arabian Samples. Materials and Methods: Eighty extracted human mandibular incisors were collected from Saudi patients. The teeth were accessed by small round bur then placed in 5.25% sodium hypochlorite for 24 hours to dissolve the organic debris. Indian ink was injected inside the root canal systems under negative pressure. The teeth were decalcified in 5% nitric acid for three days then dehydrated in different concentrations of ethyl alcohol. Following the decalcification process, the teeth were cleared in methyl salicylate and evaluated according to Vertucci's classification. Result: Fifty six of both mandibular central and lateral incisor teeth (70%) had type I canal configuration (one main canal and one main apical foramen), while the remaining 30% of the sample (24 teeth) had a type III canal configuration (two separate canals and merged into one canal before exiting the tooth through single apical foramen). Conclusion : The incidence of two canals in mandibular incisor teeth is about one third of the examined Saudi Arabian samples with no difference between the centrals and laterals. The clinician should deal with these teeth as if they have two canals unless it is proved otherwise.

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Aim: To assess the effects of three root canal preparation techniques on canal volume and surface area using three-dimensionally reconstructed root canals in extracted human maxillary molars. Materials and Methods: Thirty extracted Human Maxillary Molars having three separate roots and similar root shape were randomly selected from a pool of extracted teeth for this study and stored in normal saline solution until used. A computed tomography scanner (Philips Brilliance CT 64-slice) was used to analyze root canals in extracted maxillary molars. Specimens were scanned before and after canals were prepared using stainless steel K-Files, Ni-Ti rotary ProTaper and rotary SafeSiders instruments. Differences in dentin volume removed, the surface area, the proportion of unchanged area and canal transportation were calculated using specially developed software. Results: Instrumentation of canals increased volume and surface area. Statistical analysis found a statistically significant difference among the 3 groups in total change in volume (P = 0.001) and total change in surface area (P = 0.13). Significant differences were found when testing both groups with group III (SafeSiders). Significant differences in change of volume were noted when grouping was made with respect to canal type (in MB and DB) (P < 0.05). Conclusion: The current study used computed tomography, an innovative and non destructive technique, to illustrate changes in canal geometry. Overall, there were few statistically significant differences between the three instrumentation techniques used. SafeSiders stainless steel 40/0.02 instruments exhibit a greater cutting efficiency on dentin than K-Files and ProTaper. CT is a new and valuable tool to study root canal geometry and changes after preparation in great details. Further studies with 3D-techniques are required to fully understand the biomechanical aspects of root canal preparation.

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Whenever unrestorable teeth need to be extracted or tooth agenesis is evident, other treatment alternatives, such as tooth transplantation, should be considered, instead of immediately replacing teeth with fixed, removable, or implant-supported prostheses. Supernumerary and impacted teeth should be considered as a reservoir for transplants. Transplanted tooth should be managed carefully during transplantation and endodontic treatment. This present case report discusses an autotransplantation of an impacted third molar into an unrestorable second molar.

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Dilaceration of teeth can ocur as a result of trauma to its primary predecessors. Crown dilaceration is more rare than root dilacerations. This report describes a rare case of crown dilaceration of the mandibular central incisor caused by trauma. Periapical radiography and cone beam computed tomography scans revealed a severe crown dilaceration in the labial direction. After conventional root canal treatment, a glass fiber-reinforced post was placed and the tooth was restored using the original crown which was removed from the root before root canal obturation. One year after the treatment, the tooth was clinically intact without mobility and there was no sensitivity during percussion. Radiographic examination revealed that the periodontal tissues were healthy and there was no sign of root resorption. It was concluded that correct diagnosis and prompt treatment help to achieve desirable esthetics and function for crown dilecaration.

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Removal of all organic debris and microorganisms from the root canal system, and shaping the root canal space is a very important step in root canal therapy. This will facilitate adequate irrigation and filling of the entire root canal space. A number of techniques using hand instruments have been described, all of which have been designed to produce a tapered preparation. These techniques have a lot of deficiencies, but they are still considered to be the most efficient and suitable for clinical dental practice. Research into root canal preparation has led to significant changes in instrumentation techniques. New instruments have been developed, employing different metals and different engineering philosophies. There has been a significant move away from the ISO standard 2% taper instrumentation. Recent designs of endodontic instruments have variable tapers giving improved shaping ability. Nickel-titanium rotary instruments will rapidly and safely open the main root canals creating a deep space to permit full penetration of irrigant solutions. Practitioners considering changing their endodontic techniques, are advised to read the following preparation technique to gain competence before using these instruments in their clinical practice.

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This study compared the flare-up rate of endodontically treated molar teeth with necrotic pulp, using a Root ZX apex locater and NI-TI files in one-visit versus two-visits. Root canal treatment was done in 251 patients (129 in one visit group and 122 in two visits) using the same technique and filling materials. Patients were asked to circle the type of pain in a written form after 24 and 48 hours and after one week of finishing the root canal treatment. Pain was reported by very few patients of both groups during the first 24 and 48 hours, which disappeared during one week. A statistically significant difference (P= 0.029) in the reported pain was found between the two groups. It was found to be more in the two visit group. It was concluded that both techniques have to be viewed as part of a total endodontic treatment spectrum. The choice of preferring one over the other has to be determined by the circumstances surrounding each individual case.

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