Fluoride seal to forbid dental cavity in children and teenagers

Objective

High dental cavity commons disease affecting a big part of the world wide population, including around 65% to 80% of school-age children. In general, levels of dental cavity varies substantially between and breast of the several countries, but in low socio-economic position (SES), children have higher levels of dental cavity than those in higher SES groups. Treatment of cavity causes of the teeth accompanied by suffering and pain. Repair and alternate of dental cavity is costly, that represents a significant drain on resources for health care systems.

Fluoride seal is a potential option to prevent dental cavity in children. This developed in the 1960s and has been widely used in Europe and Canada. Use in other countries appears to be increasing, including in the US, where it can be used outside of the label as preventive agents of decay.

Two large meta-analysis reviews indicated significant reductions in caries in deciduous and permanent teeth. However, there was significant heterogeneity among the studies within each body of meta-analysis of the evidence for the two meta-analyses of average quality.

Thirteen tests allowed data for meta-analysis of the surface of the permanent tooth, and the fraction bundle of FS (M) prevented estimate comparing fluoride seal with placebo or no treatment was 43% (95% confidence interval (CI) 30-57%). d (e/m) to prevent the perceptiveness of the falling out was 36% (90% CI(: 25% to 52%) Ten tests provided data for meta-analysis of the surface of the tooth. Prevents any significant correlation between the d (M) FS or FS fractions d (e/m) has been found on the baseline of caries risk of infection factors. It was background exposure to fluoride, the capacities of the application such as prevention, fluoride concentration, and continually of application. It there was also no significant association in models meta-regression between estimates of d (M) FS or FS d (e/m) prevents fractures and after special factors such as whether the use of a placebo or no treatment control, duration of follow-up, or whether to use individual or randomized cluster. There was little information on potential adverse effects or accept treatment.

This updated review conclusions remain the same when you appear first, but are enhanced by the addition of various more recent studies. The analysis suggests significant effect prevents caries of primary and permanent dental varnish fluoride, but the quality of the evidence was considered to be moderate, because they included mainly studies present a high risk of bias and heterogeneity.

Endodontic management of Mandibular first molar with five canals

Dr. Rafeza Sultana

Ms- Resident, Department of Conservative Dentistry & Endodontic.

BSMMU

Abstract: The purpose of this study was to demonstrate the importance of knowledge of the internal anatomy of root canals for the success of endodontic treatment. Lack of knowledge of anatomic variations & their characteristics in different teeth has been pointed out as one of the causes of endodontic therapy failure. The present report  describes a right mandibular first permanent molar requiring root canal therapy, found to have three separate canals ( type-1 configuration) in the mesial  root & two separate canals ( type-1 configuration) in the distal root . So emphasizes the need for the clinicians to be aware of & look out for such variation & use adequate diagnostic methodologies prior to & during therapy to detect such variations. The operator experience has also shown to be a key factor in negotiation & management of this aberrant canal configuration.

Key Word: Mandibular 1^st Molar, Middle Mesial canal, % root canal, Root canal anatomy.

Introduction: Knowledge of internal dental anatomy is fundamental to the success of endodontic treatment. Incomplete instrumentation, inadequate cleaning & shaping, & the subsequent defective obscuration of root canals are the main causes of endodontic treatment failure¹. Anatomical characteristics of the different types of teeth and their possible variations are challenges routinely faced by practitioners performing endodontic treatment.

The correct access into the pulp chamber, which should allow access to the orifices of the root canals and an optimum view of the chamber floor, is a fundamental step in endodontic therapy as it enables the identification of any variation in the number and position of root  canals² .

The middle mesial canal has been more commonly located in mandibular 1^st molar¹⁰.  Several studies have evaluated the degree of variation in the number of roots and root canals in mandibular 1^st molars¹⁰ .  Fabra  campons¹⁰ studies 145 mandibular 1^st molars & found that 2.75% of the teeth had five canals. Martinez-burna and Badanelli⁵ conducted a canal investigation & found 29 teeth with five root canals in a sample of 2362 mandibular permanent molars and reported that 12 out of 100 molars studied had a third mesial canal.

Aminsobhani et all studied the occurrence and location of the middle mesial canal of mandibular 1^st molar & second molar in relation to other two mesial canals that were treated in private practice that middle mesial canalwas located in the middle of the distance between the mesiobuccal and mesiolingual canals. The canal configuration  was found in 6 2^nd molars & 21 1^st molars. Middle mesial canals in all of the cases joined to mesiobuccal or mesioligualcanals. None of the teeth consisted  of three independent canals with three apical foramina . Beatty & krell described  a mandibular 1^st molar with three independent canals in the mesial root . Author Dr. carlos Heibom et  al reported the number of roots, total number of canals, the number of middle mesial canals & number of foramina in the following chart

Number of roots Number of molars studied                  18,781                        3-rooted molars in %                  13 % (2,450)

Total number of canals Number of molars studied                   4,745         61.3 % 3 canals        35.7 % 4 canals       0.8 % 5 canals

Number of canals in mesial root Number of mesial roots studied           4,535         3.3 % 1 canal            94.2 % 2 canals      2.6 % 3 canals

Mesial and distal roots. Canal system configuration                                                                            Type I (1-1)   Type II (2-1)   Type IV (2-2)   Type VIII (3-3) Number of mesial roots studied           4,331                               35 %               52.3 %                0.9 % Number of distal roots studied             2,992         62.7 %           14.5 %            12.4 %

Number of foramina in mesial and distal roots                                                                                    1 foramen                2 foramina                   3 foramina Number of mesial roots studied          4,817                  38.2 %                      59.2 %                         1.6 % Number of distal roots studied            3,378                  77.2 %                      22.2 %

Intercanal communications. Type V isthmuses                                                                                               Mesial root                                 Distal root Number of molars studied                   1,615             54.8 % middle & apical 1/3              20.2 % middle 1/3

According to ingle¹² one of the most important causes of endodontic treatment failure is the incomplete obturation of the root canal system. Therefore, the correct location, instrumentation & obturation of all canals are indispensable procedures. 

Case report: A 19 years old male patient reported to the department of conservative dentistry & endodontics BSMMU with decayed tooth & associated pain over his right mandibular region. Intra oral examination revealed class 1 deep carious lesion in mandibular right 1^st molar. The tooth exhibited no mobility, was mildly tender to percussion and gives a negative respond to vitality test. The pre operative diagnostic radiograph of the tooth revealed a deep carious lesion involving the pulp with widening of apical periodontal space. A diagnosis of necrotic pulp with apical periodontitis was made and endodontic treatment was scheduled. After administration of local anesthesia & isolation, the carious lesion was removed and an

Endodontic access was made. Inspection of pulp chamber floor showed orifices corresponding to mesiobuccal, mesioligual, distobuccal abd distolingual canals. On careful examination of the groove between the mesiobucccl and mesiolingual canal orifice was identified and subsequently negotiated. The working length was established (MB-20mm, ML-20mm, Middle Mesial-19mm,DB-19.5mm,DL-19mm).The canals were instrumented with NiTi  file and irrigation was done with  2.5% NaOCl solution. After preparation the canal was finally flushed with normal saline & dried with sterile paper points and Ca(OH)2 was given at the full length of the canals with Lentulo-spiral  for 1 week. At the subsequent visit the Ca(OH)2 dressing was removed, the master cone fit was cheeked and the root canal was dried with absorbent paper point and was obturated with GP cone.

Discussion: Before root canal treatment clinician should adequate knowledge of the pulp chamber and anatomy of teeth. All root canals should be accessed, cleaned and shaped to achieve a hermetic obturation of the entire root canal space.

There is an abundant amount of reports that relate the anatomic variations of the mandibular molars. This should induce the clinician to observe the pulp chamber floor to locate possible canal orifices. This will increase the long term prognosis of endodontic therapy. Searching for additional canal orifice should be standard practice for clinician. A round bur or ultrasonic tip can be used for removal of any protuberance from the mesial axial wall would prevent direct access to the developmental groove between MB & ML orifices. This developmental groove should be carefully cheeked with sharp endodontic explorer (DG-16, JW-17). If orifices are located the groove can be troughed with ultrasonic tip, its mesial aspect until small file can negotiate this intermediate canal^{4 .} New technology such as dental operating microscopes and dental loupes offer magnification and illumination of the operating field and substantially improved the visualization of the root canal orifices^5-6. But we did not use these new technologies during treatment session.

Numerous studies in the past decade have described the morphology of teeth including mandibular molars⁷. The morphology of mesial root canals in mandibular molar is complex and high frequency of intercanal communication and or isthmuses ^{(7,8,9,10-13)}.

The presence of third canal (middle mesial) in the mesial root of the mandibular molars has been reported to have an incidence of 0.95% to 15%^{(4,7,11,14,15,19)}.In almost all of the clinical cases  reported until today these canals joined the mesiobuccal & mesiolingual canal in the apica third²⁰.

Radiographic examination using intraoral periapical view is important for the evaluation of the canal configuration. However it has its inherent limitation to access the root canal system completely. Digital radiography at different angles with subsequent image analysis can be used effectively. Computed tomography (CT) imaging has been widely used in medicine since the 1970s and was introduced in the endodontic field in 1990. Recently cone beam CT (CBCT) and RVG imaging has been shown to provide comparable images at reduced dose and cost to be considered as an alternative to multi detector CT imaging in endodontic. La et al. 2010 suggested clinical detection and management of an independent middle mesial  canal in mandibular molar by using CBCT imaging.

Various diagnostic aids like dyes, champagne bubble test , ultrasonic’s, micro openers and transillumination  aids, irrigators to improve pulp chamber visibility (Stropko) and observing the chamber for bleeding spots could be used by the clinician as an effective means to locate additional canal orifices.

Conclusion: knowledge of dental anatomy in fundamental for good endodontic preparation. Identification of these extra canals and their instrumentation is one of the key factors in the prevention of unsuccessful treatment outcomes. In addition to the various diagnostic aids, operator experience has also been identified as a key factor in locating these aberrant canals. The clinician should be aware of the incidence of this type of variation in the mandibular first molar tooth and perform a preoperative radiological assessment from different angles, a proper access preparation, and thorough examination of the pulp chamber to locate and debride all the canals. An accurate clinical evaluation of root canal and morphology in mandibular first molar should be done using various diagnostic methodologies with magnification and illumination, which would pave the way for long-term success of endodontic therapy.

References

1. Leonardo MR. Aspectos anatômicos da cavidade pulpar:

relações com o tratamento de canais radiculares. In:

Leonardo MR, Leal JM, eds. Endodontia: tratamento de

canais radiculares. 3rd ed. São Paulo: Panamericana;

1998. p. 191.

2. Balleri P, Gesi A, Ferrari M. Primer premolar superior

con tres raíces. J Endod Pract 1997; 3: 2.

3. Hess W. The anatomy of the root canals of the teeth of

the permanent dentition. Part 1. New York: Williams

Wood; 1925.

4. De Deus QD. Endodontia. 5th ed. Rio de Janeiro: Medsi;

1992.

5. Martinez-Berna A, Badanelli P. Investigación clinica de

molares inferiores con cinco conductos. Boletín de

Information Dental 1983; 43: 27–41.

6. Okumura T. Anatomy of the root canals. JADA 1927;

632–6.

7. Skidmore AE, Bjorndal AM. Root canal morphology of

the human mandibular first molar. Oral Surg 1971; 32:

778–84.

8. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic

investigation of 7,275 root canals. Oral Surg

Oral Med and Oral Path 1972; 33: 101–10.

9. Hartwell G, Bellizzi R. Clinical investigation of in vivo

endodontically treated mandibular and maxillary molars.

J Endod 1982; 8: 555–7.

10. Fabra-Campos CH. Unusual root anatomy of mandibular

first molars. J Endod 1985; 11: 568–72.

11. Jacobsen EL, Dick K, Bodell R. Mandibular first molars

with multiple mesial canals. J Endod 1994; 20:

610–13.

12. Ingle JI. Endodontics. 3rd ed. Philadelphia, PA:

Saunders; 1985.

13. Vertucci FJ. Root canal anatomy of the human permanent

teeth. Oral Surg Oral Med Oral Pathol 1984; 58:

589–99.

14. De Grood ME, Cunningham CJ. Mandibular molar

with 5 canals: report of a case. J Endod 1997; 23:

60–2.

15. Marshall FJ, Papin J. A crown-down pressureless preparation

root canal enlargement technique. Technique

manual. Portland: Oregon Health Sciences University;

1980.

16. Tagger M. Use of thermo-mechanical compactors as an

adjunct to lateral condensation. Quintessence Int 1984;

15: 27–30.

17. Vande Voorde HE, Odendahl D, Davis J. Molar 4th

canals: frequent cause of endodontic failure. III. Dent J

1975; 44: 779–86.

Figure 4 Final radiograph of obturation of five canals.

F. B. Barletta et al. Mandibular Molar with Five Root Canals

© 2007 The Authors 3

Journal compilation © 2007 Australian Society of Endodontology

18. Badanelli P, Martinez-Berna A. Obturacion de un molar

inferior con cinco conductos. In: Lasala A, ed. Endodoncia.

Barcelona: Salvat S. A.; 1979. p. 407.

19. Carvalho MC, Zuolo ML. Orifice locating with a microscope.

J Endod 2000; 26: 532–4.

20. Bueno CE, Cunha RS, Dotto SR, Ferreira R. Um molar

inferior com cinco canais – caso reportado. Rev Fac

Odontol Univ Passo Fundo 2002; 7: 51–3.

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