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Key Words
Mineral trioxide aggregate, perforation, repair
208
Mente et al.
oot perforations are artificial connections between the root canal system and the
periodontium and/or the oral cavity. They can be iatrogenic or noniatrogenic.
Examples of iatrogenic causes are incorrectly aligned trephination (mostly by high
speed bur) or post perforations. Perforations can also occur while the root canal is
being prepared. The main noniatrogenic causes are progressive resorption and caries.
Sealing perforations of iatrogenic, resorptive, or carious origin poses a challenge
even for dentists with endodontic experience. The rationale of treatment of such cases
should be immediate sealing with a biocompatible material that is insoluble in the presence of tissue fluids (1) and allows regeneration of surrounding tissues (2).
The following materials have been recommended for sealing root perforations:
Cavit (3), silver amalgam (4, 5), super EBA cement (6), calcium hydroxide (7),
hydroxyapatite (8), calcium phosphate cement (9), light-cured glass ionomer (10),
and decalcified freeze-dried bone (11). None of these perforation sealing materials
is adequately biocompatible to ensure a good treatment outcome when it comes into
direct contact with bone tissue. Inadequate biocompatibility of the sealing material
frequently causes problems when it comes into contact with the neighboring tissue,
especially when the perforation is large and there is an increased likelihood of the material extruding into the surrounding tissue (12). Therefore, the prognosis for teeth with
root perforations was considered very uncertain before the introduction of mineral
trioxide aggregate (MTA) (13, 14). Many studies have documented the biocompatibility
of MTA (1518). In addition, its ability to set is not affected by the presence of body
fluids such as blood (19).
The biocompatibility of MTA, the ability of this material to seal root perforations
effectively (20, 21), and its setting properties in the presence of moisture and even
blood are important characteristics that may result in greater success rates when
used for treating root perforations. Animal studies (2224), case reports, and case
series are available on the successful use of MTA as a perforation sealing material
(2530).
The number of cases in the clinical trials available to date is, however, rather small
so it is important to collect further clinical data on the use of this material in the repair of
root perforations. In Part II of this Heidelberg Study project for determining the success
of MTA treatment, the outcome of 21 endodontically treated teeth with root perforations, which were repaired exclusively with MTA (ProRoot MTA, gray version; Dentsply-Maillefer, Ballaigues, Switzerland), are evaluated.
Clinical Research
1 year. Criteria for exclusion were compromised immune status, pregnancy at the time of follow-up, incomplete pre- or intratreatment
records, and unwillingness to participate in the study.
Recruitment of Patients
Subjects who met the inclusion criteria were contacted by letter
and subsequently by telephone and were invited to attend the followup examinations. On the day of the follow-up examination, the patients
were again given a detailed explanatory information sheet and were
asked to sign a declaration of informed consent to participate in the
study. The patients were also given the opportunity to ask the examiner
any questions concerning the study and the planned procedure. Clinical
and radiographic follow-up examinations were performed after written
informed consent had been given.
Calibration
Because the clinical recall examinations for the clinical study
Mineral Trioxide Aggregate Apical Plugs in Teeth With Open Apical
Foramina: A Retrospective Analysis of Treatment Outcome (31) and
the present study were running concurrently, the calibration of the clinical investigators (NH and JT) was undertaken for both study projects at
the same time.
Calibration was performed by both investigators independently
examining 21 patients on the same day. The clinical parameters recorded were entered into separate database sheets and analyzed statistically for interexaminer reliability. These duplicate examinations were
also approved by the Ethics Committee of the University of Heidelberg
and undertaken only after the patient had given written permission.
One independent investigator (MK) was designated to perform all
the radiographic interpretations. Before the study radiographs were
evaluated, this examiner (MK) was calibrated for radiographic interpretation using the periapical index (PAI) calibration kit of 100 periapical
radiographs (32). Intraexaminer reliability and interexaminer agreement with the calibration kits gold standard were assessed by using
Cohen kappa statistic.
Endodontic Treatment Intervention
Teeth had been treated in accordance with current endodontic
techniques using a rubber dam for isolation. Six of the root canal treatments (29%) were performed by supervised undergraduate students,
11 teeth (52%) by general dentists, and four teeth (19%) by dentists
who had focused on endodontics for at least 3 years (EN). The latter
performed the complete treatment with the aid of a dental operating
microscope (Zeiss, Oberkochen, Germany). All treatment providers
used a dental operating microscope when applying the MTA cement itself.
Before the perforation was sealed, the defect was carefully irrigated, first with 3% sodium hypochlorite and then with 0.12% CHX solution (Glaxo Smith Kline GmbH, Buhl, Germany). If necessary, it was then
dried with sterile paper tips, or, if the perforation was in the furcation
area, sterile cotton pellets were also used. In cases in which bleeding
from the perforation area would have complicated the sealing process,
a mixture of calcium hydroxide powder and CHX solution (0.12%) was
applied to the perforation area and the root canals for a few days so that
the sealing of perforation using MTA could be undertaken under ideal
conditions.
The MTA cement was applied to the perforation area in small
portions using an MTA gun (Dentsply-Maillefer, Ballaigues,
Switzerland). The MTA cement was thoroughly compressed and compacted in the defect using Machtou pluggers (Dentsply Maillefer) of
different sizes (0, 12 , and 34 ). An absorbable matrix was not used.
JOE Volume 36, Number 2, February 2010
209
Clinical Research
fillings were documented. If they did not agree, both examiners met to
discuss the radiographic findings and come to a consensus.
The outcome was assessed on the basis of clinical and radiographic findings. All elicitation of clinical and radiographic findings
in this study was undertaken by calibrated examiners (MK, JT, and
TP), who themselves had not performed any of the perforation sealing
procedures and were therefore unbiased. A case was classified as
healed when there was no indication of apical periodontitis (PAI
#2), no radiolucency adjacent to the perforation site, no continuing
root resorption, no clinical signs and symptoms, and no loss of function. Outcome was classified as diseased if one of the following findings was observed at the follow-up examination: clinical signs and
symptoms (such as sensitivity to percussion, sinus tract, longitudinal
fracture, loss of function, pain, or discomfort experienced by the patient
regarding the tooth with the repaired perforation), apical periodontitis
(PAI $3), radiolucency adjacent to the perforation site, or signs of
continuing root resorption. Multirooted teeth were assessed according
to the highest score given to any one of the roots.
Statistical Analysis
Median, first and third quartile, minimum and maximum, and
relative and absolute frequencies were calculated for descriptive analysis. The Fisher exact test was performed to investigate the effect of
potential outcome predictors as shown in Tables 1 through 3. The
data were processed by using the SAS statistical package (Version
9.1; SAS Institute Inc, Cary, NC). Because of the exploratory nature of
the study, no adjustment was made for multiple testing. All tests were
performed at a significance level of 0.05.
Results
The details of clinical and radiographic calibration have been
described previously (31). There was a high level of consensus
regarding the clinical findings performed by the two designated investigators.
Intraexaminer reliability for the PAI calibration results was k =
0.77, indicating substantial agreement (33). The interexaminer
agreement (examiner scores vs. the calibration kit authorized scores)
was k = 0.82, indicating almost perfect agreement (33).
Thirty-four subjects (34 teeth) were initially identified for potential
inclusion, eight of whom were excluded because the follow-up period
was too short (follow-up of at least 1 year was one of the inclusion
criteria). Twenty-six patients met the inclusion criteria. Of these, 21
patients took part in the follow-up study (recall rate 81%). Four of
the perforations were in the furcation area (Fig. 1A-C), seven at crestal
bone level, five at the midroot level (Fig. 2), and five in the apical third of
the root (Fig. 3).
The reasons for drop out were recorded; three patients (11.5%)
could not be reached despite repeated letter writing or telephone calls
and two patients (7.5%) had moved away. Eighteen teeth (86%) could
be classified as healed and three (14%) as diseased. Two of the three
diseased teeth were found to have a longitudinal root fracture. The third
tooth was extracted elsewhere 34 months after the endodontic treatment.
The outcome in relation to the recorded pre-, intra-, and postoperative variables is shown in Tables 1 through 3. Minor differences in
the healed rate were observed for several variables, whereas larger
differences ($15%) were noted for four preoperative variables
(number of roots, localization of perforation, size of perforation, and
pulp status), three intraoperative variables (root filling technique, treatment sessions, and experience of the treatment providers), and two
postoperative variables (quality of coronal restoration and type of resto210
Mente et al.
Healed
10
11
48
52
8
10
80
91
9
12
43
57
7
11
78
92
13
8
62
38
12
6
92
75
10
11
48
52
9
9
90
82
13
8
62
38
11
7
p
value*
0.59
0.55
0.53
1.00
1.00
85
87.5
1.00
4
7
5
5
19
33
24
24
4
6
4
4
100
86
80
80
1.00
6
5
10
29
24
48
5
4
9
83
80
90
10
8
3
48
38
14
9
7
2
90
88
67
10
11
48
52
9
9
90
82
3
18
14
86
3
15
100
83
9
12
21
43
57
100
8
10
18
89
83
86
13
8
62
38
11
7
85
87.5
0.52
1.00
1.00
1.00
1.00
ration). Interestingly, the healed rate for single-root teeth (12/13 teeth,
92%) was higher than that for multirooted teeth (6/8 teeth, 75%). The
healed rate for teeth with larger perforations (size >3 mm) was less (2/
3 teeth, 67%) than the healed rate for those with smaller perforations
(size 1-3 mm) (7/8 teeth, 88%) and very small perforations (size #1
mm, 9/10 teeth [90%]). However, none of the differences observed was
statistically significant.
Discussion
All available patients at the Department of Conservative Dentistry at
the University Hospital of Heidelberg who had undergone endodontic
treatment with repair of root perforations using MTA and who fulfilled
the inclusion criteria were considered for this study. Twenty-six patients
who had undergone endodontic treatment with perforation repair
between 2000 and 2006 were identified. Twenty-one of these patients
JOE Volume 36, Number 2, February 2010
Clinical Research
TABLE 2. Outcome Distribution across Intraoperative Variables
Teeth
Variable
Root-filling technique
Lateral compaction
Warm vertical
compaction
Pure MTA filling
Other
Treatment sessions
for whole
endodontic
treatment
2
>2
Treatment providers
Supervised
undergraduate
student
General dentists
EN
Healed
16
3
70
14
13
3
81
100
1
1
5
5
1
1
100
100
p value*
1.00
0.55
5
16
24
76
5
13
100
81
29
83
1.00
11
4
52
19
9
4
82
100
Postoperative
variable
Quality of coronal
restoration after
treatment
Acceptable
Unacceptable
Type of restoration
TemporaryA
Amalgam fillingB
Composite fillingC
Crown and access
cavity sealed with
composite fillingD
CrownE
Lost restorationF
Post or screw
after treatment
Absent
Present
Teeth
n
Healed
n
p value*
0.14
20
1
95
5
18
0
90
0
11
3
52
14
11
2
100
67
33
71
0.121
1.00
16
5
76
24
14
4
87.5
80
were available for recall; thus, the recall rate was 81%. The recall rate
should be $80% in order to obtain significant interpretations of findings (34).
Mineral trioxide aggregate (MTA) was used as perforation repair
material in all cases. As described by other authors (30), in cases of
excessive hemorrhaging, calcium hydroxide was placed in the perforation site for a few days so that the perforation repair using MTA could be
performed under ideal conditions.
All investigation criteria and the documentation of the study data
were established with standardized protocols before the start of the
follow-up examinations. Both clinical and radiographic evaluations
were performed after the examiners had been calibrated. Examiners of
follow-up examinations and radiographs should not be identical with
the providers of treatment because their interpretation may be biased
toward a more favorable assessment (34, 35). The PAI index used in
the present study (32) is a validated, reproducible method for unbiased
Figure 1. (A) A radiograph of a maxillary first molar with large perforation of furcation area (almost the entire pulp chamber floor is affected). (B) A follow-up
radiograph after 5 years (see Fig. 1A). The outcome is classified as healed. The MTA cement has extensive contact with the bone tissue. (C) A photograph of
perforation repair with MTA (clinical picture corresponding to 1A and B). The perforation covers the entire floor of the pulp chamber.
211
Clinical Research
Mente et al.
Clinical Research
Conclusions
Although this study was limited by the relatively small sample size
and the lack of a control group, the results indicate that (1) a high
success rate for treatment of root perforations in all areas of the root
can be achieved with MTA; (2) the use of MTA to repair root perforations appears to be a valid treatment option, even in undergraduate clinical courses, when students are supervised by endodontically
experienced dentists; and (3) further longitudinal prospective clinical
studies on the use of MTA for repairing root perforations that include
more teeth are necessary.
Acknowledgment
The authors would like to thank Dag rstavik for providing the
PAI reference radiographs. In addition, the authors wish to thank
Mrs Joanna Voerste and Mrs Kirsten Stoik for his assistance in preparation of this manuscript and Mr Jens Trautmann for his valuable
help with this study.
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