Student : Mary Roman Evidence Based Project Date: July 5th 2012 Clinical Problem: A patient was transferred

to me in May. He received endodontic treatment on #6 that had an ill-fitting pre-existing crown and was not treatment-planned to get it replaced or even close the access-cavity with a permanent restoration after RCT completion. My patient showed up with the crown in his hand, cavit was not completely sealing the access opening and the underlying cotton pellet was wet with saliva. This tooth will need retreatment and I asked myself if there is a way to avoid more microleakage once I started retreatment and until delivery of the new crown for the tooth. Structured Question: State your problem in the form of a PICO question. Population/problem: A tooth receiving endodontic treatment Intervention: Intra-orifice filling in addition to an intra-coronal filling. Comparison: intra-coronal filling only. Outcome: Establishing a coronal seal on a tooth receiving endodontic treatment that will prevent microleakage to the root canals. Clinical Question: How can we adequately seal the access cavity so that no microleakage occurs between visits? Type of question: X Therapy/Prevention Diagnosis X Prognosis Etiology/Harm Other

Ideal type of study: X RCT Meta-Analysis Cohort Study Systematic Review Case Series/Case Report/Case Control 2-3 Citation/References (e.g., author(s); article title; journal; volume/issue/pages; year): Discuss each one separately First Article: Intraorifice Sealing of Gutta-Percha Obturated Root Canals to Prevent Coronal Microleakage Donna M. Pisano, DDS, MS, Peter M. DiFiore, DDS, MS, Scott B. McClanahan, DDS, MS, Eugene P. Lautenschlager, PhD, and James L. Duncan, PhD. Journal of Endodontics. Volume 24, Issue 10, October 1998, Pages 659662. Second Article: Microleakage Evaluation Of Intraorifice Sealing Materials In Endodontically Treated Teeth. Sauia TS, Gomes BP, Pinheiro ET, Zaia AA, Ferraz CC, Souza-Filho FJ. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Aug;102(2):242-6. Epub 2006 Apr 21. Type of Study: both studies are In-vitro experiments. Resources (e.g., Cochrane; PubMed) and Search Terms: PubMed ("Root Canal Obturation"[Mesh]) AND "Dental Leakage"[Mesh], intraorifice [PubMed] Summary of Evidence: -Is the study valid? Both studies are valid. They were both published in highly renounced dental journals, Journal Of Endodontics and Journal of Oral Surgery, Oral Pathology, Oral Radiology, and Endodontology, respectively. Both studies are Randomized controlled trials and utilize acceptable means to conduct the studies. -What are the results? The first study found that Cavit offered a better intra-orifice seal compared to IRM and Super-EBA. Leakage was demonstrated by turbulence in the soy broth. Only 15% of teeth filled with Cavit in contrast to 35% of both IRM and Super-EBA leaked after 90 days.100% of the positive control teeth (no intra-orifice filling material on gutta-percha) leaked before 49 days. The second study measured leakage by the amount of dye penetration into the teeth after they have been immersed for 5 days. Only 10% of the teeth that received a Cavit intraorifice seal showed coronal leakage. 65% of the teeth that received Flow-it (Light cure flowable composite material) and 55% of the teeth that received Vitremer showed dye penetration. Like the first study, 100% of the teeth of the positive control group leaked. Clinical effect: Removing about 3 mm of gutta-percha below the level of the CEJ and placing a filling there significantly decreases the risk of coronal microleakage into the canals. If given the choice between materials, Cavit has demonstrated superior results in both studies when compared to other materials. Precision & statistical evaluation: Both studies have the challenge that they were both conducted in vitro instead of in live patients. The first study successfully utilized trypticase soy broth, which is a common medium for bacterial growth and human saliva. I like the fact that they used human saliva because it is the main cause of microleakage in vivo, which makes the study somewhat realistic However, there was no quantitative measurement as to how much leakage occurred. It was only measured by turbidity in the broth medium. Also, authors only focused on analyzing the net results after 90 days, not putting much weight on the behavior of these materials during the 90 day period, in which, in my opinion, IRM performed better relative to Super-EBA because the amount of teeth demonstrating microleakage only rose to 10% after 50 days versus 20% after 20 days for super EBA and 25% after 30 days. In addition, I find the positive control group (5 teeth obturated, no intra-orifice seal) to be a small number.

The second study used low p-values, (0. 01), which demonstrates a statistically better performance of Cavit compared to Flow-it and Vitremer. However, in this study, the extent of microleakage was not quantified either. Results were either no microleakage (if less than 3 mm of leakage occurred without the dye penetrating the GP) or total leakage (if more than 3 mm and the dye penetrated into the GP. A disadvantage to the study that I see is that the teeth were only examined after 5 days, which is a much shorter time than the amount of days expected between office visits and thus, does not give an close indication of the performance of the materials over a longer period of time. On the other hand, the study subjected the teeth to thermal cycling between 5C and 55C for 750 cycles, which represent the normal extremes of the oral environment, and which made it possible to demonstrate the behavior of the three materials under those circumstances. Do they apply to my patient? These studies do apply to my patient. I wanted to find a way to increase the quality of the coronal seal against microleakage between appointments and according to the study, adding additional Cavit 3 mm below the CEJ increases the seal of the gutta-percha from coroal microleakage. Bottom Line: Summary of this paper: The first study was conducted to compare Cavit, Intermediate Restorative Material, and Super-EBA as intraorifice filling materials for the prevention of coronal microleakage in root-canal treatment. 74 extracted single rooted teeth were instrumented and obturated with gutta-percha. 3.5 mm of the gutta-percha was removed from the coronal third of the root canal filling and replaced with either Cavit, IRM or Super-EBA. The control teeth were left with only the gutta-percha in the canal without the 3.5 mm preparation or any coronal seal. The teeth were suspended in scintillation vials containing trypticase soy broth, and human saliva was added to the pulp chambers. Microleakage was determined by the occurrence of turbidity in the broth corresponding to bacterial growth. At the end of 90 days, 15% of the Cavit-filled orifices leaked, 35% of the Intermediate Restorative Material and Super-EBA-filled orifices leaked and 100% of the positive control group leaked. All in all, the gutta-percha obturated root canals that received an intraorifice filling material leaked significantly less than the obturated, unsealed control group. The second study evaluated Cavit, Vitremer, and Flow-It filling materials to prevent coronal microleakage. 80 extracted human molars were instrumented and obturated with gutta-percha. 3 mm of the gutta-percha was removed from the coronal third of the root canal filling and replaced with either Cavit, Vitremer or Flow-It and subjected to thermocycling (5C to 55C) and 5 days of immersion in dye. The teeth were then cleared for stereomicroscope evaluation for dye penetration into the sealing material and along canal walls to the gutta-percha. All groups demonstrated dye penetration into the root canal but with varying degrees. Cavit successfully prevented leakage in 90% of the specimens followed by Vitremer (dye penetration in 55% of specimens) and Flow-It (65% of specimens). Like the first study, leakage occurred in 100% of the positive control group. How does this evidence affect your practice? Adding an intra-orifice seal is a very simple but also very effective way to protect the root canal from microleakage and thus a likely failure of the endodontic treatment. I will surely employ this technique especially if I am treating a tooth that does have enough coronal tooth tooth structure to ensure an adequate permanent coronal restoration, after I consult with my restorative and endodontic instructor. Additional notes/comments/questions:

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