PAD™ in Endodontics

Mr Steve Bonsor BDS (Hons) DPDS FHEA
The Dental Practice
21 Rubislaw Terrace
Aberdeen
Scotland, UK

 

Background:

A 29 year old accountant with a clear medical history attended for a three monthly hygienist visit as part of his ongoing periodontal maintenance.  A symptomless sinus was noticed by the hygienist on the attached gingivae buccal to 35/36 and the patient was referred to the operator for investigation.  There was no deep periodontal pocketing in the region.  A periradicular radiograph was taken with a
size 20 GP point in the sinus [fig.1] using a long cone technique with an EndoRay film holder. This indicated a large periradicular radiolucency associated with the apex of 35.  A diagnosis of chronic suppurative periradicular periodontitis of 35 was made and after discussion of the options, the patient elected to have root canal therapy performed on the tooth.

After local anaesthesia had been administered (2ml 4% articaine 1:100000 epinephrine), 35 was opened and the canal was identified and accessed.  Rubber dam was placed and sealed using OraSeal Caulking. The necrotic pulp was then extirpated and the working length was determined by using an apex locator. The canal was prepared using GT Rotaries in the coronal aspect of the canal and Profiles to prepare the apical 2mm to a size 30 04.  Copious irrigation with 20% Citric Acid solution and 2.25% sodium hypochlorite solution (in the form of 4.5% commercial thin bleach Tesco, UK diluted 50:50 with water) was used alternately during the canal preparation.  A cone fit radiograph was then taken to check the apical extent of the master apical point [fig.2].  The canal was flushed using sterile water and the canal dried using sterile paper points.  All the irrigants were introduced into the canal using a gauge 27 endodontic micro-needle and used at ambient temperature. PAD™ using the endodontic tip was performed in the canal at 100mW for 150s as per the manufacturer’s instructions.  The canal was finally flushed with sodium hypochlorite solution and after drying with sterile paper points, the canal was dressed with UltraCal.  A cotton wool pledget was placed in the pulp chamber and a dressing of IRM placed in the access cavity.

The patient was seen one week later having experienced no symptoms and on examination, the sinus was found to have healed completely.  Local anaesthesia was again administered as before, rubber dam reapplied and the canal re-entered.  The same irrigants were used to remove all the non-setting calcium hydroxide and the canal dried as before.  The canal was then obturated using GP and TubliSeal EWT using System B and backfilled using Obtura. Vitrebond was placed over the canal orifice and a DO amalgam was bonded into place using Rely X ARC. A postoperative periapical radiograph was then taken [fig.3] so that periradicular healing could be subsequently followed up.

Figures 4, 5 and 6 show periapical radiographs at 9 months, 21 months and 47 months respectively.  A gold inlay/onlay was placed between the last two views to protect against coronal fracture.

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