Summary of medical doctoral thesis: The impact of operating microscope on the outcome of endodontic treatment in first maxillary molar

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Describe the clinical and radiological features of the upper first molar indicated for endodontic treatment; assessing the effectiveness of microscope application in the treatment of upper first molar; evaluation of the results of the upper first molar’s endodontic treatment.

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Nội dung Text: Summary of medical doctoral thesis: The impact of operating microscope on the outcome of endodontic treatment in first maxillary molar

MINISTRY OF EDUCATION & TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY BUI THI THANH TAM THE IMPACT OF OPERATING MICROSCOPE ON THE OUTCOME OF ENDODONTIC TREATMENT IN FIRST MAXILLARY MOLAR Specialty : Odonto and Stomatology Student No : 62720601 SUMMARY OF MEDICAL DOCTORAL THESIS HA NOI - 2020
WORK IS COMPLETED AT: HANOI MEDICAL UNIVERSITY Scientific supervisor: 1. Ph.D. Nguyen Manh Ha 2. Asso.Prof. Ph.D. Pham Thi Thu Hien Opponent 1 Opponent 2: Opponent 3 The thesis will be defended before school level Jury at Hanoi Medical University. You can learn about the thesis in: National Library Library of Hanoi Medical University
1 PROBLEM STATEMENT With the development of science and technology, microscopes have also been applied in dentistry in many countries around the world. Many scientific works have shown the outstanding advantages of microscopes applied in dentistry. The use of endodontic microscopes helps to identify symptoms, diagnose the disease correctly, and detect the root canal more easily. With the remarkable advantages of the microscope in terms of magnification and focus, the microscope really opens a new era for dentsitry in general and Endodontic in particular. In Vietnam, the research and application of microscopy in endodontic treatment is still limited. In order to evaluate the applicability of microscopes in dental treatment of endodontics, we conducted the study "Study of microscopy application in root canal treatment of upper first molar" with the following objectives: 1. Describe the clinical and radiological features of the upper first molar indicated for endodontic treatment. 2. Assessing the effectiveness of microscope application in the treatment of upper first molar. 3. Evaluation of the results of the upper first molar’s endodontic treatment. The need of the study Endodontic diseases always make up a high proportion in dental diseases. Endodontic treatment is an important area of restorative dentistry to restore function and aesthetics to diseased teeth. The upper first molar is one of the earliest erupted teeth and has the most endodontic treatment, but the rate of failure of endodontic treatment is the highest among the molar teeth. Many studies show that the presence of MB2, as well as unsatisfactory cleaning of the pulp chamber, is the main cause of treatment failure. Therefore, the application of technical advances such as dental microscopes to detect root canals, wall crevices, pulp chambers, granules and calcified blocks is extremely necessary to support the dentist in detect, clean, shape the canal, and pulp chamber treatment.
2 New contributions of the study - This is a research project following the new trend of microscope application in the accurate diagnosis and examination of fissures before and during treatment, the discovery of calcified particles and calcification chamber, and management of complications when encountered in the treatment of upper first molar. - The thesis specifically evaluates the efficiency of using a microscope to detect the orifice of the root canal, of which the most effective is to detect the MB2 is much higher than naked eye. - The results of the study are monitored up to 24 months after treatment, which is long enough to generalize the results, making recommendations in the application of microscopes in endodontic treatment. Layout of the thesis The thesis has 143 pages, including sections: problem statement (2 pages), introduction (44 pages), subjects and research methods (18 pages), results (47 pages), discussion (29 pages), conclusion (2 pages), Suggestion (1 pages), The thesis has 49 tables, 47 pictures, 8 charts, 1 diagram. 131 references including Vietnamese and English documents. CHAPTER 1: INTRODUCTION 1.1. Anatomy of the upper first molar root canal system The upper first molar is the earliest permanent tooth, so it is the first to decay. Upper first molar has three root: two buccal root (MB and DB) and one platal root. Each root corresponds to 1 root canal, sometimes 2 canals, usually found in the proximal canal. 1.1.1. Outer anatomy Viewed from the occlusal surface: The contour is usually diamond shape. Three large cusps form a typical pattern for maxillary molar teeth, which are linked together into a triangle. These are important anatomical landmarks applied when opening pulp for endodontic treatment of the upper fist molar teeth. 1.1.2. Inner anatomy The inner form includes the pulp chamber and the canal system. 1.1.2.1. Pulp chamber On the near and far view: the pulp chamber has two horns, the horn is near the outside and the horn is far away. The two canals are quite narrow.
3 On the external outer view: the pulp chamber is wider, the horn of the pulp is usually protruding. Usually has 3 legs with 3 root canals. The proximal canal is shorter than the inner canal, the proximal canal is usually very wide and in most cases there is an additional root canal. On a view across the pulp chamber in the neck of the tooth: the shape of the pulp chamber in the neck of the tooth is shaped like a parallelogram. * The pulp chamber ceiling is the upper limit of the pulp chamber, usually far from the floor in young people and is lowered in the elderly due to the development of dentine as well as mechanical and chemical stimuli. * The pulp floor is the lower limit of the pulp chamber, on the floor of the pulp chamber has an opening of the root canal. However, the calcification of the pulp chamber makes it difficult for endodontic treatment, the orifices can be obscured making it more difficult to access the pulp chamber and the risk of instrument fracture. This phenomenon is quite common in root canal. 1.1.2.2. Root canal system The root canal system starts from the orifice of the root canal at the floor of the pulp chamber and ends at the end apex. There are 3 or 4 root canals forming triangles with acute distal angle. The root canal system in the upper first molar is analyzed by the Weine classification system, most teeth have 3 roots, each root usually has 1 root canal, the additional root canal is MB (79.2%) and DB (1.65%). 1.1.3. The study of internal anatomy of teeth Laboratory or clinical studies to describe internal anatomy include many different types of methods. 1.1.4. Some landmarks open marrow anatomy application The entry point to the pulp chamber of upper first molar starts from 1-2mm from the MB cusp towards the central groove, using a round drill or Endo access to open into the pulp chamber. According to Hess, the opening is a trapezoid shaped narrower than the pulp floor. In the case of not seeing the orifice, open the chamber further and follow the mesial diagonal.
4 1.2. Pathology of dental pulpal and periapical disease Causes: bacterial infection, physical factors Classification of the pathology and diagnosis is based on clinical and paraclinical symptoms according to the American Endodontic Association recommendations for use in 2008. Diagnosis of pulpal disease: Classification of pulp pathology is mainly based on clinical signs, subclinical and physical symptoms. Periapical disease: include acute, subacute or chronic lesions. Injury area usually refers to lesions in the ligament and bone region around the apical area. 1.3. Endodontic treatments: Conservative treatment (Pulp capping. Partial pulpotomy), root canal treatment 1.4. Some causes of failure in endodontic treatment: Opening wrong path, broken instrument, obturation over apex 1.5. Microscope application in endodontic treatment and treatment results 1.5.1. Introducing the microscope A microscope is a device for viewing very small objects that are invisible to the naked eye. The visibility of a microscope is determined by its resolution. Advantages of magnifying devices: The three main advantages identified are related to the use of endodontic amplification devices, that is, (1) a clearer working field, (2) improved working posture and (3) increased persuasion ability. Disadvantages of microscopes Some of the reported drawbacks are the time it takes to get used to new equipment, the cost of magnification equipment and related accessories, the need for additional infection control, and possibly injury. due to the sharp instruments. 1.5.2. Some research results using microscopy in endodontic treatment Several studies have shown that it significantly increases the ability of dentist to locate and access the root canal. Therefore make the results of treatment increase.
5 CHAPTER 2: MATERIALS AND METHODS 2.1. Materials Maxillary first molars which needed endodontic treatment, were treated at Department of Endodontics, National Hospital of Odonto- Stomatology from January 2013 to April 2019.  Inclusion criteria - Maxillary first molar needed nonsurgical endodontic treatment - Restorative management is available after root canal treatment - Patients accepted - Mature teeth  Exclusion criteria - Patients with severe diseases: cardiovascular diseases, hypertension, diabetes, psychiatric diseases. - Patients unaccepted 2.2. Methods 2.2.1. Method: thepary study with intervention 2.2.2. Sample size and selection  Sample size n: minimum sample size : α = 0,05 = 1,96 p: Prevalance of success endodontic treatment (90%) After calculating, n=97. In fact, we treated 105 maxillary first molars Sample selection: satisfactory. All the patients with inclusion criteria were screening, explained and invited to participate. We collect until adequate volume.
6 2.3. Procedures Information collected Examine, pulp testing (with microscope) X-ray: periapical view Diagnosis, etiology Anesthesia Rubber dam Pulp access Identify orifice Eyes vision Microscope Irrigation and shaping Obturation Restoration Follow - up
7 2.4. Diagnosis and treatment 2.4.1. Symptoms and Xray - Reasons - Symptoms + Pain/no pain + Pain level - Examine + Fever/no fever + Swelling/no swelling + Soft tissue: red, swelling, painful when press, sinus tract + Hard tissue: caries dectection, cracked teeth (by eyes and microscope). - X-ray: periapical view - Diagnosis: pulp diseases, periapical diseases - Protocol: base on the protocol that AAE recommend in 2008 2.4.2. Treatment Treatment procedure - Anesthesia: local (vital pulp) - Wall build –up (if needed) - Place rubber dam - Access - Observe pulp chamber: calcification or not, cracked line (by eyes and microscope) - Detection and shaping (2 phases) Phase 1: Identify orifice by endodontic explorer and eyes. Take photos of pulp floor Phase 2: Identify orifice by endodontic explorer and microscope. After finding the forth or fifth orifice, continue to: - Open - Identify working length - Shaping by rotary files Protaper - Cold lateral compaction and warm vertical compaction - Master cone fit radiograph - Restoration - Follow up
8 2.4.2.3. Results * After obturation on Xray Standard Good Average Bad Final - Adequate -Underextension 1- Underextension master working length 2mm or >2mm or or cone (apex or 0,5mm overexthension ≤ overexthension length shorter) 1mm ≤ >1mm -Well condensed - Bad condensed * Post-op afer 1 week Symptom Good Average Bad Bite Normal Mild pain Can not bite Soft tissue No swelling No swelling Red, swelling, pain when press Percussion No pain Mild pain Sharp pain * Post-op after 3-6 months, 12 months and 2 years: Examine, Xray Outcome Symptoms Xray -Bite: normal - No periapical lesion Good -No pain, no swelling - Apical lesion: smaller - Percussion: no pain -Bite: normal Periapical lesion: no change Average -No pain, no swelling - Percussion: mild pain -Bite: pain Periapical lesion: bigger Bad -pain, swelling - Percussion: pain 2.6. Errors and error corrections 2.6.1. Errors 2.6.2. Error corrections 2.7. Data processing: STATA 15.1 softwar
9 2.8. Ethical aspect of research * Ethics in research The research was allowed by the Council of PhD, School of Odonto-stomatolgy, Hanoi Medical University. It is also accepted by the Director of National Hospital of Odonto-Stomatology. All the patients included was explained clearly about the purpose, meaning, benefit and risk of this research. All the information and data collected is protected and used only for this research. CHAPTER 3: RESULTS 3.1. Clinical and X-ray characteristics of the maxillary first molar before treatment Table 3.1. Distribution of study population by age and gender Gender Male Female Total Age n (%) n (%) n (%) 44 30 (49,2) 17 (38,6) 47 (44,8) Total 61 (100) 44 (100) 105 (100) The percentage of subjects in the study increased gradually by age group, respectively: 16.2%, 39.0%, 44.8%. This difference is statistically significant with p
10 Table 3.5. Distribution of causes by age group Age 44 Total Cause n (%) n (%) n (%) n (%) Decay 15 (88,2) 18 (43,9) 14 (29,8) 47 (44,8) Cracked tooth 2 (11,8) 21(51,2) 33(70,2) 56 (53,3) Other 0 (0) 2 (4,9) 0 (0) 2 (1,9) Total 17 (100) 41 (100) 47 (100) 105 (100) The tooth crack increases with age; in the group 44 is 70.2%. In contrast, the incidence of tooth decay decreases with age. This difference is statistically significant with p 44 is 57.4%, in the group of 30 - 44 is 51.2%, in the group
11 Table 3.9. Images of the pulp chamber and the periapical X-ray by age group Age 44 Total Xray (n=17) (n=41) (n=47) (n=105) Without Pulp 16(94,1) 21 (51,2) 7 (14,9) 44 (41,9) calcification chamber Calcified 1 (5,9) 20 (47,8) 40 (85,1) 61 (58,1) Normal 16(94,1) 31 (75,6) 33 (70,2) 80 (76,2) Periapical Lesion 1 (5,9) 10 (24,4) 14 (29,8) 25 (23,8) - On the x-ray image, the proportion of calcified chamber was 51.8%, increased significantly with the 3 increasing age groups, respectively, the age group 44 years old is 85.1%. The difference was statistically significant with p 44 years and 29.8%, then to the group of 30 -44 years old with 24.4% and the lowest was the group 44 years of age is
12 70.2%; group of 30-44 years old is 53.6%; The group
13 increasing by 29.4%, 70.7%, 82.3%, respectively. The difference in the proportion of calcified masses in pulp chamber by age group was statistically significant with p
14 3.3. Treatment results of maxillary first molar using a microscope Table 3.34. Treatment results after one week by age group 44 Total Result n (%) n (%) n (%) n (%) Good 13 (76,4) 33 (80,5) 43 (91,5) 89 (84.8) Quite good 4 (23.6) 6 (14,6) 3 (6.4) 13 (12.4) Poor 0(0,0) 2 (4,9) 1 (2,1) 3 (2,9) Total 17 (100) 41 (100) 47 (100) 105 (100) After 1 week of root canal obturation, the rate of good results increases with age groups, 76.4%; 80.5% and 91.5%, respectively. This difference is not statistically significant with p> 0.05. - The rate of quite good results in the group under 30 years achieved the highest result, 23.6% and the lowest was the group above 44 years old. The rate of poor results in the group 44 years old is 2.1%. The difference is not statistically significant with p> 0.05. 5.2% 4.2% Tốt Khá 90.6% Kém Figure 3.6. Treatment results after 3 - 6 months (n = 96)
15 - After 3-6 months of treatment, there were 96 patients coming to follow-up appointments, so we summarized and evaluated the treatment results on these 96 patients. - Up to 90.6% of patients healed and achieve good results after 3- 6 months. However, there are still 5.2% of patients who are recovering after this period of time with quite good results, still 4.2% of patients who have not healed and get poor results. The difference was statistically significant with p
16 CHAPTER 4: DISCUSSION Researching on 105 first maxillary molars were treated endodontically, we had some issues to discuss as follows: 4.1. Clinical and X-ray features of the first maxillary molar before endodontic treatment. 4.1.1. General information of research subjects In this study, the average age of the study subjects was 41.9 ± 11.9 (years). The proportion of patients in the group higher 44 age accounted majority, with 44.8%. The generality of study patients were male, accounting for 58.1%. The age of the study subjects (in both men and women) increased gradually by age group, the group over 44 years old have disease was highest with 44.8%. Our research results are similar to those reported by Pham Thi Thu Hien with the study participants aged over 40 accounting for the highest proportion (50%), the proportion of patients aged 20 - 40 is 45 % (p
17 53.3%. The rate of causes of tooth decay in our study is consistent with the author Cao Thi Ngoc (causes of tooth decay accounted for 55.7%). But lower than Nguyen The Hanh’s study caused by caries accounted for 95.1%, Tran Thi Lan Anh’s study caused by caries accounted for 80.6%, ... In our study, eye exams often found cracked teeth in 46.7% of cases, using a microscope to detect 68.6% of cases. Thus, the identification of cracked teeth when observed under a microscope will give higher results with the naked eye. In the group has the cause is pulp pathology by tooth decay accounted for 78.7%, periapical pathology accounted for 21.3%, the reason is that tooth fracture has pulp pathology is 73.2%, periapical pathology accounts for 26.8%. Pulpal pathology accounts for 75%, periapical pathology 25%. Our results are similar to those of Pham Thi Thu Hien that the pulpitis is the most common disease accounting for 48%. Similarly, author Muhammad Hasan Pakistan showed that the acute periodontal group had irreversible pulpitis symptoms accounting for 17%. 4.1.3. X-ray features of the first molars before treatment Our research results show that the proportion of calcified pulp chamber is 58.1%, the non-calcified pulp chamber is 41.9%. The higher the age has the higher of calcified pulp chamber image. The dental ligaments have a rate of relaxation also increases with age: 29.45%, 51.2%, 53.2%, respectively and the condition of periapical almost is normal. 4.2. Effective of microscope application in the endodontic treatment of the first maxillary molar. * With calcified teeth: In our study, patients with calcified pulp chamber in x-ray images accounted for 58.1%, but could not distinguish the type of
18 calcification. When the pulp chamber is opened and when observed under the microscope it is clearly seen that there are two types of calcification, sometimes discrete particles of calcium or continuous cement blocks associated with the structure of the pulp chamber wall. Therefore, identifying and eliminating them is difficult. Discrete images of calcified particles as observed by the naked eye have 13 cases accounting for 12.4% and observing under the microscope 29 cases accounting for 27.6%. When observed under a microscope, in the age group under 30 and 30-44 years of age, the proportion of discrete calcified particles accounting for high percentage is 35.2% and 34.1%, while in the age group over 44 years accounts for 19.1%. Our results are similar to those of Colak H and Celebi (2012) with the highest rate of scattered calcium in middle age, accounting for 76.24%. And in our study, the typical calcium block with the naked eye was able to see 51 (48.6%) cases, when observed under a microscope saw 75 (71.4%) cases and especially increased by age. Observations under the microscope show that the calcium image is more visible than the naked eye. * With cracked teeth: Our study has recorded that the group has the cause is pulp pathology by cracked tooth accounts for 52%, the higher the age, the more common ration of cracked tooth. Bajaj et al. found differences in micro features of the fractured surface between dentin in the elderly and young people. In this study, cracked teeth were commonly reported in people aged 50-59. In our study the male group accounted for 38 teeth, the female group was 17 teeth. But there are many studies in Korea do not show a difference in the number of cracked teeth between men and women. In our study, before the treatment, the visual examination detected 49 cases of cracked teeth, under the microscope detected 72 cases of