Lauren Kuhn Nuth presents a successful root canal re-treatment case she completed using Septodont’s BioRoot Flow.
Introduction
The success rate of non-surgical root canal treatment is high. However, inadequate obturation and inability to seal anatomical complexities can play a role in the long-term success of endodontic treatment.
Traditional root canal sealers tend to shrink or wash out. BioRoot Flow is a mineral-based, tricalcium silicate sealer with bioactive properties which slightly expands upon setting and has a high pH, therefore providing antimicrobial properties.
Methods
The patient presented with a previously treated tooth #30 (mandibular right first molar) with apical periodontitis, and unobturated disto-lingual (DL)
and middle mesial (MM) canals. The case was re-treated by the author and at the one-year follow-up, excellent apical healing had occurred.
Discussion
The success of root canal re-treatment requires that bacteria be eradicated from the canals, and the canals be sealed long-term. Active biosilicate technology in BioRoot Flow allows for antimicrobial effects and apical bone healing.
Conclusion
BioRoot Flow played a critical role in the success of the root canal re-treatment of this case, with excellent sealing and antimicrobial properties.
Clinical signs and symptoms
The patient presented in June 2022 for a consultation. Her dentist and hygienist recently noted periapical radiolucencies associated with tooth 30 (mandibular right first molar) on a full mouth set of radiographs. The patient was asymptomatic, but since she was told she may have ‘infection’, she presented to the author for an endodontic consultation.
The dental history was remarkable for root canal treatment of tooth 30 being performed in 2016. No follow-up radiographs had been taken since 2017.
Diagnosis
An extra-oral and intra-oral examination were performed. There was no lymphadenopathy, swelling, erythema, or a sinus tract. Tooth 30 was non-sensitive to percussion and palpation, had physiologic mobility, a 4mm mid-buccal probing (all others were <4mm), and was non-responsive to cold due to previous endodontic treatment. The tooth was currently restored with a porcelain- fused to metal (PFM) crown with composite in the access cavity.
For radiographic diagnosis, a periapical (PA) radiograph (Figure 1) and limited field of view CBCT were exposed (Figures 2a-d). The previous endodontic treatment included obturation of three canals, with inadequate density of obturation in the apical 1/3 of the M and D roots. Apical radiolucencies were present at the mesial (3x3mm) and distal (3x5mm) apices.
The CBCT (Figures 2a-d) confirmed an unobturated distolingual (DL) canal and possible middle mesial (MM) canal; the coronal CBCT slice of the mesial root (Figure 2c) also suggests an apical delta, rather than a single apical foramen. No signs of cracks or fractures were visible.
Procedure and treatment
Two days after the consultation appointment, the patient presented for non-surgical root canal re-treatment of tooth 30. Informed consent was reviewed and obtained.
Local anaesthetic and rubber dam isolation were performed. The access cavity was opened to give access to the previously obturated, as well as the untreated canals.
Hand and rotary instruments, along with solvent, were used to remove existing gutta percha in the MB, ML, and DB canals. The DL and MM canals were also identified and instrumented. The electronic apex locator was used to determine working lengths for each canal. Patency was obtained on all canals. The canals and chamber were irrigated with 6% NaOCl (30-gauge, side-vented needle).
Gentle Wave irrigation was utilised as an adjunct to traditional irrigation. Gutta percha was fitted in each canal and a master cone radiograph was exposed to ensure appropriate fit. The canals were dried, and BioRoot Flow sealer was injected to mid-root of all canals, using the luer-lock tip provided by the manufacturer.
The tip of the BioRoot Flow syringe was then removed and the gutta percha cones were coated by inserting them carefully into the remaining sealer in the tip of the syringe. This allows to save on sealer but also to fully obturate. Once the cones were coated, they were seated to length. A heated plugger was used to sear gutta percha at orifice level, followed by compaction. The access was then restored.
A post-operative PA radiograph was exposed (Figure 3) and home care instructions were reviewed. The next day, the patient was called on the telephone to see if she had any questions or concerns. She said she was doing well, but was mildly sore, and had taken ibuprofen one time.
Six-month follow up
In January 2023, the patient returned for a routine six-month follow-up appointment and stated: ‘I’m doing well!’
A clinical exam was performed, and the mid-buccal probing had returned to a normal depth of <4 mm. All teeth in the quadrant were non-sensitive to percussion and palpation; there were no signs of erythema, swelling, or a sinus tract.
The patient consented to a PA radiograph and limited field of view CBCT scan. The PA radiograph (Figure 4) shows a small mesial sealer puff. The apical radiolucencies associated with the mesial and distal roots have decreased in size from June 2022 (comparison of Figure 1 and Figure 4).
The CBCT (Fig. 05) shows a significant decrease in the size of the apical lesions, demonstrating excellent healing at the six-month mark.
Recommendation: Follow-up in six months, since healing is expected to be near completion at the 12-month mark.
One-year follow up
In June 2023, the patient returned for a 12-month follow-up, stating: ‘I’m doing well. Just here for a routine check.’
The patient is asymptomatic and probing depths were all <4mm around 30. Tooth 30 was non-sensitive to percussion and palpation, with physiologic mobility. The patient consented to PA radiographs (Figures 6a-b) and a limited field of view CBCT scan (Figures 7a-c). The PA radiographs (Figures 6a-b) show signs of healing at both the mesial and distal apices.
The CBCT (Figure 7a) highlights the obturation of the middle mesial canal, and the convergence/joining of the DB and DL canals. The M and D coronal views (Figures 7b-c) confirm apical healing of both roots.
Clinical and radiographic findings indicate 30 as healed. No further follow-up is required unless the patient or her dentist notice changes in clinical or radiographic signs/symptoms.
Creating an environment for healing
The goal of endodontic treatment is to create an environment where apical periodontitis can heal. Studies show that ‘failure in endodontic treatments is associated with the low quality of root canal fillings’ (Marconi et al, 2022). Many clinicians desire to improve their obturation techniques, since this can minimise the chance of failure and re-infection.
A systematic review in 2022 found that there are ‘no differences in the success rate of primary non-surgical endodontic treatments when the cold lateral compaction technique and other obturation techniques are performed. Further well-designed studies are still necessary’ (Marconi et al, 2022). Therefore, clinicians can choose from a variety of obturation techniques, and can select the technique that works best in their hands.
In this case study, a single-cone/hydraulic condensation technique was utilised. This technique is generally considered to be a ‘cold’ technique since heat is only applied at the orifice level to remove excess gutta percha. Cold techniques are mandatory with some sealers since heat application can alter the sealer’s setting process. This is not the case with BioRoot Flow, since the sealer sets in the canal using the inherent moisture and humidity of the root dentin. This means that warm and cold techniques are all acceptable for use with this sealer.
Antimicrobial treatment
In addition, it is known that approximately 35% of the root canal walls are un-touched by endodontic instruments (Peters et al, 2001). This means that endodontic success relies on a combination of antimicrobial treatments (such as irrigants and sealers) and obturation to minimise the space where bacteria can survive and multiply.
BioRoot Flow is highly pure and biocompatible. This allowed the small sealer puff on the mesial root of this case to be well-accepted by the body. In addition, BioRoot Flow slightly expands upon setting, which helps to block dentinal tubules where bacteria may survive and multiply. Finally, the high pH of the sealer contributed to the anti-microbial efforts of the provider/author.
BioRoot Flow builds on the legacy of BioRoot RCS, which was introduced in 2016. BioRoot Flow became available in 2022, making active biosilicate technology easier to use in a syringable form. Studies show that ‘calcium silicates-based sealers promote apical healing, possess antibacterial activity, and bond to tooth structure.
Their biological properties depend on a hydration reaction followed by a precipitation reaction of calcium phosphate and formation of hydroxyapatite’ (Zavattini et al, 2020). These properties have empowered clinicians to achieve high quality endodontic results for their patients.
Conclusion
Septodont’s BioRoot Flow builds on the legacy of BioRoot RCS, which is known for being non-cytotoxic, and induces angiogenesis and osteogenic growth (Camps et al, 2015). In this case study, BioRoot Flow played a critical role in the success of root canal re-treatment, with excellent sealing and antimicrobial properties.
References
- Camps, Jean et al. Bioactivity of a Calcium Silicate–based Endodontic Cement (BioRoot RCS): Interactions with Human Periodontal Ligament Cells In Vitro. Journal of Endodontics, Volume 41, Issue 9, 1469 – 1473 (2015).
- Marconi DF, da Silva GS, Weissheimer T, Silva IA, Só GB, Jahnke LT, Skupien JA, Só MVR, da Rosa RA. Influence of the root canal filling technique on the success rate of primary endodontic treatments: a systematic review. Restor Dent Endod. 2022 Oct 11;47(4):e40. doi:10.5395/ rde.2022.47.e40. PMID: 36518607; PMCID: PMC9715375 (2022).
- Peters, O. A., et al. (2001). Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro computed tomography. Int Endod J, 34(3), 221–230.
- Zavattini A, Knight A, Foschi F, Mannocci F. Outcome of Root Canal Treatments Using a New Calcium Silicate Root Canal Sealer: A Non- Randomized Clinical Trial. J Clin Med. 2020 Mar 13;9(3):782. doi: 10.3390/jcm9030782. PMID: 32183124; PMCID: PMC7141324.
For more information about BioRoot Flow, visit www.septodont.com.
This article is sponsored by Septodont.
