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Foraminal Enlargement Analysis CONTINUING EDUCATION Foraminal enlargement analysis Drs. Carlos Henrique Ferrari, Frederico Canato Martinho, Ricardo Machado, and Leticia Aguiar analyze the benefits and risks of intentional foraminal enlargement, considering the impact both locally and systemically n recent years, endodontics has seen a Iconsiderable paradigm shift as a result Educational aims and objectives of technical and scientific developments. This clinical article aims to make a critical analysis, based on the literature, to assess the However, the concept of shaping and advantages and disadvantages and the local and systemic risks related to the intentional enlargement of the apical foramen. cleaning (Schilder, 1974) remains one of the pillars of the specialty especially when Expected outcomes dealing with infected canals. Endodontic Practice US subscribers can answer the CE questions on page XX to Historically, the literature has demon- earn 2 hours of CE from reading this article. Correctly answering the questions will strated how anatomical complexities make demonstrate the reader can: it so difficult to adequately shape and clean • Realize that there is no scientific evidence to support intentional foramen enlargement in humans. the root canal system, especially the apical • Recognize that the methodological design of future studies for performing this procedure should be one-third (Paqué, et al., 2009; Paqué, et undertaken with caution, because the literature consulted in this paper reiterates that intentional foraminal al., 2010). Furthermore, in some cases, enlargement poses both local and systemic risks. endodontic infection extends beyond the limits of the apical constriction, for example, to the apical foramen or beyond (extraradical has postulated that apical patency can clear et al., 2000; Marroquín, et al., 2004; Abarca, biofilm) (Noiri, et al., 2002; Chavez De Paz, the apical foramen and promote micro- et al., 2014). 2007; Ricucci, Siqueira Jr, 2010). In these biological disruption in this area, using a Several clinical studies have shown situations, intentional foraminal enlargement small caliber instrument to lightly touch a high frequency of instrument fracture in may be performed to decrease the micro- the walls of the apical foramen (Buchanan, the apical third when anatomically complex bial load to levels more favorable for repair 1989; Cailleteau, Mullaney, 1997; Flanders, and narrow canals are present (Ehrhardt, et (Borlina, et al., 2010). Previous studies have 2002; Souza 2006; Coutinho–Filho, et al., al., 2012; Madarati, et al., 2013). Moreover, shown encouraging results for intentional 2012; Mounce, 2015). However, intentional especially when dealing with posterior teeth, foraminal enlargement, enabling more effi- foraminal enlargement is performed with the apical foramen may be located laterally to cient mechanical action of instruments and different techniques and instruments and the anatomical apex (Pineda, Kuttler, 1972), the chemical action of irrigating solutions (de consists of the mechanical enlargement and intentional foraminal enlargement may Souza Filho, et al., 1987). of the apical foramen for the purpose of predispose to weakening of the tooth with a Therefore, the purpose of this paper decontamination by excising infected dentin higher incidence of fracture. was to perform a critical literature review by and cementum (Borlina, et al., 2010; Silva, Another factor limiting foraminal enlarge- analyzing the likely benefits and risks of inten- et al., 2013). Accurate intentional foraminal ment is the clinician’s inability to achieve tional foraminal enlargement, considering the enlargement requires the shape and diam- apical potency of the apical foramen in impact both locally and systemically. eter of the apical foramen to be accurately some situations. This may occur because assessed and measured. Clinically, this of abrupt curvatures, the existence of two or Local effects would seem to be impossible (Dummer, et more main apical foramina, apical deltas, or Anatomical considerations al., 1984; Abarca, et al., 2014). Conven- complete or incomplete isthmuses (Meder– Undeniably, pulp necrosis and peri- tional endodontic instruments are unable Cowherd, et al., 2011; Verma, Love, 2011; radicular lesions are an indication that the to perform this, because of the oval shape Villas–Bôas, et al., 2011). entire length of the root canal is contami- of the apical foramen (Goldberg, Massone, Considering all the facts and appreciating nated (Ricucci, Siqueira Jr 2010, Tronstad, 2002; Marroquín, et al., 2004; Herrera, et al., that foraminal enlargement is a plausible idea et al., 1990; Nair, et al., 2005, Siqueira, 2011; Akisue, et al., 2014). Consequently, from a microbiological standpoint, it cannot Rôças 2008). For this reason, the literature adequate cleaning cannot be achieved (Wu, always be performed. In controlled clinical studies with robust samples and appropriate Carlos Henrique Ferrari, DDS, is a PhD endodontic student at São Jose dos Campos Dental School, State University of São Paulo inclusion and exclusion criteria (Imura, et al., – UNESP, São Jose dos Campos, São Paulo, Brazil. 2007; Ricucci, et al., 2011; Liang, et al., Frederico Canato Martinho, DDS, MSc, PhD, is a professor of endodontics at São Jose dos Campos Dental School, State 2013), there have been no reports of inten- University of São Paulo – UNESP, São Jose dos Campos, São Paulo, Brazil. tional foraminal enlargement in the clinical protocols adopted. Nonetheless, the success Ricardo Machado, DDS, MSc, PhD, is a professor of multidisciplinary clinic I and II and supervised stage in multidisciplinary clinic I (endodontics), Paranaense University – UNIPAR, Francisco Beltrão, Paraná, Brazil. rates of these studies are high even in cases of pulp necrosis with radiographically visible Leticia Aguiar is a graduate student from Paranaense University – UNIPAR, Francisco Beltrão, Paraná, Brazil. periradicular disease (Imura, et al., 2007; Ricucci, et al., 2011; Liang, et al., 2013). 26 Endodontic practice Volume 9 Number 1 CONTINUING EDUCATION Extrusion of sodium hypochlorite, calcium cements (Strindberg, 1956; Engstrom, 1964; et al., 1995; Moinzadeh, et al., 2013). These hydroxide, and filling materials Yusuf, 1982; Nair, et al., 1990; Sjögren, et al., statements are based on bisphosphonates Sodium hypochlorite is the most widely 1990; Orstavik, Hörsted–Bindslev, 1993). interfering directly with the bone remodeling accepted and used irrigant solution world- It is important to consider the hypoth- process and inhibit the chemical mediators wide (Stojicic, et al., 2010; Zou, et al., 2010; esis that the greater the enlargement of the of the inflammatory process (Katz, 2005; Wong, et al., 2014; Guneser, et al., 2015). apical foramen, the greater the possibility of Edwards, et al., 2008). Nonetheless, it has a highly adverse effect after extrusion of any substance used in the root When considering the need for endo- extrusion into the periradicular tissues or maxil- canal (Hülsmann, Hahn, 2000). Neverthe- dontics in patients who are or have been using lary sinus, or when injected into the gingival less, more research is required to confirm bisphosphonates recently, it seems obvious mucosa (Pashley, et al., 1985; Gatot, et al., this hypothesis. that intentional foraminal enlargement is a 1991; Ehrich, et al., 1993; Kavanagh, et al., completely contraindicated procedure. 1998; Kleier, et al., 2008; de Sermeño, et al., Systemic effects 2009; Wang, et al., 2010; Kerbl, et al., 2012). Patients who are taking or have taken Patients with coagulation disorders or using The most common consequences of bisphosphonates recently anticoagulants this type of accident are the following: (Huls- Bisphosphonates are drugs used to treat Homeostasis in healthy patients is asso- mann, Hahn, 2000; Serper, et al., 2004). bone diseases and prevent tumour metas- ciated with four main factors: • severe pain tasis (Moinzadeh, et al., 2013). Their exten- • Blood vessel walls • instant inflammation of the affected sive use is directly related to osteonecrosis • Blood platelets area of the jaw after performing dental procedures • The coagulation system • swelling extended to the face, lips, (Katz, 2005; Sarathy, et al., 2005; Edwards, • The fibrinolytic system and infraorbital region et al., 2008; Moinzadeh, et al., 2013). Since Blood vessel constriction is the first • hemorrhage descending from the these drugs are widely used today, dentists stage, followed by platelet adhesion and root canal should be knowledgeable about some likely aggregation, and by fibrin deposition. In • interstitial hemorrhage with skin and effects that can influence the prognosis of the next stage, the coagulation process is mucosa bruising the treatment. regulated by physiological anticoagulants. • secondary infection, Specifically related to endodontics, some Activation of fibrinolysis is triggered by the • paresthesia important precautions should be borne in mind: presence of fibrin and tissue plasminogen The use of calcium hydroxide as an inter- • Antiseptics, such as chlorhexidine, activator-types at the site of fibrin formation, appointment dressing can have adverse conse- must be used to reduce the bacte- a process regulated by physiologic inhibitors quences if it is accidentally extruded beyond rial load of the oral cavity (Cousido, such as 2-antiplasmin, histidine-rich glyco- the apical foramen (Fava, 1993; Marais, Van et al., 2010) and the risk of bacte- protein, and plasminogen activator inhibitor Der Vyver, 1996). Fava (1993)
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