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My seven years at Riyadh Al Kharj Hospital (RKH)

It is said, “If you build it, they will come”. Well, we built it and they did come, but one must realize, building is the hardest part.
Education is like rivers, it has no borders. We are all the same in the pursuit of knowledge as we all desire to drink from its waters. My life’s experiences in education have shown me this and the mission in Saudi Arabia was a powerful example of what can be accomplished.
This is a record of my seven years at Riyadh Al Kharj Hospital (RKH) that started with a simple training agreement that expanded into an institute and a new RKH Dental Department.

Directory 1972 - 1996

DEPARTMENT OF ENDODONTICS
ADVANCED ENDODONTICS PROGRAM
GRADUATES OF CLASSES 1972 - 1996
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UNIVERISTY OF SOUTHERN CALIFORNIA, DEPARTMENT OF ENDOOONTICS

UNIVERISTY OF SOUTHERN CALIFORNIA, DEPARTMENT OF ENDOOONTICS
October 1996

Microorganisms in closed periapical lesions

The purpose of this study was to investigate the microor­ ganisms of strictly selected closed periapical lesions associated with both refractory endodontic therapy and pulpal calcification. Definitive criteria were established that assured complete clinical isolation of the periapical lesion from the oral and periodontal environment. A total of 13 criteria-referenced lesions were selected from 70  patients  with  endodontic  surgical   indications.  A well controlled culturing method was used in all cases and samples were taken by one clinician at three separate sitesduring each surgery. Samples taken at the surgical window and within the body of the lesion served as controls , whilst a third sample was taken at the apex. In all 13 cases, samples taken from the apex vielded mic roorganisms comprising 63.6% obligate aerobesand36.4%  facultative  anaerobes. Prevalence of the  isolated species was  31.8% for Actinomyces sp., 22.7% Propio11ibacterlum sp., 18.2% Streptococcus sp., 13 .6%   Staphlyococcus  sp.,   4.6% . Porphyromonas gingivalis, 4.6% Peptostreptococcus micros and 4.6% Gram-negative enterics. The results of this investigation indicate that closed periapical lesions associated with calcified teeth or those resistant to root canal treatment harbour bacteria. The inability to eradicate all root canal microorganisms during root canal treatment, along with anatomical factors, may allow further bacte­ rial colonization of the root apex and surrounding periapical tissues, and consequently prevent healing.
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Cementogenic repaire of root fractures

Results of longitudinal radiographic and clinical studies of 65 anterior maxillary and mandibular simple root fractures and of a study of six of these fractures have revealed that the integrity of the periodontal membrane is the essential requisite in root repair; that cementum will be found at the two fractured ends of the segments if other factors necessary for root repair are present; that the pulp is not necessary for root repair; that the prognosis for midroot and apicai fractures is more favorable than for cervical fractures; and that the prognosis for vertical fractures is unfavorable. The practicat applications of this study support the conservative and preventive approach to treatment—most simple root fractures are reparable and the fractured teeth need not necessarily be extracted.

Determinants of periodontopathogens in microbiological

Methods: This cross-sectional study included 352 diabetic patients with periodontitis who were registered at Riyadh Armed Forces Hospital, King Faisal Specialist Hospital and Research Centre, King Abdul Aziz Medical City, Naval Base Hospital, and Sultan Bin Adulaziz Humanitarian City, Riyadh, Kingdom of Saudi Arabia from July 2004 to August 2008. Microbiological analysis comprised the detection of Bacteroides forsythus (BO, Awegatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), and Prevotella intermedia (Pi) by polymerase
chain reaction method.
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Evaluation of dental extractions

Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy

S. Al-Mubarak,1 N. Al-Ali,2 M. Abou Rass,3 A. Al-Sohail,4 A. Robert,5 K. Al-Zoman,6 A. Al-Suwyed7 and S. Ciancio8

Objective : To examine the consequences of temporary withdrawal of warfarin and/or suturing on bleeding and healing pattern following dental extractions.
Methods : Two hundred and fourteen patients on long-term oral anticoagulation (warfarin) therapy scheduled for dental extraction were randomly divided into four groups: no suturing and discontinued (group 1) or continued warfarin (group 2), and suturing and discontinued (group 3) or continued warfarin (group 4). International normalised ratio (INR) was determined at different time points (baseline, days 1, 3 and 7).

Thromboembolic risk and bleeding in patients

Thromboembolic risk and bleeding in patients maintaining or
stopping oral anticoagulant therapy during dental extraction
S . AL-MUBARAK,* M. A. RASS, A. ALSUWYED, A. ALABDULAALY§ and S . CIANCIO–
*Dental Department, Sultan Bin Abdulaziz Humanitarian City; Prince Abdulrahman Advanced Dental Institute; Dental Department, King
Abdulaziz Medical City; §Hematology Department, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia; –Department of Periodontic
and Endodontics, School of Dental Medicine, State University of New York at Bualo, New York, NY, USA
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A new paradigm between mechanical scaling and root planing combined with adjunctive chemotherapy for glycated hemoglobin improvement in diabetics

Aim: The objective of the study was to evaluate the effectiveness of scaling and root planing (SRP) and adjunctive chemotherapy (doxycycline hyclate, 20 mg) on gingival health, specific cytokines and glycemic control in diabetic subjects.
Methods: Three hundred and forty-six type 1 and 2 diabetic subjects were randomized into four test groups: (1) one session of SRP at the baseline visit and placebo tablets twice/day, started at the baseline visit, for 3 months, (2) one session of SRP at the baseline visit, and doxycycline hyclate (20 mg, twice/day) started at the baseline visit for 3 months, (3) two sessions of SRP, first at the baseline visit and second at the 6 months, with placebo tablets twice/day started at the baseline visit and 6-month visit, for 3 months at each visit, and (4) two sessions of SRP, first at the baseline visit and the second at the 6-month visit, and doxycycline hyclate 20 mg twice/day, started at the baseline visit and the 6-month visit, for 3 months
at each visit. Venous blood samples were obtained to evaluate TNF-a, IL-1a and glycated hemoglobin (HbA1c); dental measurements were also included.

Interim Endodontic Therapy for Alveolar Socket Bone

The immediate placement of implants in the fresh extraction sockets of infected teeth with periradicular andperiapical lesions iscontraindicatedbecause ofboth the infectionandthe loss of
architecture required for proper implant placement. There are 4 approaches for implant replacement of a hopeless tooth with lesions: (1) extraction and delayed implant placement; (2)
extraction, debridement, guided bone regeneration (GBR), guided tissue regeneration (GTR), and delayed implant placement; (3) extraction, intrasocket debridement, and immediate implant placement; or (4) extraction, debridement, GBR, GTR, and simultaneous implant placement. The extraction of such hopeless teeth often results in large bone and soft tissue defects that are difficult to repair.
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Changing Concepts In Endodontic Retreatment

A few years ago many dentists considered rootcanal therapy to be a controversial and questionable treatment with unpredictable results.
Root-canal therapy was mostly performed on carefully selected single-rooted teeth. Infected or diseased posterior teeth were routinely extracted and replaced with removable or fixed
prostheses. Endodontic failures were routinely treated by extraction or apical surgery.

Changing trends in endodontics

The advancement and acceptance of endodontics as a special discipline has been meteoric. Its rise was predicated on a foundation of principles laid down by the early investigators of the field.
Acceptance of endodontics probably would not have occurred without the efforts of Callahan, Johnston, Coolidge, Sharp, Sommer, Blayney, Grossman, and others who disagreed with and
disproved the focus of infection theory proposed by Rosenow! and his Mayo Clinic disciples.
Through the perseverance of these dentists who demonstrated predictable success of treatment, who used cultures to verify sterility, and who employed the “‘miracle drugs,”’ a positive attitude developed toward the value of root canal therapy.
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Crack Lines : The Precursors of Tooth Fractures

Various terms have been used to describe cracked teeth, e.g., incomplete fracture, greenstick fracture, and cracked tooth syndrome. Here the term tooth structure crack will be used to describe a line that breaks or splits the continuity of tooth dentinal surface but does not perceptibly separate that surface. This line cannot be wedged, or separated apart.
Tooth structure cracks should be differentiated from craze lines of tooth enamel or vertical fractures of the tooth (Figs. 1 and 2). These cracks can be found in symptomatic or symptomatic
teeth. The crack itself can be an etiological factor in pulpal disease if it extends to the pulp cavity and irritates the pulp physically, or through leakage of liquids and bacterial toxins. In other situations, the crack is of no etiological relationship to the pulp disease and happens to be present in a pulpally involved tooth. Finally a crack line can be considered a precursor to a tooth fracture.

A Comparaison of three methods of hand and automated instrumentation using the CFS and M4

One hundred and twenty-five (125) plastic blocks with simulated narrow and curved canals size ISO 15 with curvature of 50° - 70° were divided into 5 equal groups.
Group I was prepared by hand instrumentation with ISO 18 - 30 Flex-O-Files. Group II was prepared cervically with CFS Master File 15, 20 to the level of curvature about 5mm short of the apex, the working length was then estabilished and the canal was prepared by hand instrumentation with 15 - 30 Flex-O-Files. The final flare was then made with the CFS to size Master File 25 - 30.
Group Ii was similar to Group I] except for using the M4 handpiece for automation. Group IV was prepared to the full working length 0.5mm short of the foramen with CFS Group V was similar to Group IV except for using the M4 for automation. All 125 blocks were evaluated by a panel of 4 endodontists and rated for overall and specific quality.
Time scores were also analyzed for all groups. The results were analysed for significance and the conclusions were that automated instruments (CFS and M4) can be used to start cervical preparation of narrow curved canals, size ISO 15, less which should stop 3 - 5mm short of the apex or the apical curvature level should be used. The apical curvature area and the rest of canal is then prepared with hand files to size ISO 15 - 30 to working length, followed by final flaring and finishing the preparation with automation to size 30.
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The Endodontic Restorative

ِAs society has become more health-conscious over the past several decades, the demand for endodontic therapy has continued to increase. In the United States alone, it has been estimated that more than 14 million teeth receive such treatment annually. The majority of these teeth require extensive restoration before masticato- ry function and acceptable esthetics can be regained. Thus, the relationship between endodontic therapy and restorative therapy is inseparable.

Endodontic File Design and Dynamics in Automated Root Canal Preparation

Many treatment failures in endodontic s are caused by problems that occurred during canal preparation. This article reviews principles of endodontic instrument design and analyzes the design as it relates to an automated handpiece. After a review of the problems of automation, there will be an introduction of a new automated handpiece and a new modified file known as the Anticurvature File.
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Evaluation and clinical management of previous endodontic therapy

Increasingly, endodontists are reaching  a  consensus on the criteria for acceptable and unacceptable endo­ dontic treatment (Table I). The reasons for endodontic successes and failures have been reported in the litera­ ture (Figs. 1 and 2).-1 20 The evaluation of previous root canal therapy is discussed in this article and guidelines proposed for the retreatment of endodontic failures.

Post and core restoration of endodontically treated teeth

This review discusses the multifactorial nature of tooth strength and concludes that endodontic treatment alone does not weaken intact anterior teeth. Therefore, restoration of such teeth does require post placement or fulI-coverage resto ration s. Posterior teeth, however, require full-coverage protection. It appears that the full-crown restoration "covers up" some of the disadvantages or deficiencies of some post and core restorations. The Iiterature supports the use of the amalgam coronal-radicular core or the post-retained amalgam core, as well as the composite post and core. The literature does not support use of the glass ionomer post and cores. As to which post system to select, the literature indicates that the parallel-sided, serrated Para-Post or Para-Post plus is a safe post when seated passively in the canal and cemented with zinc phosphate cements or composite resin cement , or when retained with amalgam. Dentin-retained, stress-producing posts such as the threaded posts should be avoided.
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Preparation of space for posting: effect on thickness of canal walls and incidence of perforation in molars

Preparation of space for posting can be prepared manually or mechanically with rotary instruments, such as Peeso drills, Gates-Glidden burs, or other types of rotary instruments. Regard­ less of the type of instrument used, ac­ cidents and errors, such as perfora­ tions and stripping of root structures can occur. Specific information on the effect of rotary drill size on the thick­ ness of canal walls is not provided in the literature. Unfortunately, post cav­ ity preparation is sometimes consid­ ered as nothing more than a hole drilled into the canal to receive a post, with little attention given to the anatomy of the root.

Tooth Fracture: A Comparison Of Endodontic And Restorative Treatments

A comparison was conducted among three groups of central incisors: control teeth with normal morphology; endodontically treated teeth without posts (restored only with composite); and endodontically treated teeth restored with two different sizes of parallel stainless steel posts and composite. All groups underwent the same impact testing. The results revealed that both treated and untreated central incisors had comparable fracture resistance; teeth with larger-diameter posts showed decreased resistance, whereas those with longer roots exhibited higher fracture resistance.


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The Elimination Of Tetracycline Discoloration By Intentional Endodontics And Internal Bleaching

Tetracyclines were widely used as broad-spectrum antibiotics during the 1950s and 1960s for various infections. In 1958, their potential to cause permanent teeth discoloration was identified as a side effect. Traditional treatments involved crowns and veneers, which come with notable drawbacks. This article introduces an alternative approach that offers substantial aesthetic benefits without complications. The technique consists of removing the stain sources through intentional endodontics and internal bleaching, providing predictable, effective, and patient-accepted results.

Long-Term Prognosis Of Intentional Endodontics And Internal Bleaching Of Tetracycline-Stained Teeth

A total of 112 teeth with severe tetracycline stains in 20 patients underwent endodontic treatment combined with non-thermal internal bleaching. All teeth remained healthy, intact, and without a history of trauma. Patients were followed for 5 to 15 years. The procedure achieved excellent and lasting aesthetic results, with no side effects. The long-term success was significantly influenced by the quality of endodontic treatment and the restoration of lingual access.


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The Effects Of Temperature, Concentration, And Tissue Type On The Solvent Ability Of Sodium Hypochlorite

This laboratory study examines how varying sodium hypochlorite concentrations and temperatures affect the dissolution of rat connective tissue. It mainly investigates whether increasing the concentration and temperature accelerates tissue breakdown. Additionally, it examines whether tissue type—fresh, fixed, or necrotic—affects the efficacy of sodium hypochlorite.

The Effectiveness Of Four Clinical Irrigation Methods On The Removal Of Root Canal Debris

This study aims to examine how different root canal irrigation methods affect the removal of dental debris. Specifically, it compares four techniques to identify which is most effective:
1. Flooding the pulp chamber and guiding the irrigant into the canal using a No. 15 file.
2. Flushing with a 23-gauge endo Lock irrigating needle.
3. Flushing with a 30-gauge anesthetic needle.
4. Using the effervescent action generated by the chemical reaction between hydrogen peroxide and sodium hypochlorite.
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The Effects Of Decreasing Surface Tension On The Flow Of Irrigating Solutions In Narrow Root Canals

This study aims to assess how lowering the surface tension of root canal irrigants affects their flow properties. The findings show that adding polysorbate 80 to distilled water, alcohol, sodium hypochlorite, and EDTA resulted in:
1. A reduction in their surface tension by 15 to 20 percent.
2. An increased flow of these solutions into the root canal after 5 minutes of application, although no significant flow increase was observed after 7 days.

The Use Of Rotary Instruments As Auxiliary Aids To Root Canal Preparation Of Molars

This study investigates how engine-driven rotary instruments impact the quality of root canal preparation. Specifically, it examines whether using the no.1 Peeso reamer or the no.1 Gates-Glidden drill as adjuncts to manual instrumentation enhances the quality of canal preparation and significantly reduces the time required. The findings show that employing the no.1 Peeso reamer to enlarge the cervical third effectively improves the quality of root canal preparation, offering notable time savings and minimal errors.


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The Stressed Pulp Condition: An Endodontic-Restorative Diagnostic Concept

The stressed pulp condition refers to pulps that have experienced repeated injury and now exhibit reduced responses and repair ability. Before starting restorative procedures, the dentist should thoroughly assess the pulpal health of the teeth involved. This assessment should include (1) standard pulp testing methods and (2) reviewing the tooth's history, current condition, and future treatment plans. This process typically highlights teeth with stressed pulps. Such teeth should be addressed prior to undertaking complex restorative work.

The Anticurvature Filing Method To Prepare The Curved Root Canal

This method for preparing curved root canals allows placement of endodontic filling material with minimal risk of damaging the canal walls. The anticurvature filling approach helps preserve the canal walls and reduces the risk of root perforation or stripping. It enables the dentist to maintain precise digital control over the instrument, thereby facilitating the preparation of curved canals.
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Clinical and Microbiological Aspects of the Sargon™ Immediate Load Implant

A maxillary lateral incisor suffering from severe periodontal damage was extracted following forced eruption and replaced with a Sargon™ Immediate Load Implant. This case report details both the clinical and microbiological outcomes. The Sargon™ Immediate Load Implant is an apically expandable, five-connection, root-shaped dental implant crafted for immediate loading with a provisional fixed restoration in proper occlusion.


Endodontics: What’s Going On

Creating a comprehensive scientific journal involves the support of many individuals. The joy of assembling this issue was accompanied by engaging conversations, correspondence, and faxes with authors worldwide, making it a memorable experience. Dr. Abou-Rass, who authored the first article, was the key scientific contributor to our 1982 issue on endodontics. He is the perfect person to reflect on the past developments and future directions of endodontics. We hope you enjoy reading this issue. Keep it as a reference and show appreciation to our advertisers for their support.


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The Restoration of Endodontically Treated Teeth

Over the past few decades, the subject of restoring endodontically treated teeth has been controversial. A large part of this debate stemmed from limited scientific evidence supporting or opposing many common beliefs in the field. Recent extensive research has helped clarify many of these contentious issues. To understand the current best practices for restoring such teeth, a series of questions on key areas of debate was sent to leading experts. These questions focused on four main topics:
  • Endodontic Treatment Planning
  • Post Placement in Endodontically Treated Teeth
  • Coronal Restoration of Endodontically Treated Teeth
  • Materials-Related Topics
This summary compiles the responses from experienced clinicians and researchers. In many cases, there was a consensus. When opinions varied significantly, statements were credited to specific contributors.

The Problems with Wait-and-See Endodontics

The "wait and see" approach is typically the default method in empirical treatment, where "anything goes." It permits treatments that do not meet current biologic and technical endodontic standards, with patients being monitored and recalled until symptoms emerge. When symptoms appear, corrective treatments are provided on an "as needed" basis, focusing on symptomatic teeth—the "squeaky wheels"—which may receive additional therapy or extraction. This approach often neglects asymptomatic failures; calcified canals are viewed as "nature's fillings," radiolucent lesions as "apical scars," broken instruments become part of the filling, and untreated canals are considered "mummified." By endorsing inadequate and incomplete techniques like paste fillers and mummification, the "wait and see" approach contributed to their prevalence in the 1970s. Proponents hope that time will allow for repair of unresolved issues or damage caused by lesion or clinician errors.


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Development and Evaluation of a Self-Instructional Program in Endodontic Diagnosis and Treatment Planning

This study compared traditional lectures and slide-tape methods for a course in endodontic diagnosis and treatment planning with 108 freshmen. Results showed no significant difference in student performance, although the lecture group spent more time studying. Students using slide-tapes viewed the instructor and course material more favorably.

Dentistry Models for Evaluating Clinical Performance

An effective clinical evaluation system requires the active involvement of experienced faculty in planning, implementation, and ongoing improvement. A trained evaluation committee should be established to develop clear performance criteria, evaluation forms, manuals, and instructional aids, all of which should be field tested before finalization. Dental procedures should be analyzed step by step, with error analysis informing the derivation of performance standards. Clinical instructors must be properly trained in utilizing these criteria and evaluation tools. A comprehensive model for competency testing and overall clinical evaluation is proposed, emphasizing the practical application of performance criteria, identification of critical errors, and methods for assessing competency.
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Effects of Varying Sequence and Amount of Training on Learning and Performance in Preclinical Endodontics - Part I: Design, Experimental Procedures and Sequencing

  • Performing endodontic therapy on a molar tooth is more difficult than on a central tooth, considering the learning curve and the risk of errors.
  • The simple-complex sequence (central then molar) requires less learning time, with an average savings of approximately 30-40 minutes.
  • The complex-simple sequence (molar then central) reduces the probability of errors during treatment of both molars and centrals.
  • Training students exclusively on a simple (central) tooth is the least effective; these students made more errors during training and testing than any other group.
  • Students trained only on a molar were able to treat the central tooth effectively without additional instruction, with 11 performance differences compared to those trained on the central tooth.
  • While all students preferred working on the central tooth, those who began with a molar developed a more positive attitude toward working on either tooth.
  • The molar-central or molar-only training sequences perform better than the central-molar sequence and are clearly superior to training exclusively on a central tooth; however, the optimal approach may vary with individual abilities and course objectives.
  • Students more readily achieved high-quality results on central teeth than on molars.

Effects of Varying Sequence and Amount of Training on Learning and Performance in Preclinical Endodontics - Part II: Study on Amount of Training

This study highlights that training focused only on a single central tooth is not recommended, as students trained exclusively on it are unable to deliver criterion-quality endodontics on molars. Conversely, students trained on one molar can perform high-quality endodontics on both molars and central teeth without requiring additional focus on the central teeth. However, it's important to note that there is no universally ideal training sequence or duration suitable for all students and contexts. The success of any teaching approach depends on individual differences and specific course goals.
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