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South African Dental Journal

On-line version ISSN 0375-1562
Print version ISSN 0011-8516

S. Afr. dent. j. vol.71 n.10 Johannesburg Nov. 2016





Fig 1 & 2: the large lesion of left mandible shows a honeycomb-like distribution of calcifications. The borders are corticated. The tumour has displaced the mandibular molar tooth. A histological diagnosis of calcifying epithelial odontogenic tumour (Pindborg Tumour) was made. Fig.3 shows a Pindborg tumour distal to left second premolar associated with displacement of the first molar tooth. Fig.4 shows a similar tumour with mixed lucency-opacity between right premolar and molar teeth. Figs 5 & 6 show coronal and axial CT views of a large Pindborg tumour affecting the right maxilla. Note the marked expansion and cortical destruction. Calcifying epithelial odontogenic tumour is a rare benign neoplasm, accounting for less than 1% of all odontogenic tumours. The average age at diagnosis is 40 years; however, the tumour can occur at any age. It occurs equally in males and females. Approximately two thirds of cases are reported to occur in the mandible. Most cases occur in the premolar-molar area and are commonly associated with an unerupted tooth. The tumour is a painless, slowly enlarging mass. Histologically the tumour has a very characteristic appearance. Sheets of polyhedral cells with well-defined eosinophilic cytoplasm and hyperchromatic nuclei are featured. Amyloid and ringlike calcification may also be present. The tumour may be irregular or, in some cases, the cystic lesions may be well defined and corticated, whereas others appear ill defined. Small unilocular lesions may have a completely radiolucent centre (Fig.3). Others may have variable amounts of small flecks of calcifications scattered throughout. Larger lesions have a multilocular or honeycomb appearance. The tumour can displace and often prevent the eruption of teeth. Radiologically the tumour may be very similar to the calcifying odontogenic cyst, adenomatoid odontogenic tumour and ameloblastic fibro-odontoma.



1.Farman AG, Nortje CJ & Wood R E: Oral and Maxillofacial Imaging, 1st Ed, Mosby. St. Louis, Missouri 1993 pp. 244-246.         [ Links ]




What's new for the clinician? Summaries of and excerpts from recently published papers



V Yengopal

BChD, MChD (Community Dentistry) Stellenbosch. Department of Community Dentistry, School of Oral Health Sciences, University of the Witwatersrand. E-mail:



1. Pulpectomies in primary mandibular molars: a comparison of outcomes using three root filling materials

Pramila R, Muthu MS, Deepa G, Farzan JM, Rodrigues SJL. Int Endod J. 2016; 49:413-21.

Pulpectomies for the management of irreversible pulpitis in primary teeth remain controversial for several reasons, including the complex root canal morphology of primary molars, the inherent risk of physiologic root resorption, the close proximity of deciduous teeth to the permanent successors, the difficulty in obtaining good radiographic views of the apices of primary teeth, complex diagnosis due to the patient's immaturity, need for behavioural guidance of paediatric patients and choice of technique and root filling materials.1 An ideal root filling material for primary teeth should be easily placed and removed, should resorb at a rate similar to that of the primary root, should not set to a hard mass that could deflect an erupting permanent tooth, should be radiopaque and not discolour the tooth, should adhere to the walls, should not shrink and should possess antiseptic properties as well as be harmless to the periapical tissues and permanent tooth germ.1

The most commonly used root filling materials for primary teeth include zinc oxide-eugenol (ZOE), iodoform-based pastes and calcium hydroxide. None of these currently available materials meet all these criteria. Pramila and colleagues (2016)1 reported on a prospective, double-blind, randomized controlled trial that sought to evaluate the success of the currently used root filling materials for pulpectomy in primary teeth. The trial aimed to investigate the clinical and radiographic success of three materials - RC Fill, Vitapex and Pulpdent root canal sealer- used for primary molar teeth with necrotic pulps and irreversible pulpitis in patients aged 6, 12 and 30 months.



This single-centre, double-blind, randomized controlled trial conducted in India included 129 teeth in 88 children (40 girls and 48 boys aged between 4 and 9 years).

Teeth with one or more of the following criteria were included for pulpectomy: - (1) Caries-affected teeth with intra-oral and/or extra-oral swelling or draining sinus tract; (2) Teeth with deep caries lesions and associated inter-radicular and/or periapical radiolucencies; (3) Caries-affected teeth with abnormal mobility due to periapical pathosis, and not associated with normal exfoliation; (4) History of spontaneous pain in caries-affected teeth; and, (4) Caries-affected teeth with internal root resorption involving the cervical 1/3 of the root or external resorption (not physiologic resorption) involving less than 1/3 of the root length.

Children with systemic pathosis (any medically compromising conditions) or allergies to any of the materials used were excluded from this trial.

Patients were randomly assigned by a block randomization method with random table numbers of blocks 10 and 9. Allocation concealment was performed with sequentially numbered, opaque and sealed envelopes. The participants and outcome assessors were blinded about the filling materials used.

The selected participants were randomly divided into 3 groups:

  • Group I (GI) - RC Fill (ZOE with iodoform),

  • Group II (GII) - Vitapex (calcium hydroxide with iodoform) and

  • Group III (GIII) - Pulpdent root canal sealer (ZOE).

A standardised approach to the pulpectomy procedure was used in all three groups.

Calcium hydroxide with iodoform (Vitapex) was available in pre-loaded syringes. The syringe was inserted into the canal near the apex. The paste was extruded into the canal, and the syringe was then slowly withdrawn as the paste filled the entire canal. The RC Fill and Pulpdent root canal sealer were available in powder and liquid form. They were mixed to the desired consistency according to the manufacturer's instructions. A lentulo spiral was used to place the RC Fill, and an Endodontic Pressure Syringe (EPS) was used to place the Pulpdent root canal sealer. The pulp chamber was also filled with the filling material, Type IX GIC was placed as a core, and an immediate postoperative radiograph was taken. The teeth were then restored with stainless steel crowns (3M) at the same appointment immediately following canal filling.

The outcome measures were evaluated both clinically and radiographically at 6, 12 and 30 months.



In total, ninety teeth (90) were followed up at 30 months (12% attrition of sample). All three materials were associated with 100% clinical success at 6, 12 and 30 months. Regeneration and reduction in the size of furcation and periapical radiolucencies were observed, and none of the teeth had developed new lesions at the follow-up. However, in a few cases furcation radiolucency and external root resorption increased, and there was thickening of the lamina dura and widening of periodontal ligament space, which were considered as failures. Hence, overall success was determined by the radiographic evidence which showed success rates of the three materials at 30 months of 94%, 90% and 97% for RC Fill, Vitapex and Pulpdent, respectively. The differences in the success rates amongst the materials were not significant (P > 0.05). An intention-to-treat strategy was used, and the results were analysed according to the assigned treatment groups. Based on this, the results were observed to be similar to the pre-protocol results of the study with respect to all clinical and radiographic parameters.



All three materials, RC Fill, Vitapex and Pulpdent, were shown to be equally effective root filling materials at 30 months post-operatively for primary molars with necrotic pulps and irreversible pulpitis.



The results of the trial suggest that dentist preference for the material of their choice should not affect the outcome as all three materials showed equivalent clinical performance.



1.Pramila R, Muthu MS, Deepa G, Farzan JM, Rodrigues SJL. Pulpectomies in primary mandibular molars: a comparison of outcomes using three root filling materials. Int Endod J. 2016; 49:413-21.         [ Links ]


2. Efficacy of mepivacaine-tramadol combination on the success of inferior alveolar nerve blocks in patients with symptomatic irreversible pulpitis: a randomized clinical trial.

Rodríguez-Wong L, Pozos-Guillen A, Silva-Herzog D, Chavarría-Bolaños D. Int Endod J. 2016; 49:325-33.

Mepivacaine is an amide-type anaesthetic that is recommended for cases in which systemic conditions restrict the use of other anaesthetics.1 Tramadol hydrochloride is a centrally acting drug with a mechanism that is not fully understood. Tramadol hydrochloride is used for the management of acute and chronic pain, and it is effective in moderate-to-severe pain with low addiction incidence.1

In the last decade, it has been proposed that the use of other drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), opioids and tramadol, could be used as adjuncts to anaesthetics to obtain a higher success rate and longer duration of the anaesthetic effect under the concept of multimodal analgesic or pharmacological synergism1 However, oral administration of drugs can cause adverse systemic effects and that is why local application is an alternative that increases the concentration on the damaged tissue locally, reducing the possibility of interactions with other drugs and their adverse effects1.

The inferior alveolar nerve block (IANB) is the most common anaesthetic technique used on mandibular teeth during root canal treatment. Several studies have reported a 30-80% failure rate for IANBs in patients with symptomatic irreversible pulpitis (SIP)1. Rodríguez-Wong and colleagues (2016)1 undertook a randomized double-blinded trial to compare the success of an inferior alveolar nerve block after applying a combination of mepivacaine and tramadol or mepivacaine alone in patients with symptomatic irreversible pulpitis in mandibular permanent molars. The null hypothesis was that the combination of mepivacaine-tramadol will not increase the success of the IANB in patients with SIP.



This Mexican study was a double-blind, randomized clinical trial. Seventy-four patients were pre-selected to participate according to a preoperative pain scale and preliminary clinical evaluation following the guidelines suggested by the CONSORT group for planning and reporting clinical trials; 56 patients were included and 18 were excluded. Inclusion criteria were as follows: age 18 years or older, acute moderate-to-severe preoperative pain in the posterior mandibular region, SIP in a first or second mandibular molar, no intake of analgesics for 12 h prior to the treatment and acceptance and signing of the consent form. The exclusion criteria were as follows: pregnancy, allergy to tramadol or mepivacaine, poor tooth integrity for restoration, periodontal disease, root resorption, root fracture, systemic diseases such as diabetes and uncontrolled hypertension, intake of drugs or narcotics and patients with sensory impairment or paraesthesia. The elimination criteria were teeth with necrotic pulps found after diagnosis and during endodontic access (partial necrosis), intraoperative accidents such as perforations or crown fractures and patients who decided to withdraw from the study.

Initially, preoperative pain was scored using a modified Heft-Parker VAS of 100mm with 11 measurement points for determining the intensity of pain, where the end-points were the extremes of no pain and the worst pain (0-10, respectively). A previously calibrated independent clinician performed the initial diagnosis. Diagnostic tests were performed by applying thermal cold testing with a cold spray (Endo-Ice) on a cotton pellet in the middle third of the buccal surface of the tooth until the patient responded (maximum 7). The patient was asked to indicate the intensity and the duration of the thermal sharp sensation once identified. Equivocal or confusing responses to cold test were recorded, and these patients were excluded from the study. SIP was diagnosed if there was a prolonged response to the cold test, when compared to the control contralateral tooth. In addition, the diagnosis was complemented with the absence of radiographic evidence of periapical pathosis.

Patients were assigned sequential numbers in the order of enrolment and received their allocated treatment according to a computer-generated randomization schedule prepared before the start of the study. Patients were randomized using the block randomization method to obtain equal sample sizes in each group. This method keeps a balance in number of subjects in each group across the study. The block size was determined as four.

The control group (mepivacaine) received the IANB using 1.8mL of mepivacaine 2% 1:100 000 epinephrine, and the experimental group received 1.3mL of mepivacaine 2% 1:100 000 epinephrine mixed with 0.5mL of tramadol 50mg mL1. The anaesthetic was injected with a metallic syringe with a 27-gauge 1.25-inch needle. All of the anaesthetic cartridges had the same appearance to blind both operator and patients.

The same operator carried out all the anaesthetic blocks by a direct (Halsted) approach, and an independent investigator carried out the evaluation of the treatment.

After 15 min, a progressive four-step examination was performed to analyse the success of the IANB in both groups as follows: lip numbness was determined and compared with the contralateral lip. Isolation of the target tooth was carried out, and a second cold test was performed to determine the presence or absence of a painful response. Then, endodontic access cavities were prepared to confirm a painful response in hard tissues (enamel, dentine or restorations). Finally, canal negotiation was performed to confirm profound anaesthesia in the pulpal tissues. If the patient reported any pain or discomfort during any evaluation, the anaesthetic blockade was categorized as a failure, and the patient received a second cartridge of mepivacaine as a repetition of the IANB or the intrapulpal technique. Only patients with no response advanced to the next examination test, and anaesthetic success was defined as no response during the whole diagnostic process. Only those patients with no response (or a zero value on VAS) in all of the sequential four-step examinations were considered as an anaesthetic success.

Patients were monitored 24 h after the procedure to assess the duration of the anaesthetic effect, the consumption of postoperative analgesics and side effects. The patient received three tablets of ibuprofen 600 mg and one tablet of sublingual ketorolac 30 mg for emergency and rescue medication, respectively, in case they experienced pain after treatment.



Of the 74 patients who were evaluated, 56 patients were included and 18 excluded. No significant differences between the experimental and control groups were found for gender (P > 0.05), age (P > 0.05), duration of treatment (P > 0.05), intensity of preoperative pain (P > 0.05) and pain produced by the injection (P > 0.05). Therefore, the groups were considered homogeneous. After administration of the inferior alveolar nerve block (IANB), all of the patients reported lip numbness, except one patient in the control group. The anaesthetic success was 57.1% for the experimental group and 46.4% for the control group with no significant difference (P = 0.05). There was a significant difference (P < 0.05) in the duration of the anaesthetic effect, with higher values in the experimental group (142 min). No patient in either group reported adverse effect.



The combination mepivacaine-tramadol solution achieved similar success rates for the inferior alveolar nerve block (IANB) when compared with mepivacaine 2% epinephrine 1 : 100 000. There was no significant difference in the anaesthetic efficacy between the control and experimental solutions, and none of the solutions tested were completely successful.



The addition of a pain control medication in the local anaesthetic did not improve the performance of the local anaesthetic in patients who were undergoing root can treatment for symptomatic irreversible pulpitis (SIP).



1.Rodríguez-Wong L, Pozos-Guillen A, Silva-Herzog D, Chavarría-Bolaños D. Efficacy of mepivacaine-tramadol combination on the success of inferior alveolar nerve blocks in patients with symptomatic irreversible pulpitis: a randomized clinical trial. Int Endod J. 2016; 49:325-33.         [ Links ]




Rustication and rejuvenation



WG Evans

Managing editor,




June or Juno was the wife of Jupiter. Caesar gave the sixth month her name. However, there is another version which ascribes the name of the month to Iunius... meaning Youth and indeed June is celebrated as Youth Month in South Africa. This is a time of rededication and of commitment to the future. The energy and enthusiaism and excitement of Youth are recognised and encouraged.

In many ways June may be a time of rebirth, of a determination to seek new paths and directions. So it has been for at least three of our Association colleagues who in the month of June have relinguished aspects of their current lives and are embarking on new and stimulating opportunities. This issue of the Journal recognises the enormous contributions made by those three colleagues.. disparate though their fields of endeavour may have been.



Johan Smit may just have set a world record for he has been Chief Dental Officer of South Africa for more than 25 years! He has retired to the Lowveld where he has every intention of taking advantage of country life, walking, reading, wildlife studies. The profession awards Dr Smit a resounding accolade for his dedication and for his commitment in representing Dentistry at the highest levels of government over all those years. A burdensome, challenging and at times frustrating responsibility, carried out with sincerity and with achievement. He held our trust and deep respect. Well done, Johan and thank you.

For many readers the Journal has over several years offered a truly impressive and valuable service -the accumulation of Ethics CPD points has been wonderfully facilitated by the regular columns contributed by Professor Su Naidoo. A more consistent contributor you will not find. Month after month an article appeared, a pertinent ethical topic was explored, some careful observations made and excellent advice and guidance delivered. This has been a column on which all could totally rely and it will be a source of sadness and distress that Su has now delivered her last Ethics commentarynumber 61 appears in the June issue, an unbroken line over all those Journals. Professor Naidoo is seeking a new direction in her life and has indicated that no longer will her bye-line be appearing in our Journal. Sad for us all but we wish her such success and happiness. Our sincere appreciation and congratulations on a significant contribution to the enormous benefit of readers.

Although Maretha Smit will be with us until the middle of August it was in June that the news of her impending departure was first announced. The vacant chair in the office of the CEO will emphasise just how much she will be missed. Over the years of her tenure the Association has matured and developed. Maretha can depart knowing she leaves an Association in shipshape condition. Her dedicated and intense and innovative efforts on behalf of Dentistry South Africa have earned her the respect and admiration and congratulations of members.

The Journal has profited from the input of all three of these colleagues, whether as author, referee or involved executive. Now changes are due.. and we may philosophize about change, ranging from Heraclitus (540-475?BC) who wrote: There is nothing permanent except change to Alfred North Whitehead (1861 -1947) who observed: The art of progress is to preserve order amid change and to preserve change amid order. In both quotations we should find truth. On that understanding the Journal and the Association will be encouraged to seek the youthful energy promised by June, and to continue to move forward in pursuing the ideals and the examples set by our departing colleagues to each of whom the warmest good wishes are extended.




A Peripeteia a sudden change



WG Evans

Managing editor,



In 2009 Phillip Baldwin, Chief Executive of The Hong Kong Institute of Chartered Secretaries, offered a definition of what is meant by a "professional body". The definition is actually derived from The Analytic Quality Glossary, Quality Research International and reads:

A professional body is a group of people in a learned occupation who are entrusted with maintaining control or oversight of the legitimate practice of the occupation.

In 1995, Professor Lee Harvey and Selena Mason recognised a paradoxical situation in that a professional body is set up to safeguard the public interest. but also represents its own self interest. Hence it is a controlling body. but that control may paradoxically be based on self interest.

Perhaps it was a recognition of the implied challenge in that paradox that motivated Maretha Smit, at least in part, to seek appointment as the CEO of our professional body, The South African Dental Association. In January 2011 Maretha assumed the office and brought a perspective that has cast a whole new light on the role of the Association, our responsibilities, our position in society, our need to recognise that the introduction of the principles of corporate governance have in fact become central to the effective management of our professional body.

Whatever the motivation that prompted this elegant lady to take on the multiplicity of roles which must be played by our CEO, then January 2011 was a propitious time for SADA. Elegant is an appropriate description but it belies the brave determination and commitment which has enabled Maretha with her previous business experience to safely guide the Association into becoming a professional body effectively satisfying the required principles of the Companies Act. Corporate governance is recognised today as central to the proper management of companies, yes, .but equally applicable to a no profit association trying to balance that combination of social and self interests.

After some five and a half years of decisive and incisive leadership, Maretha is to depart from the Association, and indeed from South Africa, to take up a position in New Zealand. That news burst upon the Association with tsunamic force. So much has been achieved. and the Association was indeed looking forward to continued progress and further innovative enhancement of its activities. Dr Yvette Solomons, Chairperson of the Board of Directors of the Association, has listed some of the achievements of the last few years

Formulating and implementing SADA' s governance model in line with the new Companies Act.

Formulating and implementing SADA's Transformation Programme,

Formalising annual business planning and budgeting processes,

Establishing the Young Dentists' Council,

Formulating a framework for the SADA Leadership Academy,

Formulating strategies for SADA as a Private Higher Education Institution,

Formulating strategies for SADA as a Financial Services Provider.

Services Provider.

Many members may have been blissfully unaware of the King Reports, I, II and III. Under the astute chairmanship of Mervyn King, these Reports have placed South Africa in a world leading position regarding policies on Corporate Governance. It has been Maretha who has championed the awakening of the Association to the need to move ahead and to accept the triple objectives of governance under the King principles, the economic, the environmental and the social aspects of the activities of any institution. An inclusive approach should replace an exclusive approach. The King Committee comments, (with slight modifications) : Boards must apply the test of fairness, accountability, responsibility and transparency to all acts or omissions and be accountable to, but also responsive and responsible towards, the stakeholders.

Maretha Smit has brought that focus and that challenge to the Association. The Association has matured and advanced under her leadership. The monumental tasks could not have been managed without an impressive work ethic, without a total dedication and without enormous patience. But there has always been the warm person behind the driving initiatives, the genuine smile of welcome no matter the pressures, the preparedness to listen and to cogitate and to debate the issues, all with gracious forbearance. Maretha respects and acknowledges those with whom she works an indispensable characteristic of the successful CEO.

This Communique bears then the sad news of the departure of Maretha Smit from our Head Office and from RSA.. BUT it also carries the appreciation and the accolades of the Association to a CEO who has met the challenges and set a new path and done this with dedication and resolve.

Thank you, Maretha for kindness, empathy, patience. And for determination and commitment. You have graced the office of CEO. The news has indeed been a peripeteia but you have made a courageous decision and you carry with you every best wish from the Association for your new enterprise and new life.





The psychological impact of malocclusion on patients seeking orthodontic treatment at a South African oral health training centre