An Investigation Into Differential Diagnosis of Pulp and Periapical Pain: A PennEndo Database Study

Exploring deep caries management and barriers to the use of vital pulp treatments by primary care dental practitioners

AIM

The European Society of Endodontology outlines best practices for the management of deep caries and the pulp. Despite evidence supporting vital pulp treatments (VPTs) as predictable alternatives to conventional endodontic treatment, studies have shown they are not widely adopted in the UK. This study aimed to explore the barriers to implementation of VPTs by primary care general dental practitioners (GDPs).

METHODOLOGY

Qualitative one-to-one semi-structured online interviews were conducted with purposively sampled UK GDPs. Interview transcripts were analysed using reflexive thematic analysis. Recurring themes were iteratively refined as additional transcripts were reviewed.

RESULTS

Eleven participants were interviewed. A range of barriers to the provision of VPTs were identified, which aligned with two core themes: 'Motivational barriers to service provision' and 'Educational access & opportunities'. Sub-themes included lack of access to materials and equipment, deficiencies in knowledge of treatment (including protocols, outcomes and prognosis), lack of confidence (in treatment efficacy and clinical ability), time constraints and public dental service funding and remuneration.

CONCLUSIONS

This study identifies barriers to the widespread adoption of VPTs among primary care GDPs in public and private settings. Economic constraints, practitioner confidence, time limitations and educational gaps are key challenges. Addressing these may require systemic changes such as policy interventions, education and improved resource allocation.

Wavelet Guided 3D Deep Model to improve Dental Microfracture Detection

Epidemiological studies indicate that microfractures (cracks) are the third most common cause of tooth loss in industrialized countries. An undetected crack will continue to progress, often with significant pain, until the tooth is lost. Previous attempts to utilize cone beam computed tomography (CBCT) for detecting cracks in teeth had very limited success. We propose a model that detects cracked teeth in high resolution (hr) CBCT scans by combining signal enhancement with a deep CNNbased crack detection model. We perform experiments on a dataset of 45 ex-vivo human teeth with 31 cracked and 14 controls. We demonstrate that a model that combines classical wavelet-based features with a deep 3D CNN model can improve fractured tooth detection accuracy in both micro-Computed Tomography (ground truth) and hr-CBCT scans. The CNN model is trained to predict a probability map showing the most likely fractured regions. Based on this fracture probability map we detect the presence of fracture and are able to differentiate a fractured tooth from a control tooth. We compare these results to a 2D CNN-based approach and we show that our approach provides superior detection results. We also show that the proposed solution is able to outperform oral and maxillofacial radiologists in detecting fractures from the hr-CBCT scans. Early detection of cracks will lead to the design of more appropriate treatments and longer tooth retention.

A critical analysis of research methods and experimental models to study pulpitis

Pulpitis is the inflammatory response of the dental pulp to a tooth insult, whether it is microbial, chemical, or physical in origin. It is traditionally referred to as reversible or irreversible, a classification for therapeutic purposes that determines the capability of the pulp to heal. Recently, new knowledge about dental pulp physiopathology led to orientate therapeutics towards more frequent preservation of pulp vitality. However, full adoption of these vital pulp therapies by dental practitioners will be achieved only following better understanding of cell and tissue mechanisms involved in pulpitis. The current narrative review aimed to discuss the contribution of the most significant experimental models developed to study pulpitis. Traditionally, in vitro two(2D)- or three(3D)-dimensional cell cultures or in vivo animal models were used to analyse the pulp response to pulpitis inducers at cell, tissue or organ level. In vitro 2D cell cultures were mainly used to decipher the specific roles of key actors of pulp inflammation such as bacterial by-products, pro-inflammatory cytokines, odontoblasts or pulp stem cells. However, these simple models did not reproduce the 3D organisation of the pulp tissue and, with rare exceptions, did not consider interactions between resident cell types. In vitro tissue/organ-based models were developed to better reflect the complexity of the pulp structure. Their major disadvantage is that they did not allow the analysis of blood supply and innervation participation. On the contrary, in vivo models have allowed researchers to identify key immune, vascular and nervous actors of pulpitis and to understand their function and interplay in the inflamed pulp. However, inflammation was mainly induced by iatrogenic dentine drilling associated with simple pulp exposure to the oral environment or stimulation by individual bacterial by-products for short periods. Clearly, these models did not reflect the long and progressive development of dental caries. Lastly, the substantial diversity of the existing models makes experimental data extrapolation to the clinical situation complicated. Therefore, improvement in the design and standardization of future models, for example by using novel molecular biomarkers, databased models and artificial intelligence, will be an essential step in building an incremental knowledge of pulpitis in the future.

Effect of intracanal cryotherapy on postendodontic pain: a systematic review and meta-analysis of randomized controlled trials

This systematic review aimed to qualitatively and quantitatively evaluate the effectiveness of cryotherapy in the reduction of postendodontic pain. The review question was, "What will be the success rate of cryotherapy technique among human patients with postendodontic pain?". The review protocol was framed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Six studies were included in the review, and quantification of five studies was performed through a meta-analysis. In the forest plot representation of the studies comparing the control and cryotherapy groups in terms of the success rate in the management of postendodontic pain, the combined risk ratio (RR) was 0.80 (95% CI: 0.56 to 1.13) with a P value of 0.20. Based on the quantitative analysis, it can be suggested that intracanal cryotherapy does not play a significant role in reducing postendodontic pain.

Influence of Preoperative Mechanical Allodynia on Predicting Postoperative Pain after Root Canal Treatment: A Prospective Clinical Study

INTRODUCTION

Odontogenic pain can manifest as pulpal pain, periapical pain (mechanical allodynia), or both. This study aimed to assess the changes in the intensity of mechanical allodynia (MA) and to identify predictors of postoperative pain after root canal treatment (RCT).

METHODS

In total, 579 consecutive patients who required RCT were enrolled; we included patients with asymptomatic pulpal diagnoses to avoid any effects of preoperative spontaneous pain on postoperative pain and to evaluate MA independently. Using a visual analog scale (VAS), patients separately indicated the intensity of spontaneous pain, tenderness to percussion, and pain on biting; these measurements were performed before treatment (preoperative pain), at the beginning of each visit (postpreparation pain), and daily for 1 week after RCT (postobturation pain). For analytical purposes, patients were subdivided into 2 groups based on the intensity of preoperative MA (none to mild [VAS <4] or moderate to severe [VAS ≥4]) to evaluate changes in MA and predictive factors of moderate to severe postoperative pain. A generalized estimating equation, repeated-measures analysis of variance, and logistic regression analysis were used.

RESULTS

Although the intensity of MA was significantly higher in the moderate to severe group after the initiation of RCT (P < .05), 93% of them experienced alleviation in MA, and 30% of patients in the none to mild group experienced an increase in MA. After adjusting for clinical variables, moderate to severe preoperative MA and the presence of necrotic pulp were significantly correlated with moderate to severe postoperative pain with an odds ratio of 4.107 and 0.286, respectively.

CONCLUSIONS

Moderate to severe preoperative MA was a predictive factor of postoperative pain in patients undergoing RCT.

Preserving pulp vitality: part one - strategies for managing deep caries in permanent teeth

This is the first article in a series reviewing the current literature surrounding the management of deep caries in permanent teeth. Approaches to caries management are continuing to evolve, with more conservative management increasingly favoured. This philosophy has never been more important than in managing the deep carious lesion. Evidence is emerging that the use of selective caries removal to reduce the risk of pulp exposure, in conjunction with calcium silicate cements, can be successful in maintaining pulp vitality, delaying the restorative cycle and prolonging the lifespan of the tooth.

Association between overweight, obesity and incidence of advanced dental caries in South Korean adults: A 10-year nationwide population-based observational study

The objective of this study was to evaluate the association between overweight, obesity and the incidence of advanced dental caries in South Korean adults, using alternate measures. The participants included 376,077 people aged 20 years and older who had health examination at least one time between 2005 and 2008. This evaluation is based on a change of body mass index (BMI) category, for 10 years, using a nationally representative data resource available from the National Health Insurance System. Instead of using decayed, missing, and filled teeth (DMFT), the diagnostic codes which indicate dental caries, pulpal disease and visiting frequency at dental health professionals were used in this case. A multivariate adjusted Cox regression analysis was performed to examine the association between advanced dental caries and BMI. In addition to the BMI, a multivariate analysis of gender, age, lifestyle behaviors and systemic disease information was included. To this end, the hazard ratio (HR) and 95% confidence interval (CI) were calculated. Chiefly, it is noted that the overweight and obese people were more likely to develop advanced dental caries independent of the noted variables. The positive association between high BMI and incidence of advanced dental caries was more prominent in the population's characteristic of people who were in a classification of the elderly and women. Among the health and lifecycle behaviors, smoking or not was found to be one of the factors affecting the results. The alternate method used in this study showed that being overweight and obesity had a direct association with the incidence of advanced dental caries in Korean adults.

Diagnostic accuracy of three placement sites for the cold test in subjects amongst different age groups

Background

The cold test is a specific test of pulp sensitivity and is part of the endodontic diagnosis. The aim of this study was to identify the diagnostic accuracy including sensitivity, specificity, accuracy, positive predictive value and negative predictive value in three sites for the cold test in teeth with a need for endodontic treatment within different age groups from both genders.

Methods

A cross-sectional study was performed, evaluating 425 subjects. Two hundred and fifty-eight subjects from both genders from the ages of 17–27, 28–39, 40–50, and 51–65 years-old participated in the study. The cold test studied was 1, 1, 1, 2-tetrafluoroethane, and the gold standard was established through direct pulp inspection. The sites evaluated in the study were: The sites evaluated in the study were: a) the middle third of the buccal surface; b) the cervical third of the buccal surface, and c) the middle third of the lingual surface.

Results

The highest diagnosted accuracy was observed on the middle third buccal surface with an accuracy of = 0.97, a sensitivity of = 1.00, a specificity of 0.95, a predictive value of = 0.95 and a negative predictive value of = 1.00. This was in the female group aged from 40 to 50 years old.

Conclusion

The tables of this study can be used as an auxiliary for pulp sensitivity tests.

Chronic orofacial pain animal models - progress and challenges

INTRODUCTION

Chronic orofacial pain is one of the most common pain conditions experienced by adults. Animal models are often selected as the most useful scientific methodology to explore the pathophysiology of the disorders that cause this disabling pain to facilitate the development of new treatments. The creation of new models or the improvement of existing ones is essential for finding new ways to approach the complex neurobiology of this type of pain. Areas covered: The authors describe and discuss a variety of animal models used in chronic orofacial pain (COFP). Furthermore, they examine in detail the mechanisms of action involved in orofacial neuropathic pain and orofacial inflammatory pain. Expert opinion: The use of animal models has several advantages in chronic orofacial pain drug discovery. Choosing an animal model that most closely represents the human disease helps to increase the chances of finding effective new therapies and is key to the successful translation of preclinical research to clinical practice. Models using genetically modified animals seem promising but have not yet been fully developed for use in chronic orofacial pain research. Although animal models have provided significant advances in the pharmacological treatment of orofacial pain, several barriers still need to be overcome for better treatment options.

Automatic quantification framework to detect cracks in teeth

Studies show that cracked teeth are the third most common cause for tooth loss in industrialized countries. If detected early and accurately, patients can retain their teeth for a longer time. Most cracks are not detected early because of the discontinuous symptoms and lack of good diagnostic tools. Currently used imaging modalities like Cone Beam Computed Tomography (CBCT) and intraoral radiography often have low sensitivity and do not show cracks clearly. This paper introduces a novel method that can detect, quantify, and localize cracks automatically in high resolution CBCT (hr-CBCT) scans of teeth using steerable wavelets and learning methods. These initial results were created using hr-CBCT scans of a set of healthy teeth and of teeth with simulated longitudinal cracks. The cracks were simulated using multiple orientations. The crack detection was trained on the most significant wavelet coefficients at each scale using a bagged classifier of Support Vector Machines. Our results show high discriminative specificity and sensitivity of this method. The framework aims to be automatic, reproducible, and open-source. Future work will focus on the clinical validation of the proposed techniques on different types of cracks ex-vivo. We believe that this work will ultimately lead to improved tracking and detection of cracks allowing for longer lasting healthy teeth.

Intracanal Cryotherapy Reduces Postoperative Pain in Teeth with Symptomatic Apical Periodontitis: A Randomized Multicenter Clinical Trial

INTRODUCTION

A prospective, multicentered, randomized clinical trial was designed to assess if controlled irrigation with cold saline could result in less incidence and intensity of postoperative pain in patients presenting with pulp necrosis and symptomatic apical periodontitis.

METHODS

A total of 210 patients (presenting with necrotic uniradicular teeth with a diagnosis of symptomatic apical periodontitis and a preoperative visual analog scale (VAS) score higher than 7) were randomly allocated in the control or experimental group after the completion of shaping and cleaning procedures. The experimental group received a final irrigation with 20 mL sterile cold (2.5°C) saline solution delivered to the working length with a sterile, cold (2.5°C) Endovac microcannula (Kerr Endo, Orange Country, CA) for 5 minutes. The same protocol was used in the control group with room temperature saline solution. Patients were instructed to record the presence, duration and level of postoperative pain, and analgesic medication intake. A logistic regression was used to compare the incidence of postoperative pain and the need for painkillers between groups. Differences in general pain intensity between groups were analyzed using the ordinal (linear) chi-square test. Postoperative pain after 6, 24, and 72 hours (recorded in a VAS scale) and the need for analgesic medication intake between the 2 groups were assessed using the Mann-Whitney U test.

RESULTS

Patients in the control group presented a significantly higher incidence of postoperative pain, intensity, and need for medication intake (P < .05).

CONCLUSIONS

Cryotherapy reduced the incidence of postoperative pain and the need for medication intake in patients presenting with a diagnosis of necrotic pulp and symptomatic apical periodontitis.

Pain levels and typical symptoms of acute endodontic infections: a prospective, observational study

BACKGROUND

This study aimed to identify key symptoms that could be associated with the diagnosis of acute forms of symptomatic apical periodontitis (SAP) and symptomatic irreversible pulpitis (SIP), and to identify a diagnostic algorithm based on these symptoms.

METHODS

In this prospective, observational study 173 emergency patients diagnosed with acute pain of endodontic origin and no swelling or fistula were included. Patients were asked 11 specific questions from a checklist with a possible discerning value between acute SAP and acute SIP. Pain levels were recorded using the numeric rating scale (NRS-11). Subsequently, the painful tooth was diagnosed. Logistic regression was used to evaluate the checklist regarding its differentiation between SAP (N = 103) and SIP (N = 70). Moreover, a decision tree was constructed based on recursive partitioning to identify a hierarchy in differentiating symptoms.

RESULTS

With identical median NRS-11 scores of 8, the teeth diagnosed with acute SAP and SIP were severely painful. The decision tree analysis resulted in a tree with splits according to pain on cold, perceived tooth extrusion, and pain duration. The overall sensitivity of the tree to detect SAP based on key symptoms was 95 %, its specificity was 31 %.

CONCLUSIONS

The best indicator for SAP was a reported absence of pain to cold stimuli. In teeth that did have a history of pain triggered by cold stimuli, the decision tree correctly identified SAP in 72 % of the teeth that felt too high and had hurt for less than one week.

Diagnostic accuracy of periapical radiography and cone beam computed tomography in detecting apical periodontitis using histopathological findings as a reference standard

AIM

To compare the diagnostic accuracy of periapical radiography (PR) and cone beam computed tomography (CBCT) in detecting apical periodontitis (AP) using histopathological findings as a reference standard.

METHODOLOGY

Jaw sections containing 67 teeth (86 roots) were collected from unclaimed bodies due for cremation. Imaging was carried out to detect AP by digital PR with a central view (DP group), digital PR combining central with 10˚ mesially and distally angled (parallax) views (DPS group) and CBCT scans. All specimens underwent histopathological examination to confirm the diagnosis of AP. Sensitivity, specificity and predictive values of PR and CBCT were analysed using rater mean (n = 5). Receiver-operating characteristic (ROC) analysis was carried out.

RESULTS

Sensitivity was 0.27, 0.38 and 0.89 for DP, DPS and CBCT scans, respectively. CBCT had specificity and positive predictive value of 1.0 whilst DP and DPS had specificity and positive predictive value of 0.99. The negative predictive value was 0.39, 0.44 and 0.81 for DP, DPS and CBCT scans, respectively. Area under the curve (AUC) for the various imaging methods was 0.629 (DP), 0.688 (DPS), and 0.943 (CBCT).

CONCLUSIONS

All imaging techniques had similar specificity and positive predictive values. Additional parallax views increased the diagnostic accuracy of PR. CBCT had significantly higher diagnostic accuracy in detecting AP compared to PR, using human histopathological findings as a reference standard.

What are the key endodontic factors associated with oral health-related quality of life?

AIM

To determine the associations between endodontic factors and oral health-related quality of life (OHQoL), controlling for socio-demographics, pain and other oral health clinical factors.

METHODOLOGY

OHQoL assessments were conducted amongst a consecutive sample of 412 Chinese patients requiring endodontic treatment employing the short-form Oral Heath Impact Profile (OHIP-14). Information on (i) number of teeth requiring endodontic treatment, (ii) tooth type, (iii) retreatment requirements, (iv) periapical radiolucency assessment and (v) diagnostic classification was obtained. In addition, socio-demographic information (age, gender, educational attainment and family income), pain ratings on a visual analogue scale (VAS) and other clinical oral health status information were collected.

RESULTS

Bivariate analyses identified association between number of teeth requiring endodontic treatment and summary OHIP-14 score (P < 0.01) and four of its seven domain scores (P < 0.05). Need for endodontic retreatment was associated with summary OHIP-14 score (P < 0.05) and two of its seven domain scores (P < 0.05). In regression analyses having controlled for socio-demographics, other clinical factors and pain rating amongst 15 confounding variables, patients requiring endodontic treatment for multiple teeth were more than twice as likely to have poor OHQoL (upper quintile OHIP-14 scores) compared with those requiring endodontic treatment for a single tooth (OR = 2.16, 95% CI 1.17, 3.98, P < 0.05). Pain VAS rating and age also emerged as significant factors associated with poor OHQoL in the regression analysis.

CONCLUSION

OHQoL is compromised amongst patients requiring endodontic treatment. Number of teeth requiring endodontic treatment is associated with poor OHQoL, controlling for socio-demographic and other oral health clinical and pain factors.

Prevalence of apical periodontitis of root canal-treated teeth and retrospective evaluation of symptom-related prognostic factors in an urban South Korean population

OBJECTIVES

This study aimed to investigate the prevalence of apical periodontitis among root canal-treated teeth in an urban South Korean population and evaluate prognostic factors for periapical radiolucency and its symptoms.

STUDY DESIGN

The periapical status of 896 root canal-treated teeth was evaluated by using digital panoramic radiography. Five prognostic factors were analyzed: length and density of the root filling, presence of crown restoration, probability of unilateral bite, and presence of missing canals.

RESULTS

The prevalence of apical periodontitis among root canal-treated teeth in the study population was 22.8%, and 29.3% of these teeth had received dental treatment for pain relief. Evaluation of the prognostic factors indicated that inadequacy of endodontic treatment was more predictive of apical periodontitis than the absence of a crown restoration.

CONCLUSION

Inadequate root filling length appeared to be the most important prognostic factor related to apical periodontitis and its acute symptoms among root canal-treated teeth.

Preoperative predictors of number of root canals clinically detected in maxillary molars: a PennEndo Database study

The purpose of this investigation was to evaluate the concomitant influence of several variables on the number of root canals clinically detected in maxillary molars. The study used multiple logistic regression analysis on data from 1328 patients, aged 6-82 years, who received nonsurgical root canal treatment on maxillary molars at the University of Pennsylvania from 2000-2006. The number of canals was used as the dependent variable, whereas tooth type, age, caries, referral source, restoration, and pulpal and periapical diagnosis were used as independent variables. One was 0.98 times less likely to detect more canals when the age increased by 1 year. Similarly, one was 1.4 times more likely to detect canals in teeth with caries than teeth without caries. When these independent variables were controlled, only age of the individual was significantly related to number of root canals detected.