A new periapical index based on cone beam computed tomography

Cone-beam computed tomography-based descriptive classification for transverse root fracture

Transverse root fracture (TRF) is classified as a cervical, middle or apical third root fracture on a periapical radiograph. The International Association of Dental Traumatology (IADT) suggests that cone-beam computed tomography (CBCT) should be considered, when conventional radiographs provide 'insufficient' information for diagnosis and treatment planning. Considering that CBCT can divulge additional information, it would be beneficial to have a clinically pertinent three-dimensional classification for TRF. The proposed alphanumeric classification includes the traumatised tooth number, describes the number of TRF, the facial and lingual location of each fracture line on the anatomic root, and its position relative to the crest of the alveolar bone. Further, diastasis, displacement of the coronal fragment and status of the alveolar bone at the site of TRF are also documented. This comprehensive classification system would provide a standard format for reporting, aid in referral communication and can be applied for future outcome studies on TRF.

Comparison of the Outcome of Intentional Replantation in Teeth with or without Periodontal Involvement: A Retrospective Study

OBJECTIVE

Intentional replantation (IR) is considered as a viable treatment option to preserve the teeth with apical periodontitis. This study aimed to compare the treatment outcomes of IR in teeth with or without periodontal involvement, and to investigate the influence of related factors.

METHODS

A total of 157 teeth with a documented history of IR between September 2012 and November 2022 and a follow-up duration of more than 1 year were included. The samples included 100 teeth with simple apical periodontitis and 57 teeth with combined periodontal-endodontic lesions (CPEL). Clinical and radiographic criteria were used to evaluate treatment outcomes including functional retention and extraction. Chi-square analyses and Fisher's exact tests were used to compare bivariate associations between outcomes and clinical or demographic variables. Kaplan-Meier analyses were used to evaluate the cumulative survival rate of the intentionally replanted teeth.

RESULTS

The overall cumulative survival rates were 93.0% at 1 year, 76.7% at 5 years, and 56.2% at 10 years. Among the 100 teeth with simple apical periodontitis, the survival rates were 93.0%, 86.7%, and 78.8% at the same time points. In contrast, 57 teeth with CPEL exhibited survival rates of 93.0%, 65.0%, and 36.9%, respectively. The primary postoperative complications that led to extraction were periodontal involvement (51.9%), tooth fracture (18.5%), external root resorption (18.5%), and persistent apical periodontitis (11.1%). The outcomes of teeth with CPEL were significantly affected by the presence of a sinus tract and crown restoration. In contrast, no significant prognostic factors were identified for teeth without periodontal involvement.

CONCLUSION

The long-term prognosis of teeth with CPEL is significantly worse than those with simple apical periodontitis. The main reason of extraction was periodontal involvement. Regular periodontal maintenance and appropriate crown restoration may help to improve the prognosis for teeth with CPEL.

Two-Dimensional Radiographs and Cone-beam Computed Tomography Assessment of Concentrated Growth Factor and Platelet-Rich Fibrin Scaffolds in Regenerative Endodontic Treatment of Immature Incisors with Periapical Radiolucency: A Randomized Clinical Trial

INTRODUCTION

The primary aim of this study was to compare the radiographic changes of immature incisors with periapical radiolucency after treatment with platelet-rich fibrin (PRF) and concentrated growth factor (CGF) platelet concentrate scaffolds as well as assessment of the clinical success rate over 12 months. The secondary aim was to monitor the radiographic changes in terms of reduction of periapical lesion diameter (PALD), root dentine thickness (RDT), root length (RL), and apical foramen width (AFW). The tertiary aim was to assess and pulp responses, after 12 months.

METHODS

Fifty six children with seventy necrotic, single-rooted maxillary incisors with periapical radiolucency were treated with either CGF or PRF scaffolds (35 teeth per group). Two patients with 4 teeth (2 teeth in each group) failed to attain the follow-up recalls. Radiographic changes in terms of reduction of PALD, RDT, RL, and AFW were monitored using a 2-dimensional (2D) radiograph and cone-beam computed tomography (CBCT) scan. The clinical performance of teeth receiving both scaffolds was assessed after 6 and 12 months. Categorical and continuous data were analyzed using the chi-square test and the t test, respectively. The time and group effects on the means of different radiographic dimensions were tested using the general linear model. Bland-Altman plots were used to assess the level of agreement between the 2D radiographs and CBCT. The level of significance was defined at 0.05 and a 95% confidence interval.

RESULTS

The means of PALD and RL showed significant enhancement in the CGF group compared to the PRF group (P < .05). While the difference between the 2 scaffolds in terms of RDT and AFW was not significant (P > .05). The findings of the 2D radiograph and CBCT were consistent. Clinically, both scaffold success rates were similar (93.9%) over the follow-up intervals. The influence of study independent variables had no significant effect on the success of the regenerative endodontic procedures outcome (P > .05). There was no significant difference in the positive pulp responses to the thermal and electric pulp tests after one year of treatment (P > .05).

CONCLUSIONS

According to the short-term follow-up, PRF and CGF were successful in treating immature teeth with periapical radiolucency by regenerative endodontics. Both scaffold systems induced periapical healing and root lengthening with significant superiority of CGF.

Effect of Orthodontic Treatment on the Outcomes of Endodontically Treated Teeth: A Cone-Beam Computed Tomography Analysis

INTRODUCTION

Often there is the need of moving endodontically treated teeth. Orthodontic movement may have no effect on the prognosis of teeth with root canal treatment (RCT). To verify this subject, we evaluated the effect of orthodontic movement on the prognosis of RCT teeth using cone-beam computed tomography (CBCT) and further explored the influence of orthodontic movement on the prognosis of RCT teeth with and without apical periodontitis (AP).

METHODS

This retrospective study was conducted by evaluating 169 RCT teeth of 100 patients who had undergone fixed orthodontic treatment. AP was assessed and classified using the CBCT periapical index. Univariate analysis of RCT outcome was performed for the total RCT group, RCT without AP group and RCT with AP group. Multivariate logistic regression was performed for the total RCT group and RCT without AP group, respectively, but not for the RCT with AP group. Variables related to the prognosis of RCT were included, such as age, gender, tooth position, RCT quality, coronal restoration quality, periodontal condition, orthodontic traction distance, and orthodontic rotation angle.

RESULTS

The orthodontic traction distance and rotation angle were not significantly correlated to the RCT outcomes, regardless of the presence of AP. Among the total RCT group, teeth with unqualified RCT (odds ratio = 3.42, P = .004) and inadequate coronal restoration (odds ratio = 4.40, P = .031) had a lower success rate. Of the 97 RCT teeth without AP, unqualified RCT was a risk factor for treatment failure (odds ratio = 3.55, P = .041). Of the 72 RCT teeth with AP, the univariate analysis showed that RCT quality were significantly related to the outcome (P = .042).

CONCLUSIONS

Orthodontic movement had no effect on the prognosis of RCT teeth regardless of the presence of AP.

Revolutionizing Endodontics: Innovative Approaches for Treating Mature Teeth With Closed Apices and Apical Lesions: A Report of Two Cases

INTRODUCTION

Modern tissue engineering strategies have elucidated the potential of regenerative endodontic treatment (RET) as an alternative for treating mature teeth.

METHODS

Here, we report two cases in which cell-based RET (CB-RET) using encapsulated allogeneic umbilical cord mesenchymal stem cells (UC-MSCs) in a platelet-poor plasma (PPP)-based scaffold was used in two mature teeth with pulp necrosis and apical periodontitis.

RESULTS

After 5 years of follow-up, the healing response was satisfactory in both cases, with evidence of pulp revitalization.

CONCLUSIONS

This is the first study to report the success of an extended, 5-year follow-up for allogeneic CB-RET. This report presents an innovative and sustainable solution to challenging endodontic scenarios.

Prevalence of apical periodontitis and quality of root canal treatment in an adult Kuwaiti sub-population: a cross-sectional study

Objectives

This cross-sectional study evaluated the prevalence of apical periodontitis (AP) and the technical quality of root canal fillings in an adult Kuwaiti subpopulation using cone-beam computed tomography (CBCT) images.

Materials and Methods

Two experienced examiners analyzed 250 CBCT images obtained from Kuwaiti patients aged 15-65 years who attended government dental specialist clinics between January 2019 and September 2020. The assessment followed the radiographic scoring criteria proposed by De Moor for periapical status and the technical quality of root canal filling. Chi-square and Fisher's exact tests were used for statistical analysis, with significance level set at p < 0.05.

Results

Among the 2,762 examined teeth, 191 (6.91%) exhibited radiographic signs of AP, and 176 (6.37%) had undergone root canal filling. AP prevalence in root canal-treated teeth was 32.38%, with a significant difference between males and females. Most of the endodontically treated teeth exhibited adequate root canal filling (71.5%).

Conclusions

The study demonstrated a comparable prevalence of AP and satisfactory execution of root canal treatment compared to similar studies in different countries.

Assessment of the root and canal morphology in the permanent dentition of Saudi Arabian population using cone beam computed and micro-computed tomography - a systematic review

INTRODUCTION

Root canal treatment procedures require a thorough understanding of root and canal anatomy. The purpose of this systematic review was to examine the morphological differences of teeth root and their canals assessed using cone-beam computed and micro-computed tomography in Saudi Arabian population.

METHODOLOGY

An electronic search was conducted in PubMed / Medline, Scopus, Google Scholar, and Web of Science databases until January 2023 to retrieve related studies. "Root canal morphology," "Saudi Arabia," "Micro-CT," and "cone-beam computed tomography" were used as keywords. A modified version of previously published risk of bias assessment tool was used to determine the quality assessment of included studies.

RESULTS

The literature search revealed 47 studies that matched the criteria for inclusion, out of which 44 studies used cone beam computed tomography (CBCT) and three were micro-computed tomography (micro-CT) studies. According to the modified version of risk of bias assessment tool, the studies were categorized as low, moderate, and high risk of bias. A total of 47,612 samples were included which comprised of either maxillary teeth (5,412), or mandibular teeth (20,572), and mixed teeth (21,327). 265 samples were used in micro-CT studies while 47,347 teeth samples were used in CBCT studies. Among the CBCT studies, except for three, all the studies were retrospective studies. Frequently used imaging machine and software were 3D Accuitomo 170 and Morita's i-Dixel 3D imaging software respectively. Minimum and maximum voxel sizes were 75 and 300 μm, Vertucci's classification was mostly used to classify the root canal morphology of the teeth. The included micro-CT studies were in-vitro studies where SkyScan 1172 X-ray scanner was the imaging machine with pixel size ranging between 13.4 and 27.4 μm. Vertucci, Ahmed et al. and Pomeranz et al. classifications were applied to classify the root canal morphology.

CONCLUSION

This systematic review revealed wide variations in root and canal morphology of Saudi population using high resolution imaging techniques. Clinicians should be aware of the common and unusual root and canal anatomy before commencing root canal treatment. Future micro-CT studies are needed to provide additional qualitative and quantitative data presentations.

The use of guided tissue regeneration in endodontic Microsurgery: Setting a threshold

Aim

We aimed to compare the radiographic outcomes of conventional and regenerative approaches in endodontic microsurgery (EMS) and set a critical defect size for healing in conventional and regenerative therapies.

Methodology

The study evaluated 53 root canal-treated teeth (33 patients) with periapical lesions. Among them, 19 teeth (35.8 %) were treated with regenerative treatment, whereas 34 teeth (64.1 %) were managed with the conventional approach. Conventional and regenerative approaches were performed by endodontic and periodontic residents under consultants' supervision. Healing was evaluated after a minimum period of 6 months by comparing pre- and post-operative cone-beam computed tomography (CBCT) findings. The radiographic interpretation was conducted by a single examiner who was not participating in the surgeries and was blind on the type of treatment prior to CBCT evaluation. New healing criteria were proposed owing to the limitations on the present criteria in evaluating endodontic surgery after regenerative treatment. Critical measurements were calculated for each approach based on periapical lesion dimensions.

Results

The regenerative approach presented significantly better healing than conventional treatment (mean, 1.21 and 1.59, respectively; p = 0.047). Based on the critical-point calculations, the conventional approach was effective in lesions of up to 3 mm depth and height, whereas the regenerative approach resulted in better healing rates in lesions with 3-9 mm depth and 3-6 mm height.

Conclusions

Performing the regenerative approach in EMS resulted in better healing rates than those of the conventional approach. The conventional approach is recommended for small periapical lesions, whereas the first had better results in larger lesions.

Global cone-beam computed tomography adoption, usage and scan interpretation preferences of dentists and endodontists

AIM

This study investigated the adoption of cone-beam computed tomography (CBCT) by dentists and endodontists around the world, including their preferences in endodontic CBCT usage.

METHODOLOGY

An online questionnaire surveyed dental association members in Australia and New Zealand, and endodontic association members in Australia, Britain, Canada, Italy, New Zealand and the USA, about their CBCT training history, considerations in acquisition/interpretation, access to and usage of CBCT, preferred scan interpreter, and preferred endodontic scan settings. Data were analysed with Chi-squared, independent sample t-tests, Cochran's Q and McNemar's tests.

RESULTS

Responses from 578 endodontic specialists or postgraduates (Group E) and 185 non-endodontic dentists (Group NE) were included. Continuing professional education (CPE) was the most common source of CBCT training (69.2%). Factors considered in CBCT acquisition/interpretation included beam hardening (75.4%), radiation exposure (61.1%) and patient movement (58.3%). Group E reported higher CBCT usage (90.8%) than Group NE (45.4%, p < .001) and greater workplace access to CBCT (81.1% vs. 25.9%, p < .001). Scans were interpreted by the respondent in most workplace scans (83.3%) and externally taken scans (60.5%); Group E were significantly more likely to interpret themselves than Group NE. Small field of view (83.6%) and high resolution (86.6%) were most preferred as settings for endodontic CBCTs; Group NE were less likely to choose these settings. There were some geographic variations within Group E.

CONCLUSIONS

CBCT training was most commonly acquired via CPE. Endodontic respondents reported very high CBCT usage and access in the workplace. There are educational implications regarding CBCT limitations, appropriate applications and interpretation.

The association of endodontic prognostic factors with the presence of periapical lesion, its volume, and bone characteristics in endodontically treated molars: a cross-sectional study

BACKGROUND

This study intended to evaluate the association between several endodontic prognostic factors with the presence of periapical lesions (PLs), their volume, and bone characteristics including cortical bone destruction (CBD) and buccal plate bone height (BPBH) in root-filled molar teeth using cone-beam computed tomography.

METHODS

A collection of 143 scans of endodontically treated maxillary/mandibular first or second molars recorded over 8 years, were obtained from a specialized radiology center. Data on prognostic factors including tooth number, gender, jaw type, the status and number of missed canals, obturation length, restoration type, presence of a separated instrument, presence of a post or screw in the canals, and presence of perforation were collected. The assessed outcomes included PL presence, PL volume, CBD, and BPBH. The association between prognostic factors and outcomes was evaluated using multiple logistic regression models with adjusted covariates and multifactorial ANOVA at a significance level of 0.05.

RESULTS

A total of 282 molars from 82 women and 50 men with a mean age of 40.6 ± 12.27 were included. Among those, 139 teeth presented PL with a mean volume of 18.68 mm3. CBD was prevalent in 137 teeth and the mean BPBH appeared to be 9.45 mm. The presence of a missed canal (OR = 10.022, P < .05), underfilled canal (OR = 3.725, P < .05), overfilled canal (OR = 15.859, P = .018), and perforation (OR = 15.261, P = .013) was significantly associated with PLs. None of the prognostic factors could considerably contribute to the CBD (P > .05). The presence of a missed canal was positively associated with the PL volume (P < .05). Similarly, missed canals (P < .05), perforation (P < .05), and separated instruments (P = .004) were associated with a significantly reduced BPBH.

CONCLUSIONS

Overfillings, perforations, missed canals, and underfillings were identified as remarkable predictors of PL, arranged in descending order of their respective impact. The only factor capable of significantly increasing the PL volume was the missed canal. In brief, obturation length errors, perforations, missed canals, and separated instruments were robustly correlated with endodontic failure, which highlights the importance of mitigating the potential for errors by following the fundamentals of endodontics.

Evaluating a Periapical Lesion Detection CNN on a Clinically Representative CBCT Dataset-A Validation Study

The aim of this validation study was to comprehensively evaluate the performance and generalization capability of a deep learning-based periapical lesion detection algorithm on a clinically representative cone-beam computed tomography (CBCT) dataset and test for non-inferiority. The evaluation involved 195 CBCT images of adult upper and lower jaws, where sensitivity and specificity metrics were calculated for all teeth, stratified by jaw, and stratified by tooth type. Furthermore, each lesion was assigned a periapical index score based on its size to enable a score-based evaluation. Non-inferiority tests were conducted with proportions of 90% for sensitivity and 82% for specificity. The algorithm achieved an overall sensitivity of 86.7% and a specificity of 84.3%. The non-inferiority test indicated the rejection of the null hypothesis for specificity but not for sensitivity. However, when excluding lesions with a periapical index score of one (i.e., very small lesions), the sensitivity improved to 90.4%. Despite the challenges posed by the dataset, the algorithm demonstrated promising results. Nevertheless, further improvements are needed to enhance the algorithm's robustness, particularly in detecting very small lesions and the handling of artifacts and outliers commonly encountered in real-world clinical scenarios.

Efficacy of imaging techniques for the diagnosis of apical periodontitis: A systematic review

BACKGROUND

Apical periodontitis (AP) is a chronic inflammatory response of microbial aetiology. Pathological changes associated with AP may not be visible on radiographic images and may linger without causing any symptoms. Clinicians rely mostly on clinical examination and imaging techniques to establish a diagnosis.

OBJECTIVES

The aim of this review was to answer the following question using the PICO format: In the adult human permanent dentition (P), what is the efficacy of diagnostic imaging of the periapical tissues (I) using histopathology as a reference standard (C) in the diagnosis of apical periodontitis, in terms of diagnostic accuracy (O).

METHODS

MEDLINE, EMBASE, Scopus and Cochrane Library were searched for English articles published through October 2021. At least two independent reviewers evaluated the study design, imaging modality used, histopathological assessment, outcome measures, results and conclusions for each article. The risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies-2.

RESULTS

The initial search strategy identified 544 articles. Seven articles were included for analysis in the final review, all of which involved tissue samples obtained from cadavers. No clinical studies were identified that met the eligibility criteria. A consistently low sensitivity score and negative predictive value were reported for periapical radiography, especially in comparison to CBCT, which scored highly. Both modalities achieved high scores for specificity and positive predictive value. Diagnostic accuracy of CBCT was lower for root-filled teeth in comparison to non-root-filled teeth.

DISCUSSION

Assessment of the periapical tissues using periapical radiographs was shown to have a low to moderate agreement with the histopathological assessment. CBCT was reported to be more accurate than PR and demonstrated a good agreement with histopathology, especially for non-root-filled teeth.

CONCLUSIONS

This review identified a need for greater standardization in methodology and reporting, and as the findings are based on cadaver studies, their clinical relevance must be interpreted with caution.

REGISTRATION

PROSPERO (CRD42021272147).

Effectiveness of revitalization in treating apical periodontitis: A systematic review and meta-analysis

BACKGROUND

Revitalization procedures primarily aim to eliminate clinical symptoms and heal periapical lesions.

OBJECTIVES

The objective of the study was to elucidate the effectiveness of revitalization in treating apical periodontitis in necrotic mature and immature permanent teeth based on the following PICO question: In patients with permanent immature or mature teeth and pulp necrosis with or without signs of apical periodontitis (P) what is the effectiveness of revitalization (I) in comparison with calcium hydroxide apexification, apical plug and root canal treatment (C) in terms of tooth survival, pain, tenderness, swelling, need for medication (analgesics and antibiotics), radiographic evidence of reduction of apical lesion size, radiographic evidence of normal periodontal ligament space, radiographic evidence of increased root thickness and length (not for mature teeth), tooth function (fracture and restoration longevity), need for further intervention, adverse effects (including exacerbation, restoration integrity, allergy and discolouration), oral health-related quality of life (OHRQoL), presence of sinus tract and response to sensibility testing (O). (T) = Defined as a minimum of 1 year and maximum of as long as possible for all outcome measures, except 'pain, tenderness, swelling, need for medication (analgesics)', which is a minimum of 7 days and maximum of 3 months and OHRQoL which is minimum of 6 months and a maximum of as long as possible.

METHODS

Three databases (PubMed, Embase and Cochrane Library) were searched for human, experimental and observational studies in English, complemented with hand search, until 31/10/2021. Studies recruiting teeth with pulp necrosis (with/without apical periodontitis), with minimum 10 teeth/arm at the end of the study and with a follow-up of at least 1 year, were included. Records without an abstract and a full text were excluded. The qualitative analysis of the included (non-) randomized controlled clinical trials was performed with the Revised Cochrane risk-of-bias tools (RoB 2 and ROBINS-I). Meta-analysis for survival and success (including a subgroup analysis for mature/immature permanent teeth) was performed using the Mantel-Haenszel method. The certainty of evidence was assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation).

RESULTS

From the 365 identified records, five met the inclusion criteria. The 12 months survival rate was 100% for all (im)mature permanent teeth in all groups (3 studies). The success rate at 12 months was 100% for immature permanent teeth for I and C (1 study), however, reduced to 92% and 80% for mature teeth in I and C respectively (1 study, p > .05). The risk of bias for the most critical outcome (survival) was high for two studies and low for one. For the critical outcome success, all assessed studies were highly biased. Meta-analyses provided pooled relative risk with no statistically significant difference between I and C for both survival (RR = 1.00, 95%CI = 0.96-1.04, p = 1.00) and success (RR = 1.06; 95%CI = 0.83-1.35, p = .66). The evidence level for survival was kept 'low' and for success was downgraded to 'very low' due to inconsistency and imprecision.

DISCUSSION

The survival and success rates were favourable in all included studies and for all groups; however, these outcomes are not reliable due to the low certainty level. Clinically, the most reported adverse event was tooth discolouration, hence the application of bismuth oxide containing calcium silicate cements should be avoided in revitalization. Radiographically, caution is needed when assessing periapical bone healing and further root development with periapical radiographs, due to multifactorial inaccuracies of this imaging technique. Methodological and assessment concerns need to be addressed in future clinical trials. Long-term results are necessary for studies reporting revitalization of mature permanent teeth, as they seem to be experimental so far.

CONCLUSIONS

No robust evidence was discovered to support that revitalization is effective to treat apical periodontitis in (im)mature permanent teeth. The success and survival rates of revitalized and fully pulpectomized (im)mature permanent teeth did not differ significantly.

REGISTRATION

Prospero: CRD42021262466.

Effect of QMix as final irrigation protocol on periapical healing after single-visit root canal treatment: A randomised controlled clinical trial

The aim of this study was to evaluate radiographic periapical repair after endodontic treatment using QMix or NaOCl irrigation in single-rooted teeth with apical periodontitis. In this randomised clinical trial, 60 patients were selected and randomised into two groups (n = 30). After instrumentation of root canals, QMix or NaOCl was used as a final irrigation and the canals obturated with gutta-percha and AH Plus sealer. All the participants were recalled after 12 months and 15 patients were lost to the study so 45 patients were evaluated radiographically according to periapical index (PAI) scores. A significant decrease was seen in PAI scores after 1 year in all patients (p < 0.001). In the QMix and NaOCl group, absence or reduction of radiolucency was observed in 23 of 25 teeth (92%) and 20 of 20 teeth (100%), respectively. There was no significant difference between two groups according to the decrease in PAI score (p = 0.508). Root canal treatments with or without QMix irrigation contributed equally to periapical healing.

Endodontic management of maxillary first molar with protostylid: a rare case report

BACKGROUND

A protostylid is a relatively rare dental developmental aberration characterized as an extra cusp located on the mesial half of the buccal surface of the molars. A protostylid is rarely to be reported due to its low rate of occurrence. This case report describes a patient referred for endodontic treatment due to the presence of a protostylid on the buccal surface of the maxillary first molar that induced apical periodontitis.

CASE PRESENTATION

A 53-year-old female reported a 3-month history of pain of chewing with her upper left posterior teeth over 3 months. In the clinical examination, an abraded anomalous cusp-like structure was found on the buccal surface of tooth 26, Cone beam computed tomography (CBCT) revealed a supernumerary cusp with an intact root canal inside, which was fused with the mesiobuccal (MB) root canal in the middle of the root. In addition, extensive periapical radiolucency was observed around tooth 26. The tooth was diagnosed as apical periodontitis, and endodontic treatment was performed. The initial lesion in tooth 26 gradually healed over 1 year of observation.

CONCLUSIONS

To our knowledge, this case is the first to describe the endodontic management of a maxillary first molar with a protostylid and advances our understanding of supernumerary cusps. This case provides a reference for the treatment of protostylid.

Increased risks of maxillary sinus mucosal thickening in Chinese patients with periapical lesions

Objectives

This study aimed to evaluate the effects of factors related to periapical lesions (PALs) on sinus membrane thickening (SMT) in the Chinese population using cone-beam computed tomography (CBCT).

Methods

In this retrospective study, CBCT images (n = 512) of maxillary sinuses of 446 patients were evaluated by two examiners for SMT and PALs, PAL size, and the distance between the maxillary sinus floor (MSF), and the PAL's edge/root apex. The data were analyzed using analysis of variance, the Kruskal-Wallis test, χ²-test, and logistic regression.

Results

A binary logistic regression model showed that the prevalence and severity of SMT > 2 mm were significantly associated with older age (>60 years) (odds ratio [OR]: 4.03, 95% confidence interval [CI]): 2.24-7.72, P < 0.001], male sex (OR: 2.08, 95% CI: 1.21-3.56, P < 0.006), and PALs (OR: 6.89, 95% CI: 3.93-12.08, P < 0.001). The type of contact and penetration between the MSF and PALs or root apex showed a more significant relation with SMT > 2 mm than did distance after adjusting for confounding factors, including age and sex (PALs: OR = 10.17 and 14.57, P < 0.001; root apex: OR = 3.49 and 5.86, P < 0.001).

Conclusions

The prevalence and severity of SMT were significantly associated with older age, male sex, PALs, PAL size, and the distance between the MSF and PALs/root apex. Therefore, communication between dental surgeons and an otolaryngology specialist is important for the timely diagnosis and treatment of SMT of dental origin.

Effect of orthodontic treatment on the periapical radiolucency of endodontically treated teeth: a CBCT analysis

BACKGROUND

This study aimed to evaluate periapical radiolucency of endodontically treated teeth before and after orthodontic treatment using cone-beam computed tomography (CBCT).

METHODS

Patients who underwent orthodontic treatment at Wonkwang University Daejeon Dental Hospital between January 2009 and June 2022 were included based on the following criteria: root canal treatment, and availability of CBCT images taken before and after orthodontic treatment with an interval of > 1 year between both scans. Patients with primary teeth or orthodontic tooth extractions were excluded. The size of the periapical radiolucency (SPR) of the endodontically treated tooth was evaluated using CBCT. Pre-orthodontic treatment CBCT images and the latest post-orthodontic treatment CBCT images were analyzed. The selected teeth were further categorized based on the orthodontic duration, CBCT interval, the patient sex and age, the tooth type and position (maxilla or mandible), and quality of root canal obturation. Statistical analyses were performed to evaluate changes in SPR using the paired t-test and multiple regression analysis.

RESULTS

In total, 115 teeth (37 anterior teeth, 22 premolars and 56 molars) from 61 patients (age, 14-54 years) were included, with 39 teeth from male patients and 76 teeth from female patients. The age was ranged between 14 and 54 years old, and mean age was 25.87 years old. The mean CBCT interval and orthodontic treatment period were 43.32 months and 36.84 months, respectively. Seventy-five teeth showed good obturation quality, 80 were not used as anchors during orthodontic treatment, and 71 were maxillary. The SPR size increased after orthodontic treatment for 56 teeth and decreased for 59 cases. The average change in SPR was -0.102 mm and the difference was not significant. Significant decrease of SPR were observed between female patients (p = 0.036) and maxillary teeth (p = 0.040).

CONCLUSION

Orthodontic treatment had no significant impact on the changes in the SPR in endodontically treated teeth in most categories. However, there was a significant difference among females and the maxillary teeth. In both categories, the size of radiolucency decreased significantly.

Prevalence and morphological analysis of dens invaginatus in anterior teeth using cone beam computed tomography: A systematic review and meta-analysis

OBJECTIVES

To evaluate the prevalence and morphological characteristics of DI using CBCT.

METHODS

A literature search was performed in PubMed, Embase, Scopus, and Web of Science. Inclusion criteria were randomized clinical trials, cross-sectional studies, and prospective and retrospective cohort studies evaluating the morphological characteristics of DI in anterior teeth using CBCT. Three reviewer authors independently screened the studies, applied the eligibility criteria, assessed the risk of bias, and extracted until September (2022). The risk of bias was evaluated using the Joanna Briggs Institute criteria. Meta-analyses of proportions were used for estimate the prevalence DI according to factors at participant and tooth levels.

RESULTS

Six studies were included in the meta-analysis. Among 7373 individuals, a prevalence of 7.45 % of DI was observed (n = 258; τ2 = 0.0096; CI of 4.51-11.3; p < 0.05), with no significant influence of sex. Regarding laterality, unilateral DI showed higher mean prevalence (4.30 %; CI of 2.03-7.33). Among the 382 anterior teeth with DI (0.72 %), the most affected tooth was the upper lateral incisor (5.12 %; n = 329; CI of 2.35-8.86; p < 0.001), type I was the most prevalent (0.59 %; CI of 0.24-1.08) and the presence of open apex and periradicular pathology ranged from 4.3 % to 22.72 % and 3.5-77.92 %, respectively.

CONCLUSIONS

The prevalence of individuals with dens invaginatus was 7.45 %, the most affect tooth was the upper lateral incisor with a prevalence of 5.12 % unilaterally and type I was the most prevalent morphology.

Visualization of clinically silent, odontogenic maxillary sinus mucositis originating from periapical inflammation using MRI: a feasibility study

OBJECTIVES

Maxillary sinus mucositis is frequently associated with odontogenic foci. Periapical inflammation of maxillary molars and premolars cannot be visualized directly using radiation-based imaging. The purpose of this study was to answer the following clinical question: among patients with periapical inflammatory processes in the maxilla, does the use of magnetic resonance imaging (MRI), as compared to conventional periapical (AP) and panoramic radiography (OPT), improve diagnostic accuracy?

METHODS

Forty-two subjects with generalized periodontitis were scanned on a 3 T MRI. Sixteen asymptomatic subjects with mucosal swelling of the maxillary sinus were enrolled in the study. Periapical edema was assessed using short tau inversion recovery (STIR) sequence. Apical osteolysis and mucosal swelling were assessed by MRI, AP, and OPT imaging using the periapical index score (PAI). Comparisons between groups were performed with chi-squared tests with Yates' correction. Significance was set at p < 0.05.

RESULTS

Periapical lesions of maxillary premolars and molars were identified in 16 subjects, 21 sinuses, and 58 teeth. Bone edema and PAI scores were significantly higher using MRI as compared to OPT and AP (p < 0.05). Using the STIR sequence, a significant association of PAI score > 1 and the presence of mucosal swelling in the maxillary sinus was detected (p = 0.03).

CONCLUSION

Periapical inflammation and maxillary mucositis could be visualized using STIR imaging. The use of MRI may help detect early, subtle inflammatory changes in the periapical tissues surrounding maxillary dentition. Early detection could guide diagnostic criteria, as well as treatment and prevention.

Correlation between bacterial type/bacterial quantity and bone loss detected by cone beam computed tomography (CBCT) in primary endodontic infections

Periapical lesions (PL) of endodontic origin are one of the most common pathological conditions that affect peri-radicular tissues. The main ob-jective of this study was to evaluate the amount and species of microorganisms isolated from necrotic pulps, establish a correlation between these and the size of periapical lesions, and how the amount and species of microorganisms decreased with non-surgical root canal treatment. Twenty-seven patients with a clinical diag-nosis of dental pulp necrosis and chronic periapical lesions were selected; a Cone Beam Computed Tomography (CBCT) and microbial samples of the root canal system were taken previous to a disinfection protocol, a post-instrumentation/disinfection protocol, and a post-medication placement. Samples were processed for colony-forming unit (CFU) counting, Gram staining technique, and bacterial identification by the API-20 Strep/API-20A system. The API system identified 21 species of microorganisms in the pre-instrumentation samples, 11 species in the post-instrumentation samples, and 11 in the post-medication samples. There was a correlation coefficient of 0.598% between the initial size of the lesion and the number of bacteria, with a coefficient of determination up to 35.7%, a correla-tion coefficient of 0.486% and a determination coefficient of 23.6% between the size of the periapical lesion and the number of CFUs. This study contributes to the knowledge of the amount and species of microorganisms isolated and identi-fied from necrotic pulps, establishes a correlation between the amount and spe-cies of microorganisms and the size of the periapical lesions, and shows how the decrease of microorganisms contributes to the healing of PL, corroborating the importance of an adequate disinfection protocol.

Factors that influence the outcomes of surgical endodontic treatment

Surgical endodontic treatment encompasses a broad spectrum of procedures, amongst which root-end cavity preparation and filling, retrograde root canal treatment and through-and-through endodontic surgery, may be classified under the umbrella term 'Root-end surgery'. This narrative review considers the available data on periapical healing, soft tissue healing, tooth survival and oral health-related quality of life (OHRQoL), following root-end surgery and the factors that affect its outcomes. The pooled periapical healed rate for the studies published up to 2021 was 69% (95% CI: 65%, 73%) but increased to 76% (95% CI: 66%, 86%) when only data from the 2020's studies were analysed. The prognostic factors consistently reported for periapical healing have included: pre-operative periapical lesion with complete loss of buccal plate, quality of root-end preparation, remaining thickness of apical root dentine and restorative status. Soft tissue healing of the reflected flap was found to have a positive association with periapical healing. The survival rates following root-end surgery range from 48% to 93%, with failure of periapical healing associated with root and crown fracture, being the predominant reasons for tooth extraction. The factors influencing impact of root-end surgery on patients' quality of life could not be adequately evaluated due to design flaws in the available studies. In conclusion, if root canal treatment failure due to leakage through cracks, fractures or restoration margin are excluded, the remaining cases may represent localized residual infection and inflammation at the periapex that should be amenable to predictable management with the aid of modern root-end surgery.

The Influence of Cone Beam Computed Tomography-Derived 3D-Printed Models on Endodontic Microsurgical Treatment Planning and Confidence of the Operator

INTRODUCTION

Currently, there are no studies evaluating the impact of 3-dimensional (3D) printed models on endodontic surgical treatment planning. The aims of this study were: 1) to determine if 3D models could influence treatment planning; and 2) to assess the effect of 3D supported planning on operator confidence.

MATERIALS

Endodontic practitioners (n = 25) were asked to analyze a preselected cone beam computed tomography (CBCT) scan of an endodontic surgical case and answer a questionnaire that elucidated their surgical approach. After 30 days, the same participants were asked to analyze the same CBCT scan. Additionally, participants were asked to study and to perform a mock osteotomy on a 3D printed model. The participants responded to the same questionnaire along with a new set of questions. Responses were statistically analyzed using chi square test followed by either logistic or ordered regression analysis. Adjustment for multiple comparison analysis was done using a Bonferroni correction. Statistical significance was set at ≤0.005.

RESULTS

The availability of both the 3D printed model and the CBCT scan resulted in statistically significant differences in the participants' responses to their ability to detect bone landmarks, predict the location of osteotomy, and to determine the following: size of osteotomy, angle of instrumentation, involvement of critical structures in flap reflection and involvement of vital structures during curettage. In addition, the participants' confidence in performing surgery was found to be significantly higher.

CONCLUSIONS

The availability of 3D printed models did not alter the participants' surgical approach but it significantly improved their confidence for endodontic microsurgery.

Periapical Radiography versus Cone Beam Computed Tomography in Endodontic Disease Detection: A Free-response, Factorial Study

AIM

To assess and compare reader performance in interpreting digital periapical (PA) radiography and cone beam computed tomography (CBCT) in endodontic disease detection, using a free-response, factorial model.

MATERIALS AND METHODS

A reader performance study of 2 image test sets was undertaken using a factorial, free-response design, accounting for the independent variables: case type, case severity, reader type, and imaging modality. Twenty-two readers interpreted 60 PA and 60 CBCT images divided into 5 categories: diseased-subtle, diseased-moderate, diseased-obvious, nondiseased-subtle, and nondiseased-obvious. Lesion localization fraction, specificity, false positive (FP) marks, and the weighted alternative free-response receiver operating characteristic figure of merit were calculated.

RESULTS

CBCT had greater specificity than PA in the obvious nondiseased cases (P = .01) and no significant difference in the subtle nondiseased category. Weighted alternative free-response receiver operating characteristic values were higher for PA than CBCT in the subtle diseased (P = .02) and moderate diseased (P = .01) groups with no significant difference between in the obvious diseased groups. CBCT had higher mean FPs than PA (P < .05) in subtle diseased cases. Mean lesion localization fraction in the moderate diseased group was higher in PA than CBCT (P = .003). No relationships were found between clinical experience and all diagnostic performance measures, except for in the obvious diseased CBCT group, where increasing experience was associated mean FP marks (P = .04).

CONCLUSIONS

Reader performance in the detection of endodontic disease is better with PA radiography than CBCT. Clinical experience does not impact upon the accuracy of interpretation of both PA radiography and CBCT.

The Influence of Endodontic Lesions on The Clinical Evolution of Odontogenic Sinusitis-A Cohort Study

Endodontic disease with formation of periapical lesions (PALs) is one of the most common causes of chronic odontogenic sinusitis (ODS). It requires close collaboration between otolaryngologists and dentists, but the best sequence of management is still unknown. The aim of the present study is to clarify how radiological characteristics of teeth with PALs and previous root-canal treatment (RCT) influence the clinical evolution of the disease and to define the predictive value of its radiological and endoscopic features in determining the need for further surgical intervention. A total of 68 symptomatic patients with ODS with PALs were included in the study. The evaluation was performed by an otolaryngologist and a dentist based on a medical interview, nasal endoscopy, cold pulp testing and tomography images. Patients were prospectively followed for at least 12 months, during which nasal steroids, saline irrigations and RCT were administered. The criteria of disease improvement were: decrease of symptoms, healed sinonasal mucosa in endoscopy and radiological resolution of periapical radiolucency and sinus inflammation. Results showed that 9 (13%) patients improved after conservative treatment and 59 (87%) required further surgical intervention. Patients who improved after medical treatment and RCT were younger (p = 0.043) and had a greater distance from the top of the periapical lesion to the maxillary sinus' floor (p = 0.003). When expansion of PALs and bone destruction toward the maxillary sinus was observed on radiological imaging (p = 0.041), and when more than one tooth root was affected (p = 0.004), patients were more likely to require surgical intervention. In conclusion, the more roots that are affected and the closer the top of the PAL is to the maxillary sinus' floor, the greater the possibility of medical treatment and RCT failure. When the bone destruction extends into the maxillary sinus, patients eventually require both tooth extraction and FESS in order to resolve ODS completely.

Developments and Performance of Artificial Intelligence Models Designed for Application in Endodontics: A Systematic Review

Technological advancements in health sciences have led to enormous developments in artificial intelligence (AI) models designed for application in health sectors. This article aimed at reporting on the application and performances of AI models that have been designed for application in endodontics. Renowned online databases, primarily PubMed, Scopus, Web of Science, Embase, and Cochrane and secondarily Google Scholar and the Saudi Digital Library, were accessed for articles relevant to the research question that were published from 1 January 2000 to 30 November 2022. In the last 5 years, there has been a significant increase in the number of articles reporting on AI models applied for endodontics. AI models have been developed for determining working length, vertical root fractures, root canal failures, root morphology, and thrust force and torque in canal preparation; detecting pulpal diseases; detecting and diagnosing periapical lesions; predicting postoperative pain, curative effect after treatment, and case difficulty; and segmenting pulp cavities. Most of the included studies (n = 21) were developed using convolutional neural networks. Among the included studies. datasets that were used were mostly cone-beam computed tomography images, followed by periapical radiographs and panoramic radiographs. Thirty-seven original research articles that fulfilled the eligibility criteria were critically assessed in accordance with QUADAS-2 guidelines, which revealed a low risk of bias in the patient selection domain in most of the studies (risk of bias: 90%; applicability: 70%). The certainty of the evidence was assessed using the GRADE approach. These models can be used as supplementary tools in clinical practice in order to expedite the clinical decision-making process and enhance the treatment modality and clinical operation.

Tomographic, microbiological and histological characterization of secondary apical periodontitis: case series

This case series included a tomographic, microbiological, and histopathological description of 15 secondary apical periodontitis (SAP) lesions obtained by apical microsurgery performed in 10 patients to better understand the etiology and pathogenesis of SAP. Preoperative tomographic analyses were performed through Cone beam computerized tomography - Periapical index (CBCT-PAI), and apical microsurgeries were then carried out. The removed apices were used for microbial culturing and for molecular identification using PCR for the detection of 5 strict anaerobic bacteria (P. gingivalis, P. intermedia, P. nigrescens, T. forsythia, and T.denticola) and 3 viruses Herpes simplex viruses (HSV), Cytomegalovirus (CMG) and Epstein-Barr Virus (EBV) by nested PCR. The removed apical lesions were histologically described. Univariate statistical analyses were performed by using STATA MP/16 (StataCorp LLC, College Station, TX, United States). CBCT-PAI analyses revealed PAI 4 and PAI 5 score lesions that involved cortical plate destruction. Eight SAPs were positive by culture, while nine SAP lesions were positive by PCR. Fusobacterium species were the most frequently cultured organisms in 7 SAP lesions, followed by D. pneumosintes in 3. In contrast, by single PCR, T. forsythia and P. nigrescens were detected in 5 lesions, T. denticola in 4 lesions, and P. gingivalis in 2 lesions. Twelve periapical lesions were granulomas, and the remaining three SAP lesions were radicular cysts. In conclusion, this case series study revealed that secondary apical lesions presented tomographic involvement of PAI 3 to 5, and that most SAP lesions were apical granulomas containing anaerobic and facultative microorganisms.

Microbial identification from traumatized immature permanent teeth with periapical lesions using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

BACKGROUND

This study aims at identifying the microbiota in traumatized immature permanent teeth with periapical lesions using Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS).

METHODS

The study included 16 immature maxillary central incisors with periapical lesions in 13 patients. Field decontamination and negative control samples were performed before and after access cavity preparation. Root canal samples were taken using sterile stainless-steel hand files following field decontamination. In-office inoculation and pure sub-cultures were performed. Bacterial isolates were prepared for MALDI-TOF MS (Bruker, Billerica, MA USA) analysis using the formic acid extraction method. A comparison of the prevalence of isolated microorganisms was done using a one-sample chi-square test. Comparisons between identified microbial species with the, cone beam computed tomography periapical index (CBCT PAI) scores and lesion volume were also conducted. The Chi-square test was applied to investigate the association between the categorical variables .

RESULTS

Out of the forty isolates recovered from the 16 traumatized teeth included in the present study with the mean patients' age of 10.93 ± 1.77, 37 isolates were reliably identified by MALDI-TOF MS. Twelve teeth (62.5%) were polymicrobial. The recovered bacteria belonged to five phyla, 15 genera and 25 species. Firmicutes were the predominant phylum (P < 0.001) over Bacteroidetes, Proteobacteria, Actinobacteria and Fusobacteria. Gram positive bacteria were significantly more prevalent than Gram negative (p = 0.03). Facultative anaerobes were the most prevalent (P < 0.001) compared to the obligate anaerobes and the obligate aerobes. The latter were the least prevalent. Statistically, significant differences existed in the comparison between CBCT PAI scores according to bacterial gram staining.

CONCLUSION

Traumatized immature permanent teeth with periapical lesions showed a significant predominance of Gram-positive facultative anaerobes. MALDI-TOF MS provided accurate identification of numerous viable endodontic microbes.

Evaluation of endodontically treated teeth and related apical periodontitis using periapical and endodontic status scale: Retrospective cone-beam computed tomography study

The purpose of this study was to evaluate the technical treatment quality and the status of apical pathology of endodontically treated teeth, as well as apical periodontitis (AP) prevalence, in a Turkish population using cone-beam computed tomography (CBCT). The CBCT images obtained between January 2018 and April 2020 were retrospectively examined. The quality of the endodontic treatments and the related periapical inflammatory lesions were classified according to the periapical and endodontic status scale (PESS). The data were statistically analysed using logistic regression, crosstabs and chi-square tests. AP was detected in 41% of 429 endodontically treated teeth. The prevalence of AP was significantly higher in teeth with inadequate root canal treatment compared with those with adequate treatment, 70.8% and 29.3%, respectively. Inadequate canal length and homogeneity, and complications were significantly associated with the prognostic periapical status scores of higher risk.

Plasma Rich in Growth Factors in the Treatment of Endodontic Periapical Lesions in Adult Patients: 3-Dimensional Analysis Using Cone-Beam Computed Tomography on the Outcomes of Non-Surgical Endodontic Treatment Using A-PRF+ and Calcium Hydroxide: A Retrospective Cohort Study

The study presents results of periapical lesion healing after one-visit root canal treatment (RCT) with Advanced Platelet Rich Fibrin plus (A-PRF+) application compared to a two-visit RCT with an inter-appointment calcium hydroxide filling. The comparison was made based on CBCT-Periapical Index (PAI) lesion volume changes and the occurrence of post endodontic pain. The results of 3D radiographic healing assessments based on volume reduction criteria were different from the CBCT-PAI. Based on volume changes, the healing assessment criteria-9 cases from the Study Group and six cases in the Control Group were defined as healed. Based on the CBCT-PAI healing assessment criteria, 8 cases from the Study Group and 9 cases from the Control Group were categorized as healed. The volumes of apical radiolucency were, on average, reduced by 85.93% in the Study Group and by 72.31% in the Control Group. Post-endodontic pain occurred more frequently in the Control than in the Study Group. The highest score of pain in the Study Group was five (moderate pain, n = 1), while in the Control Group, the highest score was eight (severe pain, n = 2). In the 6-month follow-up, CBCT scans showed a better healing tendency for patients in the Study Group.

Influence of periapical lesion size on healing outcome following regenerative endodontic procedures: a clinical investigation

OBJECTIVES

The current study aimed to investigate the influence of the periapical lesion size on healing outcome following Regenerative Endodontic Procedures (REPs) in mature teeth using cone-beam computed tomography (CBCT) and Mimics software.

METHODS

The study included ten mature necrotic maxillary anterior teeth with periapical lesions ≥ 3 CBCT Periapical index score (CBCTPAI). REPs via blood clots were performed for all the teeth. CBCT scans were taken pre and postoperatively after 12 months follow-up periods and transferred to Mimics for volume measurements and comparison. Statistical analysis was performed using the Wilcoxon signed-rank test.

RESULT

All teeth were symptom-free with a statistically significant decrease in the volume of the periapical lesion (P < 0.05) after 12 months except for one case.

CONCLUSION

The study concluded that REPs could be a successful treatment modality for mature necrotic teeth with periapical lesions however the size of the preoperative periapical lesion could affect the outcome of the periapical healing.

TRIAL REGISTRATION

The study was registered in ClinicalTrials.gov (ID: NCT04646538).

Sphericity of periapical lesion and its relation to the novel CBCT periapical volume index

BACKGROUND

The purpose of this study was to assess the sphericity of periapical lesions and its relation to the cone beam computed tomography periapical volume index (CBCTPAVI).

METHODS

261 periapical lesions were assessed using cone beam computed tomography images from InteleViewer^TM. Three-dimensional analysis of the lesions was conducted using analytical imaging software Mimics Research^TM. Lesion volume and surface area measurements were determined using the semi-automatic segmentation technique and these measurements were then used to determine lesion sphericity and CBCTPAVI score. One-way analysis of variance with post-hoc Tuckey test was used to assess for differences in sphericity among CBCTPAVI groups.

RESULTS

The mean sphericity of periapical lesions was 62%. Periapical lesions with larger CBCTPAVI scores were significantly less spherical than lesions with smaller CBCTPAVI scores.

CONCLUSIONS

Periapical lesions of endodontic origin are mostly semi-spherical in their spread and as CBCTPAVI score increases, sphericity decreases, indicating that larger lesions expand less uniformly compared with smaller lesions. Clinicians should be aware that lesions of increased volume, have less sphericity, and are thus elongated or stretched in one or more anatomical plane. This information will assist clinicians in planning and performing periapical surgery and may aid in differential diagnosis of radiolucent jaw lesions.

Present status and future directions: Imaging techniques for the detection of periapical lesions

Diagnosing and treating apical periodontitis (AP) in an attempt to preserve the natural dentition, and to prevent the direct and indirect systemic effects of this condition, is the major goal in endodontics. Considering that AP is frequently asymptomatic, and is most often associated with a lesion in the periapex of the affected tooth, within the maxillary bones, imaging becomes of paramount importance for the diagnosis of the disease. The aim of this narrative review was to investigate the most relevant classic and current literature to describe which are, to date, the diagnostic imaging systems most reliable and advanced to achieve the early and predictable detection of AP, the best measures of the lesions and the disclosure of the different features of the disease. Dental panoramic tomography (DPT) is a classic exam, considered still useful to provide the basic diagnosis of AP in certain districts of the maxillary bones. Periapical radiographs (PRs) represent a valid routine examination, with few, known limitations. Cone-beam computed tomography (CBCT) is the only system that ensures the early and predictable detection of all periapical lesions in the jaws, with the minor risk of false positives. These techniques can be successfully implemented, with ultrasounds (USI) or magnetic resonance (MRI) imaging, exams that do not use ionising radiations. MRI and USI provide information on specific features of the lesions, like the presence and amount of vascular supply, their content and their relationship with the surrounding soft tissues, leading to differential diagnoses. Further, all the three-dimensional systems (CBCT, USI and MRI) allow the volumetric assessment of AP. Pioneering research on artificial intelligence is slowly progressing in the detection of periapical radiolucencies on DPTs, PRs and CBCTs, however, with promising results. Finally, it is established that all imaging techniques have to be associated with a thorough clinical examination and a good degree of calibration of the operator.

Quality of techniques used to assess clinical outcomes of regenerative endodontic treatment in necrotic mature teeth

Data sources A preliminary, randomised, prospective, controlled clinical trial of patients managed with two regenerative endodontic procedures, revitalisation and a platelet-rich fibrin (PRF)-based technique, in the treatment of mature permanent teeth with necrotic pulps.Study selection Twenty patients with mature necrotic anterior teeth with large periapical lesions treated with the blood clot and a PRF-based techniques for revitalisation. Periradicular healing and pulp sensibility was assessed at 6 and 12 months after treatment.Results Significant periradicular radiographic healing and sensibility was reported at 6 and 12 months.

Evaluation of relationship between odontogenic infections and maxillary sinus changes: A Cone Beam Computed Tomography-based study

Introduction

Odontogenic infections affects the maxillary sinus mucosa. Cone Beam Computed Tomography (CBCT) is helpful in diagnosis of maxillary sinusitis of odontogenic origin. This cross-sectional study was planned with the aim to assess maxillary sinus changes associated with odontogenic infection by evaluating CBCT images.

Material and methods

In cross-sectional analytical study, total 213 patients (404 sinuses) were evaluated on CBCT after thorough clinical examination of the individuals and taking into consideration the history of rhino or allergic rhinitis. Based upon CBCT images and clinical examination, patients were divided into, study group (odontogenic infection) and control group (no associated odontogenic infection). Effect of the size of periapical lesion, spatial relationship of lesion to the sinus floor and periodontal bone loss on maxillary sinus changes were evaluated.

Results

Mucosal changes found in 200 sinuses (49.5%), mucosal thickening being the most prevalent and more commonly associated with odontogenic infections (p = 0.004). A significantly increased risk of mucosal thickening was observed with severe periodontal bone loss (p = 0.008). Size and spatial relationship of lesion to the maxillary sinus had no impact on the prevalence of mucosal thickening (p = 0.6, p = 0.4 respectively). Periodontal bone loss was 2.2 more likely to be associated with mucosal thickening than periapical or combined lesion.

Conclusions

Most prevalent sinus change was mucosal thickening. Periodontal bone loss was significantly associated with mucosal thickening. CBCT is an appropriate method for sinus evaluation.

Automatic Detection of Periapical Osteolytic Lesions on CBCT Using Deep CNNs

INTRODUCTION

Cone beam computed tomography (CBCT) is an essential diagnostic tool in oral radiology. Radiolucent periapical lesions (PALs) represent the most frequent jaw lesions. However, the description, interpretation, and documentation of radiological findings, especially incidental findings, are time-consuming and resource-intensive, requiring a high degree of expertise. To improve quality, dentists may use artificial intelligence in the form of deep learning tools. This study was conducted to develop and validate a deep convolutional neuronal network for the automated detection of osteolytic PALs in CBCT datasets.

METHODS

CBCT datasets from routine clinical operations (maxilla, mandible, or both) performed from January to October 2020 were retrospectively screened and selected. A two-step approach was used for automatic PAL detection. First, tooth localization and identification were performed using the SpatialConfiguration-Net based on heatmap regression. Second, binary segmentation of lesions was performed using a modified U-Net architecture. A total of 144 CBCT images were used to train and test the networks. The method was evaluated using the four-fold cross-validation technique.

RESULTS

The success detection rate of the tooth localization network ranged between 72.6% and 97.3%, whereas the sensitivity and specificity values of lesion detection were 97.1% and 88.0%, respectively.

CONCLUSIONS

Although PALs showed variations in appearance, size, and shape in the CBCT dataset, and a high imbalance existed between teeth with and without PALs, the proposed fully automated method provided excellent results compared with related literature.

A perspective on the diagnosis of cracked tooth: imaging modalities evolve to AI-based analysis

Despite numerous clinical trials and pre-clinical developments, the diagnosis of cracked tooth, especially in the early stages, remains a challenge. Cracked tooth syndrome is often accompanied by dramatic painful responses from occlusion and temperature stimulation, which has become one of the leading causes for tooth loss in adults. Current clinical diagnostical approaches for cracked tooth have been widely investigated based on X-rays, optical light, ultrasound wave, etc. Advances in artificial intelligence (AI) development have unlocked the possibility of detecting the crack in a more intellectual and automotive way. This may lead to the possibility of further enhancement of the diagnostic accuracy for cracked tooth disease. In this review, various medical imaging technologies for diagnosing cracked tooth are overviewed. In particular, the imaging modality, effect and the advantages of each diagnostic technique are discussed. What's more, AI-based crack detection and classification methods, especially the convolutional neural network (CNN)-based algorithms, including image classification (AlexNet), object detection (YOLO, Faster-RCNN), semantic segmentation (U-Net, Segnet) are comprehensively reviewed. Finally, the future perspectives and challenges in the diagnosis of the cracked tooth are lighted.

Prevalence of dens invaginatus and its association with periapical lesions in a Western Indian population-a study using cone-beam computed tomography

OBJECTIVES

This study aimed to assess the prevalence of dens invaginatus (DI) and its association with periapical lesions (PLs) in a Western Indian population by means of cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

CBCT volumes of 5201 subjects were evaluated. Associations among gender, tooth type, DI type (Oehler's classification), and presence of PL were investigated. PL was codified using Estrela's Cone Beam Computed Tomography Periapical Index (CBCTPAI). Chi-square tests and descriptive statistics were used at p = 0.05.

RESULTS

Overall, 7048 CBCTs were assessed, containing 19,798 maxillary and mandibular anteriors, of which 77 maxillary teeth demonstrated DI (0.39% of all anteriors). Of all 5201 subjects, 57 had DI (1.1%). Bilateral DI was more common in females than in males (p = 0.046). DI type distribution was as follows: type I (22.1%), type II (61.03%), type IIIa (10.4%), and type IIIb (6.5%), which was significantly different (p < 0.001). Maxillary lateral incisors were the most associated with PL (p < 0.001). Type I was frequently associated with CBCTPAI scores 1 and 2 (absence of PL), whereas types II, IIIa, and IIIb were associated with CBCTPAI scores 3, 4, and 5 (presence of PL).

CONCLUSIONS

A prevalence of 1.1% identifies DI as a common developmental tooth anomaly in a Western Indian subpopulation. The percentage of maxillary anteriors affected by DI and associated PLs should be considered before diagnosis and treatment planning.

CLINICAL RELEVANCE

Knowledge about the prevalence of DI and its subtypes, and their association with/without periapical pathosis may aid clinicians in treatment planning and execution to improve patient outcomes.

Is the quality of root canal filling obtained by cone-beam computed tomography associated with periapical lesions? A systematic review and meta-analysis

AIM

To evaluate the influence of root canal filling quality on periapical lesion status using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

The bibliographic search was conducted in electronic databases of PubMed, Embase, Scopus, and Web of Science without restrictions related to the year of publication and language. Inclusion criteria were prospective or retrospective cohort studies that followed periapical pathosis for, at least, 1 year. Three reviewers independently evaluated the eligibility for inclusion, extracted data, and assessed the risk of bias. The quality of the studies was based on the Newcastle-Ottawa Scale. This meta-analysis was performed to evaluate the quality of treatment by the homogeneity and apical extension of the filling.

RESULTS

Of the 1179 studies initially recovered, six cohort studies were included, out of which four were considered with a low risk of bias. The results showed that the absence of gaps in the filling reduced the chance of unhealed periapical lesions by 2.39 times (RR = 2.39; 95% CI: 1.62-3.53; p < 0.00001; I² = 55%). An apical filling extension of 0-2 mm below the apex also contributed significantly to the absence of unhealed periapical lesions (RR = 1.49; 95% CI: 1.15-1.94; p = 0.003; I² = 2%).

CONCLUSION

The homogeneity and apical extension of the filling influenced the presence of unhealed periapical lesions in endodontically treated teeth evaluated using CBCT.

CLINICAL RELEVANCE

Apical extension of the filling ranging between 0 and 2 mm short of the apical foramen and the homogeneity of the filling without gaps are directly related to the success rate of root canal treatment.

Present status and future directions of intracanal medicaments

Two fundamental goals of endodontic treatment are to prevent or treat apical periodontitis. From a predictive perspective, several variables can affect the outcome of root canal treatment. Some of these variables depend on intraoperative factors, which include irrigation technique, size of the apical preparation, use of intracanal medicaments or the number of appointments necessary to complete the treatment. However, the outcome may also be affected by host and microbial factors. The intensity of periradicular bone loss or tissue damage, the presence of preoperative pain and associated conditions such as mechanical allodynia and central sensitization, the anatomical complexity of the apical portion of the canal, and the virulence and longevity of the bacterial infection can all have a profound influence on the outcome. Furthermore, numerous medical conditions have been reported to decrease the capability of the immune system to heal the periapical tissues. It is the clinician's responsibility to analyse these variables and incorporate them into the disinfection strategy to maximize the chances of healing. This narrative review will focus on the present status of intracanal medicaments, the clinical indications for their use and future directions for research.

Clinical characteristics of odontogenic sinusitis with periapical lesions

INTRODUCTION

Although the symptoms and radiographic signs may mimic rhinogenic sinusitis, odontogenic sinusitis (OS) with periapical lesions (PALs) is fundamentally an endodontic infection. It is considered to be one of the main causes of OS, especially when presented unilaterally. Despite this routine dental examination is not performed and periapical infection frequently remains undiagnosed by otolaryngologists and radiologists.

MATERIAL AND METHODS

This prospective observational study covered a group of 61 patients with symptomatic OS with PAL. Assessment of quality of life was done using the 22-item Sino-Nasal Outcome Test-22 (SNOT-22) and Oral Health-Impact Profile-14 (OHIP-14). Temporal and etiological relationship between the dental cause and sinonasal complication was established among the otolaryngologist and dental specialist based on the clinical symptoms, nasal endoscopy described according to the modified Lund-MacKay scale, computed tomography (CT) scans measured and scored in compliance with Lund- Kennedy, Zinreich and Estrela scales.

RESULTS

Out of 61 patients, 28 (46%) were women and 33 (54%) men. Group median age 49.1 years, ranged from 22.8 to 78.9 years. Total OHIP-14 score was 12.7 ± 11.3, with the highest value obtained in domains describing physical pain (mean 2.9 ± 2.4, median 3) in which the highest score was obtained in item 3 - painful aching in mouth and/or teeth - scored ≥2 by 52.5% of participants. Concerning dental symptoms 11.5% of patients were asymptomatic. Total SNOT-22 score was 40.7 ± 21.1, with the highest value in domains describing nasal symptoms. 23% of patients reported mild, 44.3% moderate and 32.7% severe symptoms. In the endoscopic evaluation 86.8% of cases presented discharge, 73.8% mucosal edema. In 11.5% of cases the polypoid tissues was observed in nasal cavities. The first molar tooth was the most frequently affected with an incidence of 42.6%, followed by the second molar (27.9%). In 33 (48.5%) of cases the inflammatory process caused the discontinuity of the sinus floor, which in 51.5% coexisted with total maxillary sinus opacification. 10 teeth (14.7%) had the periapical lesions with a diameter exceeding 8 mm. In case of the multi-rooted teeth, PALs were usually encountered at more than one root (57.4%). Maxillary and ethmoid sinus were affected in 54% of cases and additional frontal sinus involvement in 32.8%. In 69.6% patients, ostiomeatal complex was obstructed.

CONCLUSIONS

Persistent sinonasal symptoms such as rhinorrhea, post-nasal drip and nose congestion along with dental pain may suggest endodontic nature of OS, especially after previous root-canal treatment. The bigger the PAL is in diameter and the closer to the maxillary sinus, the greater effect on its mucosal involvement and obstruction of ostiomeatal complex is observed. PALs around molar or premolar tooth apexes with coexistence of unilateral sinus opacifications should be noticed and mentioned by radiologists and evaluated by dental specialists in order to refer the patient to further treatment.

Morphological Study of Root Canals of Maxillary Molars by Cone-Beam Computed Tomography

The aim of this study was to evaluate the root canal morphology of permanent maxillary molars by cone-beam computed tomography (CBCT) using the classifications of Weine et al. and Vertucci and to correlate the findings with sex, age, position in the dental arch, and prevalence of a second canal in the mesiobuccal root (MB2). A total of 414 scans were evaluated, corresponding to 1,000 teeth. The assessment consisted of coronal, axial, and sagittal reconstructions using i-CAT Workstation®. Type 0 was assigned when neither classification could be applied. The data were entered into an Excel spreadsheet and analyzed using SPSS. The chi-squared test or Fisher's exact test was used to compare the distribution of root canal morphology classified using the two systems. Analysis of the distribution of Weine types showed a predominance of type III in mesiobuccal roots, while type 0 predominated in distobuccal and palatal roots. Vertucci type IV predominated in mesiobuccal and distobuccal roots and type VII in palatal roots. There was no difference in the distribution of morphological canal types in permanent maxillary molars evaluated by CBCT according to sex, age group, or position in the dental arch of the patients. MB2 canals were identified in 68.4% of the teeth evaluated.

Method to Identify Accessory Root Canals using a New CBCT Software

This study describes a methodology to identify accessory root canals using the e-Vol DX software in CBCT scans. Accessory root canals are strategic shelters for microorganisms present in root canal infections. The identification of these small canals in periapical radiographic exams has limitations, besides being markedly limited accessibility to the action of endodontic instruments and to the antimicrobial agents. A significant number of accessory canals have sufficient diameters to be visible on cone-beam computed tomography (CBCT) images of high spatial resolution. Therefore, it may go unnoticed or even confused when there is no specific training for this type of diagnosis. The methodology consists in establishing thin slices (0.1mm or smaller) obtained from coronal, sagittal and axial slices. The method consists of the following steps: during navigation along the long axis of a root canal when finding a possible hypodense line of main root canal in a tomographic section (axial, sagittal or coronal), the navigation software lines of the multiplanar reconstruction (MPR) must be adjusted so that they are parallel and perpendicular to the hypodense line (parallax correction). Then, after judiciously adjusted, the accessory canal image will invariably appear as a line on one of the MPR tomographic slices, another line on another slice, and a dot on the third slice. The three sections of the MPR present images with the "line-line-dot" sequence. In this way, it is possible to identify an accessory root canal and also visualize it in volumetric reconstruction in a specific filter. The application of this method is easy to employed and may benefit the diagnosis when you want to visualize accessory root canals and distinguish it from root fracture line.

Comparative assessment of the efficacy of two-dimensional digital intraoral radiography to three-dimensional cone beam computed tomography in the diagnosis of periapical pathologies

Background:

Periapical intraoral radiographs are useful in assessing periapical pathologies; essential information often is not extracted owing to difficult interpretation and two-dimensional presentation of three-dimensional structures focusing on using cone beam CT (CBCT) and other advanced imaging modalities.

Aims:

The present study was conducted to comparatively assess the digital intraoral radiography to CBCT in the diagnosis of periapical pathologies.

Materials and Methods:

In 50 teeth, CBCT and digital imaging were compared in assessing periapical pathologies using CBCTPA and six-point scoring. The scores obtained were assessed and compared with statistical evaluation. The data were expressed in percentage and number and mean and standard deviation. The level of significance was kept at P < 0.05.

Results:

On comparing 3D CBCT and 2D digital imaging for assessing the study parameters, it was seen that resorption was seen in 33, 30, and 9 teeth, respectively, on 3, 2, and 1 rooted tooth on CBCT and 13, 16, and 7 teeth on digital radiography. The numbers of roots and root canals on CBCT were 45, 34, and 18 in 3, 2, and 1 rooted tooth and 50, 32, and 18 on digital imaging. Lesions were detected on CBCT in 16, 18, and 18 teeth on CBCT in 3, 2, and 1 rooted tooth, respectively, and in 14, 14, and 16 teeth on digital imaging. Comparing the five-point scale for lesions and CBPAI index for CBCT and digital imaging, the difference was statistically significant with P = 0.004 and <0.0001, respectively.

Conclusion:

The present study concludes that 3D CBCT is superior in accuracy to 2D imaging in diagnosing the periapical lesions, especially concerning multirooted teeth. Owing to its high radiation exposure and cost, 2D imaging can be incorporated in assessing periapical pathology for the single-rooted tooth.

Application of a Cone-Beam Computed Tomography-Based Index for Evaluating Surgical Sites Prior to Sinus Lift Procedures-A Pilot Study

OBJECTIVES

Radiography-based indices can help surgeons perform detailed examinations of the surgical site and predict the surgical difficulty of cases. We aimed to develop and validate a novel CBCT-based index that can predict the surgical difficulty of sinus-augmentation procedures.

MATERIALS AND METHODS

In the first stage, five experienced dental specialists performed a review of the literature and closed group discussions and designed the novel index. In the next stage, the index was validated. CBCT scans of 30 patients scheduled for sinus-augmentation procedures were evaluated and assigned presurgical CBCT evaluation scores (PSCESs) by five examiners. Subsequently, one oral surgeon performed sinus augmentation using the lateral antrostomy technique and assigned surgical difficulty scores (SDSs) to each of the 30 cases along with 2 observers. The PSCESs and SDSs were statistically analysed to determine the interrater reliability and validity of the index.

RESULTS

The interrater agreement of the PSCES among the five presurgical evaluators was 0.85. The PSCES of the five evaluators had highly significant correlation (P < 0.001, r = 0.68 to 0.76) with the SDS. Regression analysis revealed that for every unit increase in the PSCES, there is 0.46 to 0.57 increase in the SDS value.

CONCLUSION

The results of this pilot study revealed that a novel CBCT-based index can be used as a reliable tool for predicting the surgical difficulty of sinus-augmentation procedures. However, the novel index needs to be tested on a larger sample of patients and evaluators for a more concrete validity and reliability.

'Combined endo-perio lesions' - what is the best treatment?

Aims To assess the radiographic and periodontal healing of combined endo-perio lesions in anterior teeth treated with orthograde root canal treatment (RCT), with and without guided tissue regeneration (GTR) and bone grafting.Sample selection A total of 120 individuals attending the Dental University Hospital in Riyadh, Saudi Arabia, diagnosed with true combined endo-perio lesions were selected. Inclusion criteria included being between 25 and 55 years old and having a single-rooted non-vital maxillary anterior tooth with a true combined endo-perio lesion, assessed using a cone beam computed tomography (CBCT) scan. Exclusion criteria included uncontrolled systemic disease, a history of oral cancer or sepsis, recent use of antibiotics, the use of bone metabolism modifying drugs and the presence of fractures, resorption or associated pathological cysts. Power calculations were used to set a minimum sample size of 120 teeth.Design A randomised controlled trial involving four treatment arms: root canal treatment (RCT) with gutta percha (GP) obturation; RCT with mineral trioxide aggregate (MTA) obturation; RCT with GP obturation and guided tissue regeneration (GTR); and RCT with MTA obturation and GTR. Participants were randomly assigned using computer software to each treatment arm via block randomisation.Baseline periodontal measurements (gingival phenotype, keratinised tissue width, pocket depth and clinical attachment level) and a CBCT scan to obtain a CBCT periapical index (CBCTPAI) score were taken at visit one. Visit two involved scaling, root planing and a RCT performed using hand files and a thermoplastic obturation technique for the GP obturation arm (Obtura II, Obtura Spartan, USA) and vertical compaction for the MTA obturation arm (ProRoot White, Dentsply, USA). Visit three (for the GTR and bone-grafting arms), one week later, included regenerative periodontal surgery - raising a three-sided buccal flap, removal of granulation tissue, filling the defect with demineralised, freeze-dried bone allograft, coverage with a resorbable collagen membrane and closure with resorbable sutures. Visit two was performed by a single endodontist and visit three, for the GTR and bone grafting arms, was performed by a single periodontist. Previous or future planned treatment was concealed to operators and they were only informed of the treatment to be performed on the day. All teeth received definitive restorations.The follow-up schedule was one, three, six and twelve months post-treatment. CBCT scans were repeated at six and twelve months; clinical periodontal measurements were repeated at three, six and twelve months.Data analysis Descriptive analysis was performed and results were presented as cross-tabulations and a bar chart. Inferential statistics were used; one-way analysis of variance with Tukey's multiple comparison test to compare the mean value of measurements between treatment arms at follow-up visits and Kruskal-Wallis test to compare mean CBCTPAI scores between arms at follow-up visits. The p-value was set at ≤0.05.Results Baseline comparison showed no statistically significant differences between treatment arms. No participants were lost to follow up. At 12 months, GTR showed improved healing, with 98% of cases showing CBCTPAI scores better than 1, compared to 100% cases scoring 1 + D or worse without GTR. Statistically significant differences were found between treatment arms with respect to CBCTPAI score and pocket depth at 12 months.Conclusions GTR may improve radiographically-assessed healing of combined endo-perio lesions. MTA obturation may play a role in the management of combined endo-perio lesions. Study limitations do not allow for more definitive conclusions.