Diagnostic Accuracy of 5 Dental Pulp Tests: A Systematic Review and Meta-analysis

Full pulpotomy versus root canal therapy in mature teeth with irreversible pulpitis: a randomized controlled trial

BACKGROUND

Vital pulp therapy (VPT) is recommended as an alternative treatment to root canal therapy (RCT) for management of teeth with carious pulp exposure. This randomized clinical trial aimed to compare the outcomes and postoperative pain, and to evaluate the time and cost after full pulpotomy (FP) and RCT in mature molar teeth with irreversible pulpitis (IP).

METHODS

A total of 160 mature molar teeth with IP were randomly divided into two treatment groups. The FP group (test group) was treated with FP using iRoot BP Plus by an endodontist, the RCT group (control group) was treated with RCT using iRoot SP as sealer by the same endodontist. Pain was recorded preoperatively and daily until day 7 postoperatively. The treatment time and cost were recorded. Clinical and radiographic assessments were collected, and pulp sensibility tests were done by electric pulp test (EPT) at 3-, 6-, 12- month postoperatively. Data were analyzed through chi-square test, Mann-Whitney U test, Fisher exact and independent t test.

RESULTS

FP and RCT had comparable success rates (Clinical, 97.3% vs. 98.6%; radiographic, 93.3% vs. 94.6%) (P > 0.05). Pain levels decreased over time from day 1 to day 7 postoperative in both groups, and the FP group had larger reductions in pain intensity than RCT at day 1 (P < 0.05). In the FP group, there were 5, 3 and 3 unresponsive teeth with EPT at 3-, 6- and 12- month follow-ups, respectively. The treatment time and cost in the FP group were significantly lower than in the RCT group (P < 0.05).

CONCLUSIONS

FP could be an appropriate alternative treatment for management of mature teeth with IP in short follow-up.

TRIAL REGISTRATION

The trial was registered in Chinese Clinical Trial Registry (ChiCTR2200063380 at 05/09/2022).

The Effect of Larger Orthodontic Forces and Movement Types over a Dental Pulp and Neuro-Vascular Bundle of Lower Premolars in Intact Periodontium-A Numerical Analysis

BACKGROUND/OBJECTIVES

This numerical analysis of stress distribution in the dental pulp and neuro-vascular bundle (NVB) of lower premolars assessed the ischemic and degenerative-resorptive risks generated by 2 and 4 N during orthodontic movements (rotation, translation, tipping, intrusion and extrusion) in intact periodontium.

METHODS

The numerical analysis was performed on nine intact periodontium 3D models of the second lower premolar of nine patients totaling 90 simulations.

RESULTS

In intact periodontium, both forces displayed a similar stress distribution for all five orthodontic movements but different amounts of stress (a doubling for 4 N when compared with 2 N), with the highest values displayed in NVB. In intact periodontium, 2 N and 4 N induced stresses lower than the maximum hydrostatic pressure (MHP) with no ischemic risks for healthy intact teeth. The rotation was seen as the most stressful movement, closely followed by intrusion and extrusion. Translation was quantitatively seen as the least stressful when compared with other movements.

CONCLUSIONS

Larger orthodontic forces of 2 N and 4 N are safe (with any expected ischemic or resorptive risks) for the dental pulp and NVB of healthy intact teeth and in intact periodontium. Nevertheless, rotation and translation movements can induce localized circulatory disturbances in coronal pulp (i.e., vestibular and proximal sides) generating ischemic and resorptive risks on previously treated teeth (i.e., direct and indirect dental pulp capping). The intrusion and extrusion movements, due to the higher NVB-induced deformation when compared with the other three movements, could trigger circulatory disturbances followed by ischemia on previously traumatized teeth (i.e., occlusal trauma).

Pulp Vitality Diagnosis by Means of an Optical Pulp Scanning Device

This study aimed to evaluate the diagnostic accuracy of an Optical Pulp Scanning (OPS) device. A total of 421 teeth from 107 emergency patients were investigated. Pulp vitality was assessed using conventional diagnostic methods (ConvDia), cold pulp testing (CPT), and a final diagnosis (FinDia) based on the pulp chamber contents (PCCs) of teeth requiring endodontic treatment (EmeTe). Following ConvDia, OPS screening was performed, endodontic access was prepared, and the FinDia was established. The specificity, sensitivity, as well as positive and negative predictive values of ConvDia, CPT, and FinDia were calculated against the OPS results. The null hypothesis stated that specificity and sensitivity would be equal to or lower than 90% and 80%, respectively. OPS sensitivity was 66.2% and 72.2% (EmeTe) for ConvDia, 66.2% and 69.8% (EmeTe) for CPT, and 76.9% for FinDia. Specificity was 26.4% and 25.5% (EmeTe) for ConvDia, 26.9% and 21.7% (EmeTe) for CPT, and 31.5% for FinDia. These results suggest that, at its current stage of development, the OPS device does not provide an acceptable level of diagnostic accuracy, particularly in vital teeth.

Pulp Sensitivity Testing in Multiple Sclerosis: Disease Duration and Sensory/Motor Associations-A Cross-Sectional Study

Introduction: This study explores a relatively unexplored aspect of multiple sclerosis (MS) by examining the sensitivity threshold of dental pulp as a potential indicator of neuropathy in MS patients. Building upon earlier research that focused on assessing the response to electrical pulp testing in MS patients who did not have a history of trigeminal neuralgia, this survey is aimed at delving into the relationship between MS duration and the threshold for stimulation in response to pulp sensitivity tests. Materials and Methods: This study encompassed a total of 124 maxillary central incisors from patients diagnosed with relapsing-remitting multiple sclerosis (RRMS). The participants were uniform in terms of age, falling within the 18-50 years range, and all had RRMS with no history of trigeminal neuralgia. The electric pulp sensitivity test was conducted on all samples, and the results of the electric pulp testing (EPT) were recorded according to the grade of the pulp tester that elicited a response. The threshold was considered reached when the patient first experienced a burning sensation after EPT application and the use of 1,1,1,2-tetrafluoroethane spray. Data analysis employed paired t-tests, Fisher's exact test, and Spearman correlation, with a significance level set at p < 0.05. Results: Based on the study's findings, the average response value to EPT was 2.69 ± 1.17, while the response time to the cold test was 2.61 ± 1.03 s. There was no statistically significant difference in the response to the cold test based on age (p = 0.45). However, it was observed that the mean response time to the cold test was significantly longer among male participants (p = 0.001). No significant differences were identified in the pulpal response to EPT or the cold test between patients with and without sensory-motor involvement (p > 0.05). Furthermore, Spearman's analysis revealed a noteworthy positive correlation between the electrical pulp threshold and the time taken to respond to the cold test (p = 0.025, r = 0.2). Conclusions: The utilization of the pulpal sensitivity test in MS patients holds promise for practical clinical use. Notably, individuals with a more extended duration of the disease exhibited a notably elevated threshold for both the EPT and the cold test conducted on their maxillary central incisors.

Evaluation of pulpal blood flow during orthodontic space closure: Prospective clinical trial

INTRODUCTION

Orthodontic tooth movement (OTM) is a biological process that can affect the vascularization of the dental pulp. The forces exerted on the teeth may increase periapical pressure that could compress the arterioles, which in turn affects pulpal blood flow (PBF). The study aimed to investigate how OTM affects PBF during orthodontic space closure.

METHODS

A total of 22 adolescent participants who required orthodontic space closure in mandibular posterior sectors were enrolled in a prospective clinical study. The same sliding mechanics, wires, and active elements were used. Patients were observed before OTM, after leveling before space closure, and at the 4th, 7th, 21st, and 28th during active space closure. PBF was measured with laser Doppler (LD) flowmetry. Dental models were obtained with an intraoral scanner.

RESULTS

The LD flow values decreased significantly during the observation period (2-way repeated measures analysis of variance, P <0.001). There was a significant difference in LD flow between tooth categories (2-way repeated measures analysis of variance, P <0.001). During space closure, the most pronounced LD flow reduction was observed in single-rooted teeth closest to the residual space. A higher speed of OTM was associated with a greater decrease in LD flow on day 4 of OTM (Pearson correlation, P = 0.0299).

CONCLUSIONS

Orthodontic space closure reduced PBF; it was lowest in the early stages of space closure and showed a tendency to increase during the first month. Anterior teeth closer to the interdental space that experiences more OTM and teeth that move faster during initial OTM had a higher risk of reduced blood flow.

Accuracy of vitality and sensibility testing in mature and immature anterior teeth: a clinical trial

INTRODUCTION

Determining the health the status of the pulp is crucial in treatment planning. Both sensibility and vitality testing techniques may be employed. Sensibility testing may be inaccurate in teeth with incomplete root apices. This study intends to compare the accuracy of cold testing (CT), electric pulp testing (EPT) and pulse oximetry (PO) in determining pulpal status of mature and immature anterior teeth.

METHODS

20 mature and 20 immature maxillary permanent incisors of healthy 6-12-year-olds were included. Teeth were categorised as mature permanent central incisors, immature permanent central incisors, and a negative control group with endodontically treated incisors. Vitality and sensitivity tests were performed using EPT, CT, and PO, with measurements taken thrice per tooth. PO was measured with infant pulse oximetry probe sensors placed on the tooth surfaces and fingers. Descriptive statistics were computed, and data distribution was assessed using the Shapiro-Wilk test. The Spearman correlation coefficient analysed correlations between dental and finger SpO2 measurements, while the Kruskal-Wallis test with Dunn post-hoc analysis compared SpO2 and EPT measurements across tooth development stages, with a significance threshold set at p < 0.05.

RESULTS

SpO2 values were significantly higher in immature teeth compared to mature teeth (p < 0.05), and both were significantly higher than in the negative control group. There was no significant correlation between SpO2 values measured from fingers and teeth. EPT values were significantly higher in immature teeth compared to mature teeth (p < 0.001). The accuracy rate of PO, EPT, and cold tests was 100% in this study, with no false positive or negative responses in the control group. The SpO2 values in mature and immature vital teeth ranged between 80-92%.

CONCLUSIONS

PO is a reliable and non-invasive method for determining pulp vitality in both mature and immature teeth, comparable to traditional sensitivity tests like EPT and CT. PO can be considered an alternative vitality test, especially useful in paediatric dental patients due to its atraumatic and objective nature. Further studies with larger sample sizes and additional vitality tests like doppler flowmetry are recommended to enhance the clinical diagnosis of pulp vitality in anterior and posterior teeth.

Application of Oxygen Saturation Test after Replantation of Avulsed Immature Permanent Teeth: A Prospective Observational Study

INTRODUCTION

The evaluation of pulp status is crucial for avulsed immature permanent teeth after replantation. In addition to commonly used clinical and radiographic examinations providing clinical evidence, the oxygen saturation test may offer valuable assistance. The aim of this study was to analyze the efficacy of a pulse oximeter in evaluating pulp status in avulsed and replanted immature permanent teeth.

METHODS

A prospective observational study was performed including 51 avulsed and replanted immature permanent teeth. Routine clinical and radiographic examinations were performed and used as the basis for the diagnosis of pulp status during the 1-year follow-up period. Meanwhile, the oxygen saturation values of these teeth were recorded using a modified pulse oximeter at each visit.

RESULTS

Seven teeth completed pulp revascularization (success group), whereas 44 teeth failed to revascularize (failure group). Abnormal clinical and/or radiographic manifestations in the failure group were observed at an average period of 42.7 days, which was too late because a high incidence of inflammatory root resorption (43.18%) had occurred. For oxygen saturation tests, teeth in the success group showed an immediate postreplantation oxygen value of 70.71 ± 3.35, then an upward trend starting from the 2-week postreplantation visit, and a significantly increased final value of 81.86 ± 2.34 at the 1-year visit. In contrast, no increase trend was found for teeth in the failure group because abnormal clinical and/or radiographic manifestations emerged.

CONCLUSIONS

The oxygen saturation test is a reliable diagnostic method to evaluate pulp status of avulsed teeth as early as 2 weeks after replantation.

Revolutionizing the diagnosis of irreversible pulpitis - Current strategies and future directions

BACKGROUND

Pulpitis primarily arises from the pulp space infection by oral microbiota. Vital pulp therapy is a minimally invasive approach that relies on assessing the severity of pulpal inflammation to facilitate repair. However, the current evaluation methods prescribed by the American Association of Endodontics are subjective, leading to ambiguity in assessment. Therefore, this review aims to explore molecular strategies for evaluating the severity of pulpal inflammation to accurately predict the success of pulp vitality preservation in clinical settings.

METHODOLOGY

This review was conducted by searching relevant keywords, such as irreversible pulpitis, pulpitis biomarkers, molecular diagnosis, inflammation, and genomic strategies, in databases such as PubMed, Web of Science, and Scopus to address the subjective nature of diagnosis. The data included in this review were collected up to April 2023. The literature search revealed well-documented limitations in clinically assessing the pulp inflammatory. Molecular approaches that aid in clinical differentiation between irreversible and reversible pulpitis may potentially enhance favorable outcomes in vital pulp therapy. Non-invasive diagnostic methods for pulpal assessment would also be valuable for determining whether the inflamed pulp is reversible, irreversible, or necrotic.

CONCLUSION

The present review examines the various molecular diagnostic approaches that have revolutionized the medical field and are considered the most promising empirical methodologies for the proactive detection of pulpal diseases. It also provides comprehensive insights into the current diagnostic methods, associated challenges, next-generation strategies, and future directions for diagnosing the severity of pulp inflammation.

The clinical outcomes of vital intact teeth close to large cystic lesions of endodontic origin: A prospective clinical study

AIM

To evaluate the indication of the endodontic treatment for vital intact teeth with the root apex involved in large radicular cystic lesions of endodontic origin.

METHODOLOGY

This prospective cohort study enrolled healthy participants with radicular cysts of endodontic origin and with the root apex of vital intact teeth involved in the bone defect, as determined by cone beam computed tomography (CBCT). Thirty-two sound vital teeth were analysed by thermal (TPT) and electric pulp tests (EPT) before surgery (T0) and 1 week (T1), 2 weeks (T2), 3 months (T3) and 6 months (T4) post-surgery. Student's t-test (p < .05) was used to compare the EPT values at baseline and T4. anova (p < .05) was used to analyse the EPT variations for all maxillary and mandibular teeth. McNemar test (p < .05) was used to compare the results according to variation in EPT values gathering by variation, no variation and no response.

RESULTS

At T1, 75 and 65.7% of teeth responded positively whilst 25 and 34.3% did not respond to EPT and TPT, respectively. The variation of the EPT values between T0 and T1 was observed for 50.0% of teeth, whilst no variation was noticed in 25.0% of teeth. At T4, 90.6 and 87.5% of teeth responded positively whilst 9.4 and 12.5% did not respond to EPT and TPT, respectively. At T4, variation of the EPT values between T0 and T4 was observed for 28.1%, whilst no variation was noticed in 62.5% of teeth. There were no statistical differences in EPT results between T0 and T4 (p > .05), but significant differences were observed for EPT values between T1 and T4 (p < .05), and between mandibular and maxillary teeth. The pulp sensibility of maxillary teeth worsened after surgery, before reverting progressively to T0 values, whilst no statistically significant differences were observed for mandibular teeth at the different time points.

CONCLUSIONS

These data support the inconsistence of the prophylactic endodontic treatment in healthy vital teeth with apex involvement in large cystic lesions of endodontic origin. Post-surgery follow-up with TPT and EPT is recommended to assess pulp status.

Correlation between pulp sensibility and magnetic resonance signal intensity following regenerative endodontic procedures in mature necrotic teeth- a retrospective cohort study

BACKGROUND

With increasing studies being published on regenerative endodontic procedures (REPs) as a treatment modality for mature necrotic teeth, the assessment of outcomes following regenerative endodontic procedures has become more challenging and the demand for a better understanding of the regenerated tissues following this treatment is rising. The study aimed to correlate cold, electric pulp testing (EPT), and magnetic resonance imaging (MRI) signal intensity (SI) in mature necrotic teeth treated with regenerative endodontic procedures.

METHODOLOGY

This retrospective cohort study included eighteen adult patients who experienced tooth necrosis in mature maxillary anterior teeth recruited from the outpatient clinic, Conservative Dentistry Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt from July 2017 until December 2018 with 12 months of follow-up. regenerative endodontic procedures via blood clot were performed. The canals were instrumented by ProTaper Next (PTN) files until final sizes X3 or X5. Biodentine was used as cervical plug material. Pre and post-operative clinical follow-up was done where the patients' responses to cold and electric pulp testing were given a scoring system and were compared to the normal contralateral tooth. Pre and post-operative magnetic resonance imaging signal intensity of both the involved tooth and its contralateral at the middle and the apical thirds of the root canals were assessed after 3, 6, and 12 months. Data was analyzed using the ANOVA, Friedman and Bonferroni tests. Significance was set at a p-value < 0.05.

RESULTS

All 18 teeth scored a baseline score of "2" for cold and electric pulp testing. There was a significant difference between scores of the cold test at baseline and 12-month follow-up (p < 0.001). There was a significant difference between scores of the electric pulp testing of baseline and 12-month follow-up (p < 0.001). There was a moderately significant indirect (inverse) correlation between magnetic resonance imaging signal intensity and cold test in both the middle and apical thirds at 12 months. No significant correlations were detected between magnetic resonance imaging signal intensity and electric pulp testingat any of the time intervals (p > 0.05).

CONCLUSION

Magnetic resonance imaging is a successful non-invasive method to assess outcomes of regenerative endodontic procedures and correlating it with another reliable method of assessing pulpal responses, cold test, could validate these outcomes.

CLINICAL TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov (ID: NCT03804450).

Expression of Selected Inflammatory Mediators with Different Clinical Characteristics of Pulpal Inflammation

INTRODUCTION

Accurately diagnosing the state of dental pulp is crucial when addressing tooth pain to determine the best treatment approach. This study aimed to investigate the concentration of inflammatory mediators in the dental pulp of mature teeth that have been exposed via caries but show no signs of apical periodontitis.

METHODS

Samples of pulpal blood from adults with mature teeth responsive to pulp testing and have carious pulp exposures were obtained. These samples were analyzed for 12 inflammatory cytokines and other inflammatory proteins using the Luminex assay platform. Clinical factors were correlated with cytokine levels, and statistical analysis was performed to evaluate the impact of these factors on cytokine expression.

RESULTS

Of the 36 patients that were included, 44.44% took pain medications, 33.33% had prolonged pulpal bleeding, 41.67% felt spontaneous pain, and 72.22% were diagnosed with symptomatic irreversible pulpitis. Significant correlations existed between presenting pain scores and levels of interleukin (IL)-1α, IL-6, and IL-8 (P < .05). Factors like analgesic medication intake, pain to percussion, pain to thermal testing, spontaneous pain, and nocturnal pain were significantly associated with higher levels of specific inflammatory proteins. No significant associations were observed with pain to palpation, bleeding time, or pulpal diagnosis.

CONCLUSIONS

Inflammatory proteins, including cytokine levels may play a critical role in characterizing pulpal inflammation. Future studies should investigate the role of these potential biomarkers in determining the diagnosis of pulpitis and the prognosis of vital pulp therapy.

Pulse oximetry as a dental pulp test: A scoping review to identify barriers hindering the use of oximeters in clinical practice

Background and Objective

Although medical pulse oximeters are considered effective for endodontic diagnoses, the method remains uncommon in current dental practice. The aim of the present scoping review was to investigate clinical factors that exert a negative impact on the use of pulse oximeters in dental practice.

Methods

This study followed the PRISMA-ScR guidelines and the protocol was prospectively registered in the Open Science Framework (https://doi.org/10.17605/OSF.IO/3GQCE). A comprehensive search of the MEDLINE (via PubMed), Cochrane Library, and Web of Science databases was performed in December 2022 for articles published in English or Spanish. All types of clinical studies were included, except comments, letters to the editor, and abstracts. Two independent investigators analyzed 45 full-text articles. Data extraction included general characteristics, oxygen saturation levels, and limiting factors/barriers to the use of oximeters as pulp testers.

Results

The search of the databases yielded 1,300 records and 38 were included (quantitative data extraction was performed for 35 and three articles were systematic reviews). Publications were highest in number between 2016 and 2017, with an evident reduction occurring after 2021. The oxygen saturation level for sound/vital maxillary anterior teeth was 84.99% (overall mean). The main limiting factors/barriers were i) the difficulty in maintaining the two light-emitting diodes parallel during pulp tests, ii) infrared light diffraction by enamel/dentin/gingiva, and iii) the diversity of patient ages in studies.

Conclusion

This scoping review encountered noteworthy findings associated with the impracticability of using medical pulse oximeters as dental pulp testers. The recent decrease in the frequency of published studies compared to approximately seven years ago may imply a negative trend in the use of the method.

Retrospective Evaluation of Periradicular Biopsies: An 18-Year Study

INTRODUCTION

Radiographic findings in periradicular areas are repeatedly associated with infected root canal systems. Although non-odontogenic lesions in teeth are reported to be low, they often mimic periapical pathoses, and consequently, histopathologic examinations after surgical revisions are nurtured.

METHODS

Biopsies submitted to the College of Dentistry between 2003 and 2021 were reviewed. Clinicopathologic characteristics were collected, including age, sex, medical history, location, sensibility tests, and clinic impressions from each specimen. Histopathologic diagnosis and gross description were also part of our database.

RESULTS

A total of 72,055 pathology reports were reviewed, of which 10,031 lesions (13.9%) met the criterion of being intraosseous lesions at the periradicular area. Among those 10,031 lesions, 7.94% (n = 796) were of non-endodontic origin, 7153 were documented as non-vital, and 2.36% (n = 169) of these non-vital teeth were diagnosed with a non-endodontic origin. A total of 5707 lesions were obtained from surgeries within the periapical tissues, primarily performed by endodontists (94.02%). Non-endodontic lesions were reported in 1.09% of the cases. Odontogenic keratocyst was the most common non-endodontic diagnosis, followed by nasopalatine duct cyst and benign fibro-osseous lesion, respectively.

CONCLUSIONS

Pathologic findings of the periradicular tissues are not always from endodontic origin. The probability of encountering non-endodontic lesions is almost 8%. Even in clinically reported teeth with pulp necrosis, 1%-3% of biopsies were confirmed as non-endodontic lesions.

Evaluation of oxidative stress cycle in healthy and inflamed dental pulp tissue: a laboratory investigation

OBJECTIVES

The purpose of this study was to investigate the oxidative stress cycle consisting of reactive oxygen molecules (ROS), glutathione (GSH) and glutathione S-transferase (GST) in caries-related pulp inflammation.

METHODOLOGY

Fifty-four pulp tissue samples were collected from healthy donors with the diagnosis of reversible pulpitis, symptomatic irreversible pulpitis, and healthy pulp. Twelve pulp samples from each group were homogenized and total protein, ROS, GSH, and GST were measured by spectrophotometer. The remaining 6 samples from each group were prepared for paraffin block and used for the histopathologic and immunohistochemical evaluation of oxidative stress parameters and TUNEL labeling. Data were analyzed statistically.

RESULTS

The results revealed that total protein levels significantly decreased; however, ROS levels increased in both reversible and irreversible pulpitis compared to the healthy pulp (p < 0.01). Also, as inflammation increases, GST enzyme levels decrease while GSH levels increase significantly (p < 0.05). It was found that the number of TUNEL (+) cells was increased in irreversible pulpitis samples compared to healthy and reversible pulpitis groups (p < 0.05). GSTP1 and GSH immunoreactivity were also observed in irreversible pulpitis samples.

CONCLUSIONS

It has been revealed that caries-related inflammation alters the oxidative stress cycle in dental pulp tissue. The increase in GSH levels in the inflamed dental pulp due to the increase in ROS levels may improve the defensive ability of the dental pulp.

CLINICAL RELEVANCE

There is a relationship between oxidative stress and inflammation. Control of excessive oxidative stress in pulpitis can stimulate reparative and regenerative processes. The present findings may provide an overview of the management of oxidative stress in cases with pulpitis during regenerative treatments.

Transient apical breakdown of a discoloured maxillary central incisor during orthodontic treatment: A case report

Transient apical breakdown (TAB) appears to be a repair process taking place in the pulp and periapical area of traumatised teeth which may display crown discoloration and have no responses to pulp sensitivity tests. Few TAB cases induced by orthodontic forces have been reported so far. Presented is a case report in which TAB occurred on the maxillary right central incisor during orthodontic treatment. The affected tooth suddenly displayed crown discoloration and had no response to pulp testing at 6 weeks after the placement Invisalign Clear Aligner appliances. Condition of the discoloured tooth was monitored by periodic recall examinations without any active treatment. Six months after the occurrence of discoloration, the affected tooth recovered to its original shade and responded normally to pulp sensitivity tests.

Do orthodontic movements of traumatized teeth induce dental pulp necrosis? A systematic review

INTRODUCTION

Usually, orthodontic movements encompass children and young adult patients, which are more susceptible to the occurrence of traumatic dental injuries. It is necessary to understand whether the effects of orthodontic movements on traumatized teeth could induce pulp necrosis. The aim of this study was to answer the following question: "Do orthodontic movements of traumatized teeth induce dental pulp necrosis?".

MATERIAL AND METHODS

Searches were performed for studies published up to May 11, 2023, in the MEDLINE/PubMed, Cochrane Library, Scopus, SciELO Citation Index, Web of Science, EMBASE, and Grey Literature Report databases, without restriction for language or year of publication. The revised Cochrane risk of bias tools for nonrandomized interventions (ROBINS-I) was used to assess the quality of the included studies. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Of 2671 potentially relevant studies, five were included. Four were classified as having a moderate risk of bias and one as a serious risk of bias. It was reported a higher susceptibility to pulp necrosis in teeth subjected to orthodontic movements with history of trauma involving periodontal tissues. Additionally, orthodontic movements of traumatized teeth with total pulp obliteration had an increased risk of pulp necrosis. GRADE analysis presented a moderate certainty of evidence.

CONCLUSIONS

An increased risk for pulp necrosis when traumatized teeth are subjected to orthodontic movements was verified. However, this is based on evaluations performed with subjective tests. Further well-designed studies are necessary to confirm this trend.

CLINICAL RELEVANCE

Clinicians must be aware of the possibility of pulp necrosis. However, endodontic treatment is recommended when verified signs and symptoms of pulp necrosis.

The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis-A Systematic Review

Diagnosis is a key aspect in endodontic treatment, in a decade where invasive interventions are misapprehended as social tendency instead of medical necessity. All diagnostic facets should be considered before intending the operative phase. Intraoral endodontic radiology-based diagnosis has been shown to be limited. Periapical X-ray is the most used endodontic imaging, yet it does not provide high accuracy. Traditionally, dentists have been trained to diagnose a cyst by certain aspects (size, shape and appearance); hence, an assumption that teeth are affected by "periapical cyst" were subjected to unnecessary extraction or apicoectomy. The aim of this systematic review is to critically appraise the publications that relate the histological diagnosis of a periapical lesion (considered the gold standard) to intraoral X-ray investigation. Ovid Medline, PubMed, ScienceDirect, Mendeley and Scopus were searched for English-language studies comparing periapical diagnosis obtained by using two techniques (histopathology and X-ray). Sixteen articles were included for the final analysis (qualitative and quantitative evaluation) out of which only two supported the statement that periapical diagnosis can be coherently assessed through periapical imaging. Although there is not enough evidence to deliver a definitive conclusion, there are many publications that refute the diagnosis of a cyst via periapical X-ray.

"Comparative Evaluation of Three Different Microabrasion Techniques in Esthetic Management of Fluorosis": An In Vivo Study

Aim

"Comparative evaluation of three different microabrasion techniques in esthetic management of fluorosis"-an in vivo study.

Materials and methods

A total of 48 permanent incisors in children between the age-groups of 8-12 years with Dean's fluorosis index modified criteria 1, 2, and 3 were included. The patients were randomly divided into three groups; each group included 16 samples. Group I-phosphoric acid and pumice microabrasion (37% phosphoric acid and pumice as abrasive), group II-opalustre microabrasion [6.6% hydrochloric (HCL) acid and silicon dicarbide (SiC2)], and group III-icon etch microabrasion (15% HCL acid gel as icon etch, pumice, and resin infiltrate). Preoperative sensitivity and pulp vitality of each tooth were evaluated. Standardized preoperative photographs were captured for the evaluation of color parameters L1, a1, and b1 by Adobe Photoshop 7 software and an assessment of color enhancement was carried out. Preoperative surface roughness was evaluated with two methods like, cellulose acetate replicating tape and confocal microscope, and Epoxy resin replica obtained from the preoperative impression of teeth using additional silicone and contact profilometer. Microabrasion was done accordingly. Postoperative values of all the parameters were evaluated.

Results

Phosphoric acid and pumice showed the best color change, followed by icon etch resin infiltrate. Opalustre (6.6% HCL acid and SiC2) and was unsuccessful as it had less concentration and was more abrasive.

Conclusion

Phosphoric acid and pumice showed the best color enhancement, followed by icon etch resin infiltrate and opalustre. Icon etch resin infiltrate showed minimal surface roughness followed by phosphoric acid and pumice and opaluster group.

How to cite this article

Reddy VN, Nagar P, Lakhotia R, et al. "Comparative Evaluation of Three Different Microabrasion Techniques in Esthetic Management of Fluorosis": An In Vivo Study. Int J Clin Pediatr Dent 2023;16(4):572-581.

Clinical outcomes of teeth adjacent to the site of mandibulotomy or mandibulectomy in patients with head and neck cancer: results from a multidisciplinary mono-institutional head and neck tumor board

INTRODUCTION

The aim of this case series was to evaluate the necrosis of teeth adjacent to the site of mandibulotomy or mandibulectomy in a cohort of patients suffering from head and neck cancers.

METHODS

Fourteen patients who underwent segmental mandibulectomy or paramedian mandibulotomy for oral, oropharynx or major salivary gland cancer and a total of 23 teeth were included in this case series. Twelve patients underwent adjuvant head and neck radiotherapy. Cold sensitivity pulp testing and/or electric pulp testing were performed on teeth at the margin of mandibulectomy and on teeth adjacent to mandibulotomy after surgery. A "positive" response was considered the healthy state, and "negative" was considered the diseased state of the tooth.

RESULTS

The 10 patients who underwent mandibulotomy had 12 teeth with a negative response. The 4 patients treated by mandibulectomy had two positive and three negative responses to cold and electric pulp tests. Fifteen out of 23 teeth (65.2%) showed a negative response to sensitivity testing.

CONCLUSIONS

Tooth necrosis seems to be a common event after mandibulectomy and mandibulotomy.

CLINICAL RELEVANCE

To avoid post-surgery complications, performing root canal therapy before surgery on the teeth adjacent to the surgical site could be an appropriate strategy.

The importance of establishing a core outcome set for endodontic clinical trials and outcomes studies

Endodontic therapy aims to preserve teeth by preventing and treating apical disease, therefore, evaluation of treatment outcome in clinical trials and outcomes studies should effectively assess if it achieves these aims. Traditionally, treatment outcomes have been reported by clinicians after history and clinical examination in what is known as clinician-reported outcomes (CROs). Much less commonly employed however, are patient-reported outcomes (PROs) in which patients directly report on their condition. Endodontic treatment outcome reporting is evolving from a focus on CROs to increasing consideration for patient and disease-focused outcomes, with different criteria being proposed for assessment of treatment outcomes. Unfortunately, this has led to considerable variability and a lack of consensus on the definition, appropriate measurement and reporting of these outcomes. Heterogeneity in outcome reporting in clinical research provides a significant major barrier to conduct meta-analysis, guidelines development, clinical decision making, and ultimately affecting patient care. These effects could, however, be reduced by the establishment of a core outcome set (COS) in endodontics, which is defined as an agreed, standardized set of outcomes that should be included, measured and reported as a minimum in all trials and outcome studies. COS development is a regulated and validated process requiring involvement of appropriate stakeholders as well as a rigorous methodology. To date, COS has been developed for the management of traumatic dental injuries, orthodontic and periodontal treatment and is currently being developed for endodontic treatment. The aim of this review is to discuss the importance of COS in endodontics with focus on the evidence for and impact of heterogeneity in reporting endodontic treatment outcomes. An overview of an ongoing process for development of COS for different endodontic treatment modalities will also be provided.

Differentiating between stress- and EPT-induced electrodermal activity during dental examination

Dental pain invokes the sympathetic nervous system, which can be measured by electrodermal activity (EDA). In the dental clinic, accurate quantification of pain is needed because it could enable optimized drug-dose treatments, thereby potentially reducing drug addiction. However, a confounding factor is that during pain there is also lingering residual stress, hence, both contribute to the EDA response. Therefore, we investigated whether EDA can differentiate stress from pain during dental examination. The use of electrical pulp test (EPT) is an ideal approach to tease out the dynamics of stress and mimic pain with lingering residual stress. Once the electrical sensation is felt and reaches a critical current threshold, the subject removes the probe from their tooth, hence, this stage of data represents largely EPT stimulus and the residual stress-induced EDA response is smaller. EPT was performed on necrotic and vital teeth in fifty-one subjects. We defined four different data groups of reactions based on each individual's EPT intensity level expectation based on the visual analog scale (VAS) of their baseline trial, as follows: mild stress, mild stress + EPT, strong stress, and strong stress + EPT. EDA-derived features exhibited significant difference between residual lingering stress + EPT groups and stress groups. We obtained 84.6% accuracy with 76.2% sensitivity and 86.8% specificity with multilayer perceptron in differentiating between pure-stress groups vs. stress + EPT groups. Moreover, EPT induced much greater EDA amplitude and faster response than stress. Our finding suggests that our machine learning approach can discriminate between stress and EPT stimulation in EDA signals.

The use of electrodermal activity in pulpal diagnosis and dental pain assessment

AIMS

To explore whether electrodermal activity (EDA) can serve as a complementary tool for pulpal diagnosis (Aim 1) and an objective metric to assess dental pain before and after local anaesthesia (Aim 2).

METHODOLOGY

A total of 53 subjects (189 teeth) and 14 subjects (14 teeth) were recruited for Aim 1 and Aim 2, respectively. We recorded EDA using commercially available devices, PowerLab and Galvanic Skin Response (GSR) Amplifier, in conjunction with cold and electric pulp testing (EPT). Participants rated their level of sensation on a 0-10 visual analogue scale (VAS) after each test. We recorded EPT-stimulated EDA activity before and after the administration of local anaesthesia for participants who required root canal treatment (RCT) due to painful pulpitis. The raw data were converted to the time-varying index of sympathetic activity (TVSymp), a sensitive and specific parameter of EDA. Statistical analysis was performed using Python 3.6 and its Scikit-post hoc library.

RESULTS

Electrodermal activity was upregulated by the stimuli of cold and EPT testing in the normal pulp. TVSymp signals were significantly increased in vital pulp compared to necrotic pulp by both cold test and EPT. Teeth that exhibited intensive sensitivity to cold with or without lingering pain had increased peak numbers of TVSymp than teeth with mild sensation to cold. Pre- and post-anaesthesia EDA activity and VAS scores were recorded in patients with painful pulpitis. Post-anaesthesia EDA signals were significantly lower compared to pre-anaesthesia levels. Approximately 71% of patients (10 of 14 patients) experienced no pain during treatment and reported VAS score of 0 or 1. The majority of patients (10 of 14) showed a reduction of TVSymp after the administration of anaesthesia. Two of three patients who experienced increased pain during RCT (post-treatment VAS > pre-treatment VAS) exhibited increased post-anaesthesia TVSymp.

CONCLUSIONS

Our data show promising results for using EDA in pulpal diagnosis and for assessing dental pain. Whilst our testing was limited to subjects who had adequate communication skills, our future goal is to be able to use this technology to aid in the endodontic diagnosis of patients who have limited communication ability.

Evaluation of the Effect of Common Analgesics on Pulpal Sensibility Tests: A Clinical Trial

INTRODUCTION

Accurate diagnosis is one of the most important steps before endodontic treatment. The aim of this study was to assess the effect of 2 commonly used analgesics namely ibuprofen and acetaminophen on the cold and electric pulp test (EPT) results in participants with symptomatic irreversible pulpitis (SIP).

METHODS

This clinical trial evaluated 41 participants with pain due to SIP. The cold test and EPT were performed for teeth with SIP, and also for the corresponding tooth with healthy pulp in the contralateral quadrant. The participants then received 500 mg acetaminophen, 400 mg ibuprofen, or the placebo in the 3 groups. The cold test and EPT were repeated at 20, 40, and 60 minutes after medication intake, and the results were compared with the pretreatment values.

RESULTS

In the acetaminophen group, the results of cold test significantly decreased 40 (P < .05), and 60 (P < .05) minutes after analgesic intake in teeth with SIP and after 40 minutes (P < .05) in the corresponding contralateral teeth with healthy pulp. In the ibuprofen group, the cold test results significantly decreased at 20 (P < .05), 40 (P < .05), and 60 (P < .05) minutes after analgesic intake in teeth with SIP and after 40 minutes (P < .05) in the corresponding contralateral teeth with healthy pulp. The EPT results were not significantly affected by the studied analgesics at any time point (P > .05). There was no significant difference among the study groups regarding sex (P > .05).

CONCLUSION

It appears that both acetaminophen and ibuprofen can affect the pulpal response to the cold sensibility test. However, the studied medications had no significant effect on the EPT results. Therefore, dental clinicians should be aware of the possible effects of such medications on the cold test response.

Analysis of oral microbiota in non-vital teeth and clinically intact external surface from patients with severe periodontitis using Nanopore sequencing: a case study

Periodontal diseases include a wide range of pathological conditions, damaging the supporting structures of the teeth. Origin and propagation of periodontal disease is believed to be caused by dysbiosis of the commensal oral microbiota. The aim of this study was to evaluate the presence of bacteria in the pulp cavity of teeth with severe periodontal disease with clinically intact external surface. Periodontal (P) and endodontic (E) tissue samples of root canals from six intact teeth of three patients were sampled for analysis of microbial population using Nanopore technology. Streptococcus was the predominant genus in E samples. Porphyromonas (33.4%, p = 0.047), Tannerella (41.7%, p = 0.042), and Treponema (50.0%, p = 0.0064) were significantly more present in P than in E samples. Some samples (E6 and E1) exhibited a remarkable difference in terms of microbial composition, whilst Streptococcus was a common signature in samples E2 to E5, all which were obtained from the same patient. In conclusion, bacteria were identified on both the root surface and the root canal system, thus demonstrating the possibility of bacteria to spread directly from the periodontal pocket to the root canal system even in the absence of crown's loss of integrity.

Age-Related Variation of Pulpal Oxygen Saturation in Healthy Primary and Permanent Teeth in Children: A Clinical Study

(1) Background: Pulse oximetry (PO) is an effective method of dental pulp status monitorization but still lacks practical implementation in dentistry, as well as clear reference values for different tooth types. The study’s aim was to investigate the age-related variation of blood oxygen saturation (SpO2) from the dental pulp during different stages of tooth development in all types of primary and permanent teeth of children. (2) Methods: The pulps of 600 healthy primary and permanent teeth (incisors, canines, premolars, and molars) of patients aged 2−15 years were tested with an adapted PO device, and the results were statistically analyzed; (3) Results: Statistically significant differences (p < 0.05) were found between open-apex and closed-apex teeth and between the canines and other tooth types in both primary and permanent dentitions. (4) Conclusions: Values of SpO2 tended to decrease with age progression in both primary and permanent dentitions. Enamel and dentine thickness and their optical properties and the shape and volume of coronal pulp, which differed among tooth types, seemed to have some influence on the reading as well. The study indicates that factors such as the root development and the tooth type must be taken into account when establishing reference SpO2 values for the dental pulp.

The clinical effect of radiotherapy on pulpal microvasculature: a systematic review

Introduction/objectives Radiotherapy (RT) has a detrimental effect on the histomorphology of oral tissues. Patients undergoing RT are at risk of developing macrovascular and microvascular changes, which can lead to significant clinical consequences. Despite advances in RT delivery systems, radiation injury remains a modern-day clinical problem. The aim of this systematic review is to investigate the available evidence regarding the impact of RT to the dental pulp and the clinical manifestations of these effects.Data and sources A multi-database search (PubMed, Medline, Embase and CINAHL) was performed to identify related papers published from inception until November 2021. An additional manual search was performed to identify further articles. The data extracted from relevant papers were analysed according to the outcomes selected in this review.Study selection The search generated seven articles eligible for analysis with a total of 2,709 teeth included. RT dose exposure ranged from 30-71.2 Gray with a common finding that RT decreases the number of teeth responding to pulp sensibility testing.Conclusions Knowledge related to the impact of RT on dental pulp is limited and based on weak evidence and a low-level quality of studies. Future studies should incorporate exact RT doses to the teeth and use replicable pulpal testing methods. Understanding the pulpal status post-RT remains an important consideration as dental extractions should be avoided in this cohort due to the risk of osteoradionecrosis.

Diagnosis consensus among endodontic specialists and general practitioners: An international survey and a proposed modification to the current diagnostic terminology

INTRODUCTION

This survey aimed to determine the consensus amongst endodontic specialists in North America and practitioners worldwide to diagnose the pulp and periapical conditions of selected case scenarios encountered in daily practice using the American Association of Endodontists (AAE) pulpal and periapical diagnostic terms. Secondly, an attempt was made to suggest modifications in terms accordingly.

METHODOLOGY

A survey designed by two endodontic educators was sent to endodontists in North America and clinicians worldwide through an electronic database. The survey included socio-demographic questions followed by the clinical and radiographic presentations of four clinical scenarios. The participants were then requested to provide the pulpal and the periapical diagnosis of 11 teeth presented in these cases (22 answers in total/participant) using the AAE diagnostic terminology. Cases were designed to include 12 pulpal/periapical conditions as control (non-controversial conditions) and ten so-called controversial conditions. A proportion threshold of 10% was required for any diagnostic term to be reported in this survey. The participants were divided into two groups based on the region of endodontic training and/or practice to 'Specialised North American' or 'International Practitioners,' and their results were statistically compared using chi-squared tests (p < .05).

RESULTS

The survey included 421 participants. 74% were endodontists, and 46.1% were amongst the 'Specialised North American' group and 53.9% amongst the 'International Practitioners'. Eleven of 12 control conditions had an almost complete agreement amongst the participants regarding the diagnostic terms selected, ranging between 82% and 96%, with no other diagnostic term exceeding the 10% threshold. All the controversial conditions yielded more than one diagnostic term selected/condition that exceeded the 10% threshold for groups ('Specialised North American' and 'International practitioners'). There were no differences in the diagnostic terms selected between the two groups; however, the weight for each term varied between the groups in some cases.

CONCLUSION

There is a lack of consensus amongst clinicians, regardless of their training and region of practice, on the appropriate diagnostic terms to be used in particular clinical conditions. More diagnostic terms and modifications in the current terms may be required to establish a more reliable diagnostic terminology.

High-Resolution Single Tooth MRI With an Inductively Coupled Intraoral Coil-Can MRI Compete With CBCT?

OBJECTIVES

The aims of this study were to quantify T1/T2-relaxation times of the dental pulp, develop a realistic tooth model, and compare image quality between cone-beam computed tomography (CBCT) and high-resolution magnetic resonance imaging (MRI) of single teeth using a wireless inductively coupled intraoral coil.

METHODS

T1/T2-relaxometry was performed at 3 T in 10 healthy volunteers (283 teeth) to determine relaxation times of healthy dental pulp and develop a realistic tooth model using extracted human teeth. Eight MRI sequences (DESS, CISS, TrueFISP, FLASH, SPACE, TSE, MSVAT-SPACE, and UTE) were optimized for clinically applicable high-resolution imaging of the dental pulp. In model, image quality of all sequences was assessed quantitatively (contrast-to-noise ratio) and qualitatively (visibility of anatomical structures and extent of susceptibility artifacts using a 5-point scoring scale). Cone-beam computed tomography served as the reference modality for qualitative assessment. Statistical analysis was performed using 2-way analysis of variance, Fisher exact test, and Cohen κ.

RESULTS

In vivo, relaxometry of dental pulps revealed T1/T2 relaxation times at 3 T of 738 ± 100/171 ± 36 milliseconds. For all sequences, an isotropic resolution of (0.21 mm) 3 was achieved, with acquisition times ranging from 6:19 to 8:02 minutes. In model, the highest contrast-to-noise ratio values were observed for UTE, followed by TSE and CISS. The best image/artifact quality, however, was found for DESS (mean ± SD: 1.3 ± 0.3/2.2 ± 0.0), FLASH (1.5 ± 0.3/2.4 ± 0.1), and CISS (1.5 ± 0.4/2.5 ± 0.1), at a level comparable to CBCT (1.2 ± 0.3/2.1 ± 0.1).

CONCLUSIONS

Optimized MRI protocols using an intraoral coil at 3 T can achieve an image quality comparable to reference modality CBCT within clinically applicable acquisition times. Overall, DESS revealed the best results, followed by FLASH and CISS.

Assessment of Pulpal Status in Primary Teeth Following Direct Pulp Capping in an Experimental Canine Model

(1) Background: This study aimed to assess the pulpal response of primary teeth by pulse-oximetry (PO) in a canine model, following direct pulp capping (DPC). (2) Methods: Forty-eight primary teeth from eight canine subjects were divided into three treatment groups, based on the DPC material—calcium hydroxide (CH), MTA, BiodentineTM)—and three corresponding control groups. Data from PO pulp testing were correlated with laser Doppler flowmetry (LDF) testing, computer tomographic (CT) densitometry and histological analysis; the experiment lasted 14 days. (3) Results: SpO₂ recordings revealed statistically significant differences (p = 0.002, <0.05) between the treatment and control groups, and no significant differences (p = 0.257, >0.05) were observed between treatment groups. LDF recordings showed significant differences (p = 0.002, <0.05) between the treatment and control groups and identified significant differences between materials (p = 0.001, <0.05). CT densitometry indicated vital pulps in all teeth, with pulpal inflammation detected in 6/8 CH-capped teeth and 2/8 MTA-capped teeth. Histologic evaluation confirmed vital pulp in all specimens, with different degrees of inflammation. (4) Conclusions: Within its limitations, the present study confirms the diagnostic value of PO evaluation of pulpal status in primary teeth with histologic means after pulp-capping procedures in a canine model. However, various degrees of pulpal inflammation elicited by different pulp-capping materials seem not to correlate with the obtained PO values.

Inferior Alveolar Nerve Block Success of 2% Mepivacaine versus 4% Articaine in Patients with Symptomatic Irreversible Pulpitis in Mandibular Molars: A Randomized Double-Blind Single-Centre Clinical Trial

AIM

To assess inferior alveolar nerve block (IANB) success of 2% mepivacaine (Scandonest 2%, Septodont, France) and 4% articaine (Septanest 4%, Septodont) in patients with symptomatic irreversible pulpitis (SIP) in mandibular molars during access cavity preparation and instrumentation.

METHODOLOGY

Three hundred and thirty patients with moderate-to-severe pain in mandibular molars with SIP randomly received either 3.6 mL 2% mepivacaine hydrochloride with 1:100 000 adrenalin or 3.4mL 4% articaine hydrochloride with 1:100 000 adrenalin (n=165). Intraoperative pain (IOP) intensity was assessed during access cavity preparation and canal instrumentation using 11-point numerical rating scale (NRS). Overall success was considered if the patient felt no-to-mild pain without the need of supplemental anaesthesia throughout treatment; the incidence of need for supplemental anaesthesia was also recorded. Data were statistically analyzed using Mann Whitney U and Chi² (χ² ) tests. Relative risk (RR) and 95% confidence interval (CI) of anaesthetic failure was calculated. The effect of predisposing factors on outcome variables was assessed using multivariable regression analyses. None of the participants reported any adverse effects.

RESULTS

Baseline variables were balanced between groups (p>0.05). The IOP intensity during access cavity preparation and canal instrumentation was similar for both groups (p>0.05). IOP intensity was associated with preoperative pain intensity and tooth type (p<0.05). Overall anaesthetic success rate was 35.8% for mepivacaine and 41.2% for articaine (p>0.05) with a relative risk of failure [95%CI] 1.09 [0.92, 1.30]. The need for supplemental anaesthesia occurred 43.6% and 38.2% with mepivacaine and articaine respectively (p>0.05; RR [95%CI]: 1.14 [0.88, 1.48]). Preoperative pain level and age were associated with the need for supplemental anaesthesia.

CONCLUSIONS

2% mepivacaine and 4% articaine demonstrate similar IANB success rates for mandibular molars with SIP. Intraoperative pain experience during endodontic treatment can be associated with preoperative pain, tooth type and age.

Diagnostic Accuracy of Pulp Vitality Tests and Pulp Sensibility Tests for Assessing Pulpal Health in Permanent Teeth: A Systematic Review and Meta-Analysis

The current systematic review and meta-analysis was carried out to compare the diagnostic accuracy of pulp vitality and pulp sensibility tests in assessing pulpal health. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, Google Scholar and Open Grey databases were searched and after assessing eligibility criteria the data were extracted. True-positive, false-positive, true-negative, false-negative, sensitivity and specificity values were extracted or calculated if not presented. Quality of studies was evaluated based on the QUADAS 2 tool. Meta-analysis was performed in MetaDTA (v2.0; Shinyapps, RStudio PBC, Boston, MA, USA) and Review Manager 5.3 (RevMan web; The Cochrane Collaboration, London, UK). Ten articles were included for qualitative synthesis and five for meta-analysis. The pooled diagnostic odds ratio for pulse oximeter (PO), electric pulp tester (EPT), cold test (CT) and heat test (HT) was 628.5, 10.75, 17.24 and 3.47, respectively. Pairwise comparison demonstrated a higher pooled mean sensitivity and specificity with PO compared with EPT. Comparison between PO and CT and between PO and HT also demonstrated a higher pooled mean sensitivity and specificity for PO. Summary points on receiver operating characteristic curves confirmed the ability of PO to correctly screen negatives in presenting patients as compared to EPT, CT and HT but no study was rated as good on quality assessment. PO can be considered as the most accurate diagnostic method as compared to EPT, CT and HT. This review provides information about the reliability and diagnostic accuracy of using pulp vitality and sensibility tests for assessing pulp status.

A Diagnostic Insight of Dental Pulp Testing Methods in Pediatric Dentistry

The accurate diagnosis of pulpal pathology in pediatric dentistry is essential for the success of vital pulp therapy. Pulp testing is often a challenging task due to understanding and cooperation issues of pediatric patients, as well as the particularities of pulpal physiology encountered in primary and immature permanent teeth. Sensibility tests, although still widely used by dental practitioners, are no longer recommended by pediatric specialists mainly due to their subjective nature. Vitality pulp tests have gained popularity in the last decade in light of some encouraging results of clinical studies. However, their use is not a routine practice yet. This paper is a literature review aimed to guide dental practitioners towards selecting the appropriate pulp testing method for their pediatric cases. It provides an overview on a multitude of pulp testing methods and an update in recommendations for primary and immature permanent teeth.

Molecular Characterization of Irreversible Pulpitis: A Protocol Proposal and Preliminary Data

Introduction

An attempt to determine the association of a large array of inflammatory proteins in pulpitis with precise measurement of clinical signs and symptoms, and to correlate these findings with levels in peripheral blood has not been reported. Such an analysis could serve to identify key clinical findings and potential biomarkers to predict the prognosis of vital pulp therapy. The aim of this study was to undertake a preliminary, proof-of-concept study to correlate the levels of key inflammatory mediators in cariously exposed dental pulp of adults with reversible or irreversible pulpitis, and no apical periodontitis, with a panel of subjective and objective diagnostic clinical findings as well as the status of the pulp upon exposure. Pulpal and peripheral blood inflammatory mediators were also compared.

Methods

Dental pulp and peripheral blood were sampled. The Luminex technology was used to assess the expression of a panel of 45 inflammatory proteins to determine their association with clinical signs and symptoms of reversible or irreversible pulpitis.

Results

Data from three pulpal and three peripheral blood samples were used for the analysis. The correlation of levels of the 45 proteins in the inflamed dental pulp and peripheral blood was 0.87. The pulp had significantly higher levels of these proteins collectively than peripheral blood (t-test, p = 0.047). The following proteins had correlated at a level of ≥0.8 with the duration of pain with cold: MMP-12, MMP-9, RANTES, MIP-2, MCP-1, MMP-2, MMP-1, and P-Selectin. Relatively high correlations (0.5-0.75) were also present between these proteins and presenting pain level.

Conclusions

Several pulpal proteins correlated well with spontaneous and evoked pain parameters. Peripheral blood may not be necessary in future similar studies. Finally, additional data is needed to identify candidate proteins to be investigated as potential markers of truly irreversible pulp inflammation.

Making sense of sensibility: part 2

To reach an accurate endodontic diagnosis, it is important for clinicians to understand how to undertake pulpal sensibility tests correctly, how to interpret their results and how to understand their limitations. Part one of this series defined different terms relevant to pulp testing and detailed the diagnostic uses and diagnostic accuracy of pulp testing methods. This section describes clinical techniques for commonly used pulp tests and highlights their limitations and correct interpretation of their results. Applying these principles and techniques will enable accurate endodontic diagnosis in different clinical scenarios.

Head and neck radiotherapy effects on the dental pulp vitality and response to sensitivity tests. A systematic review with meta-analysis

BACKGROUND

There is no consensus whether radiotherapy for head and neck cancer (HNC) could induce pulp necrosis. Therefore, a systematic review of clinical studies is necessary.

OBJECTIVES

To evaluate the evidences on radiotherapy for HNC and pulp status.

METHODS

A systematic search of articles published until November 2021 was performed in the MEDLINE/PubMed, Cochrane Library, Web of Science (All Databases), Scopus, EMBASE and Open Grey databases. The eligibility criteria were based on the PICOS strategy, as follows: (P) vital teeth of adult patients with intraoral and/or oropharyngeal cancer; (I) radiotherapy; (C) control group or values of the same tooth before radiotherapy (basal values); (O) pulpal status after radiotherapy; (S) clinical studies. The Cochrane Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool was used to assess the quality of the included studies. Meta-analyses were performed using fixed and random effects. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Six studies were included for qualitative analysis. Five were classified as serious risk of bias and one as moderate risk of bias. Four studies reported altered pulp responses to cold thermal test after radiotherapy initiation. Meta-analyses were performed using three included studies. From these, all were included in the meta-analysis for pulp response values to cold sensitivity test immediately after radiotherapy initiation (risk ratio: 0.00[CI:0.00, 0.02], P < 0.00001; I² = 0%); and two in the meta-analysis for pulp response values to cold sensitivity test after 4-5 months of radiotherapy (risk ratio: 0.01[CI: 0.00. 0.06], P < 0.00001; I² = 0%). Two reported progressively higher readings to pulp response in the electrical test after radiotherapy initiation (mean difference: -11.46[-13.09, -9.84], P < 0.00001; I² = 68%) and at all periods evaluated. Two studies demonstrated a pulp oxygen saturation (SpO₂ ) decrease at the end of radiotherapy; and increase after 4-6 months of radiotherapy beginning. And other demonstrated normal dental pulp SpO₂ 4 to 6 years after treatment. GRADE analysis presented a moderate certainty of evidence.

DISCUSSION

This review verified that radiotherapy for HNC causes significant alterations on the dental pulp responses, but does not seem to induce pulp necrosis. Significant limitations regarding controlling for confounding factors, classification of interventions and measurement of outcomes were verified, evidencing the need for well-designed studies.

CONCLUSIONS

This systematic review demonstrated that radiotherapy for HNC induced significant changes in the pulp response with moderate quality of evidence. Such altered responses cannot determine pulp status accurately.

Reliability of Electric Pulp Test, Cold Pulp Test or Tooth Transillumination to Assess Pulpal Health in Permanent Dog Teeth

The aim of this study was to evaluate the reliability of electric pulp test (EPT), cold pulp test (CPT) and tooth transillumination (TTI) in the assessment of pulpal health in dog teeth. Forty-five client-owned dogs requiring tooth extraction or pulpectomy were included. For each patient, one affected and two control healthy teeth were evaluated with EPT, followed by CPT and TTI. Direct pulp inspection was used as a gold standard. The real pulpal health (vital or necrotic) was determined by the presence or absence of bleeding after creating access to the pulp chamber. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of EPT, CPT and TTI were obtained for each pulp test using the binomial Clopper-Pearson exact method to establish confidence intervals. Forty-five affected teeth were tested. Forty-three were tested with EPT, CPT, and TTI, and two were tested solely with EPT and CPT. All dogs tested with EPT and TTI were included in the study whereas 21 out of 45 (47%) dogs tested with CPT were excluded. The sensitivity, specificity, PPV, NPV and accuracy were respectively 0.96, 1.00, 1.00, 0.96 and 0.98 for EPT; 1.00, 0.89, 0.92, 1.00 and 0.95 for CPT; and 0.59, 0.95, 0.94, 0.67 and 0.76 for TTI. This study concluded that EPT is a highly reliable diagnostic test to evaluate pulpal health in dogs. The high accuracy of CPT is conditional on the patient's responsiveness to stimulation applied to its control healthy teeth. TTI was the least reliable test in the study.

The Use of Modern Technologies by Dentists in Poland: Questionnaire among Polish Dentists

Background: From one year to another, dentists have access to more procedures using modern techniques. Many of them can improve the effectiveness of dental procedures and frequently facilitate and accelerate them. Objectives: Technically advanced devices are an important part of modern dentistry. Over the years, there were developed technologies like ultrasounds, lasers, air abrasion, ozonotherapy, caries diagnostic methods, chemomechanical caries removal (CMCR), pulp vitality tests, computer-controlled local anesthetic delivery (CCLAD). The aim of this study was to investigate the requirement of Polish dentists for such technologies. Methods: An anonymous questionnaire was posted on a social media group of dentists from Poland. 187 responses were obtained. Results: It turned out that almost every respondent uses ultrasounds, but other technologies are not as popular. 43% use CCLAD, 33% use diagnostic methods, 28% use air abrasion, 25% use dental lasers, 21% use CMCR, 18% use pulp vitality tests and 6% use ozonotherapy. The most common reason for not using the aforementioned technologies were their high cost and the sufficient effectiveness of raditional methods. There was a correlation between use of a dental laser and CCLAD and size of office, CMCR use and dentists’ work time and air abrasion use and gender. Many dentists claim that they will try one of the modern technologies in the future. Conclusions: It can be concluded that Polish dentists tend to use ultrasounds and CCLAD more than any other technology. In the future this may change, so more studies in this topic are needed.

Pulpotomy for treatment of complicated crown fractures in permanent teeth: A systematic review

Background

Consensus on the treatment of choice for complicated crown fractures of teeth is limited. Recent guidance recommends vital‐pulp‐therapy; however, the preferred type is not specified. Higher success rates for pulpotomy compared to pulp‐capping have been documented, which suggests pulpotomy may be a preferable option for complicated crown‐fractures.

Objectives

The purpose of this systematic review was to determine the success rate of pulpotomy (partial and complete) on teeth that suffered complicated crown fractures. Participants: patients who have suffered a complicated crown fracture to an anterior permanent tooth. Intervention: pulpotomy (partial or complete). Comparator: pulp‐capping or root canal treatment. Outcome: combined clinical and radiographic success at or after 12 months.

Methods

A systematic literature using key search terms was conducted using PubMed, Web of Science and Cochrane‐Central‐Register‐of‐Controlled‐Trials (CENTRAL) as well as a grey literature search from inception to May 2021 and without language restricted to English. Strict inclusion criteria were applied. A standardized tool with defined criteria to assess the risk of bias in each study was used. For non‐randomized comparative trials, the Robins‐I tool was used while the Newcastle‐Ottawa scale was used for non‐comparative non‐randomized studies.

Results

Seven retrospective clinical studies were included. The studies reported high success rates for pulpotomy with overall success ranges for partial or complete pulpotomy ranging from 75% to 96%. One study compared the success rates of pulpotomy to an alternative treatment option pulp capping (90.9% vs. 67%, respectively). Due to the lack of homogeneity in the included studies, a meta‐analysis was not possible.

Discussion

This review highlights the limited evidence based for the current guidance on treatment of complicated crown fractures. The findings of the review indicate high success rates for pulpotomy; however, there is a moderate risk of bias and small sample sizes in the included studies with the result that the overall results should be interpreted with caution.

Conclusion

Within the limitations of this review, the benefits and high success rates reported for partial pulpotomy suggest this procedure, rather than pulp‐capping, should be considered as the treatment of choice for both immature and mature teeth that have suffered complicated crown‐fractures.

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.

A Mini Review: The Potential Biomarkers for Non-invasive Diagnosis of Pulpal Inflammation

For assessing the adequacy of vital pulp therapy for an inflamed pulp, the use of non-invasive diagnostic tools is necessary to avoid further damage to the teeth. Detection of biomarkers that are indicative of the inflammatory status in pulp can be a promising tool for this purpose. These biomarkers need to be reliably correlated with pulpal inflammation and to be easily detected without pulp exposure. This mini-review article aims to review biomarkers that are present in gingival crevicular fluid (GCF) in inflamed pulp conditions. Several studies have reported the availability of various biomarkers including cytokines, proteases, elastase, neuropeptides, and growth factors. Non-invasive pulpal diagnostic methods will be useful as well to determine reversibility, irreversibility, or necrosis of inflamed pulp. These types of molecular diagnoses via analyzing the proteome have revolutionized the medical field, and are one of the most promising empirical methodologies that a clinician can utilize for the proactive identification of pulpal disease.

Association between Orthodontic Force and Dental Pulp Changes: A Systematic Review of Clinical and Radiographic Outcomes

INTRODUCTION

Orthodontic force triggers a sequence of biological responses that can affect dental pulp. The aim of this study was to systematically evaluate the clinical and radiographic findings of orthodontic force application on dental pulp.

METHODS

Two reviewers comprehensively and systematically searched 6 electronic databases (Latin American and Caribbean Health Sciences [LILACS], Embase, Cochrane Library, MEDLINE/PubMed, Scopus, and Web of Science) and the gray literature (Google Scholar, OpenGrey, and ProQuest) until April 2021. According to the PICOS criteria, randomized clinical trials and observational studies that evaluated clinical or radiographic findings compatible with dental pulp changes due to orthodontic force were included. Studies in open apex or traumatized teeth, case series or reports, and laboratory-based or animal studies were excluded. The Newcastle-Ottawa Scale and Cochrane Risk of Bias 2.0 tool were used to determine the risk of bias assessment. The overall certainty level was evaluated with the Grading of Recommendations, Assessment, Development and Evaluations tool.

RESULTS

Twenty-six studies were included. Among the clinical findings, orthodontic force promoted an increased pulp sensibility response and decreased pulp blood flow. Changes in pulp cavity volume and increased incidence of pulp stones were the radiographic findings observed. The studies presented a moderate risk of bias for most of the domains. The certainty of the evidence was considered very low.

CONCLUSIONS

Orthodontic force promoted changes in the dental pulp, generating clinical and radiographic findings. It is crucial to know these changes so that orthodontic mechanics can be safely performed. The clinician has effective noninvasive methods to assess the health and possible pulp changes during orthodontic treatment.

Assessment of pulp sensibility in the mature necrotic teeth using regenerative endodontic therapy with various scaffolds - Randomised clinical trial

Aim

This study aimed to evaluate and compare the possibility of regaining pulp sensibility and objectives of regeneration procedure in mature necrotic teeth using regenerative endodontics.

Materials and Methods

A total of 36 mature necrotic teeth were selected and a regenerative endodontic procedure was performed. A total of four groups, each involving n = 9 teeth per group were randomly grouped as (1) periapical bleeding, (2) platelet-rich fibrin (PRF), (3) collagen, and (4) hydroxyapatite. Pulp testing and radiographic assessment of periapical healing (PH) were recorded at every 3-month interval for 1 year. Readings were compared as qualitative data using the Kruskal-Wallis test to see the inter-group significant difference.

Results

Readings of pulp sensibility revealed non-significant results in all intervals. At 3 and 6 months, 22.3% in the PRF group and 11.15% in collagen group; and at 9 months, 44.4% in PRF group, 33.3% in the collagen group and 22.2% in hydroxyapatite group; and at 12-months, 66.6% in PRF, 44.4% in the collagen group, 33.3% in the hydroxyapatite group and 11.1% in the periapical bleeding group showed a positive response to the cold test. But all groups did not show a positive response to heat and electric pulp testing and showed good PH in all groups at the end of 12 months.

Conclusions

The presence of sensibility to cold test is indicative of the formation of vital pulp-like tissues, which was the highest in the PRF group, followed by the collagen, hydroxyapatite and periapical bleeding groups.

Laser-Doppler microvascular flow of dental pulp in relation to caries progression

Pulpal blood supply can be measured noninvasively and objectively via laser-Doppler fluxmetry. The aim of the study was to measure and compare pulpal laser-Doppler (LD) flux values for permanent non-carious teeth and carious teeth with different degrees of caries progression. Conventional sensitivity tests were also conducted for a comparative analysis to clarify the difference between tooth sensitivity and vitality. Carious lesions were detected and assessed in 15 adult subjects using the International Caries Detection and Assessment System (ICDAS) criteria. Pulpal sensitivity of selected carious teeth (without previous prosthetic restoration or endodontic treatment) and suitable caries-free teeth were then tested with a cold stimulus and subsequently with a weak electric current, whereas their pulpal LD flux was recorded at a separate visit using individually designed silicone probe holders. The LD flux values for teeth with an ICDAS score 6 were significantly lower compared to the values for teeth with an ICDAS score 1 (p < 0.05). Pulpal LD flux values of teeth with active caries were significantly lower than those of teeth with solely inactive carious lesions (p < 0.05). The degree of agreement between sensitivity and vitality testing was fair within both of the pairs: cold test/LDF (κk = 0.232, p = 0.00) and electric test/LDF (κk = 0.354, p = 0.00). Pulpal LD flux measurement proved to be reliable in the pulp vitality assessment of carious and non-carious teeth and might improve the reliability of clinical decisions when used in addition to standard clinical diagnostic protocols.

Associations between Pain Severity, Clinical Findings, and Endodontic Disease: A Cross-Sectional Study

INTRODUCTION

Thorough pain assessment and thermal and mechanical testing are the primary diagnostic tools used to assess the status of pulp and periapical tissues in teeth with potential endodontic pathology. This study evaluated predictors of acute odontogenic pain to better understand the relationship between endodontic pain, clinical testing, endodontic disease, and diagnoses.

METHODS

Participants (N = 228) presenting with acute odontogenic pain underwent standardized clinical testing and reported their pain intensity. Univariate and multiple regression analyses were performed to evaluate the predictors of acute endodontic pain. Chi-square tests with Bonferroni adjustments were conducted to measure the frequency of endodontic diagnostic test findings and clinical observations in patients with different pulpal diagnoses.

RESULTS

A negative response to cold stimulation on the causative tooth and percussion hypersensitivity on the healthy adjacent tooth were the strongest predictors of higher levels of acute endodontic pain. Percussion hypersensitivity on the healthy adjacent tooth was present in a quarter of the cohort and was reported with equal frequency in teeth diagnosed with irreversible pulpitis, necrotic pulp, and previously initiated/treated teeth. Although painful percussion on the causative tooth was more frequently reported in teeth diagnosed with necrotic pulp, painful palpation was more frequently reported on teeth diagnosed with previously initiated/treated teeth.

CONCLUSIONS

Percussion hypersensitivity on the healthy adjacent tooth may reveal a lowered pain threshold and heightened pain sensitization. It is also possible that the 2 commonly performed mechanical sensory tests, percussion and palpation hypersensitivity, may detect different aspects of endodontic pathophysiology and pain processing.

Relationship between the difference in electric pulp test values and the diagnostic type of pulpitis

BACKGROUND

According to the diagnosis criteria of the American Association of Endodontists (AAE), sensitive responses to cold and/or heat tests of suspected teeth compared with those of control teeth can be used for the diagnosis of pulpitis, but the role of electric pulp test (EPT) is not mentioned. It is believed that EPT has some limitations in determining the vitality of the pulp. The aim of this study was to explore the association between the difference in EPT values and the differential diagnoses of reversible pulpitis (RP) and symptomatic irreversible pulpitis (SIRP) caused by dental caries.

METHODS

A total of 203 cases with pulpitis caused by dental caries were included. A diagnosis of pulpitis was made on the basis of the diagnostic criteria of AAE. Patient demographic and clinical examination data were collected. The EPT values of the suspected teeth and control teeth were measured, and the differences between them were calculated. The correlation between the difference in the EPT values and diagnosis of pulpitis was analyzed using univariate and multivariate logistic regression.

RESULTS

In the 203 cases (78 males and 125 females; 115 cases of RP, 88 cases of SIRP; 9 anterior teeth, 59 premolars, and 135 molars), the mean patient age was 34.04 ± 13.02 (standard deviation) years. The unadjusted (crude) model, model 1 (adjusted for age), model 2 (adjusted for age and sex), and model 3 (adjusted for age, sex, and tooth type) were established for the statistical analyses. In model 3 [odds ratio (OR) = 1.025; 95% confidence interval (CI) 1.002-1.050; P = 0.035], the difference in EPT values between RP and SIRP was statistically significant. However, the areas under the curve of predictive probability of the crude model, model 1, model 2, and model 3 were 0.565, 0.570, 0.585, and 0.617, respectively, showing that the model accuracy was low. The P-value for the trend in differences between the EPT values as a categorical variable showed that the differences in the EPT values, comparing RP and SIRP, were not statistically significant.

CONCLUSIONS

Based on the present data, the difference in EPT values was not sufficient to differentiate RP from SIRP.

Diagnosing odontogenic sinusitis of endodontic origin: A multidisciplinary literature review

PURPOSE

Endodontic disease is one of the most common causes of bacterial odontogenic sinusitis (ODS). Diagnosing ODS of endodontic origin involves otolaryngologists confirming sinusitis, and dental specialists confirming endodontic sources. The purpose of this study was to conduct a multidisciplinary literature review to highlight clinical and microbiological features of ODS, and the most optimal diagnostic modalities to confirm endodontic disease.

METHODS

An extensive review of both medical and dental literature was performed by rhinologists, endodontists, and an infectious disease specialist. Frequencies of various clinical and microbiological features from ODS studies were collected, and averages were calculated. Different endodontic testing and imaging modalities were also evaluated on their abilities to confirm endodontic disease.

RESULTS

ODS patients most often present with unilateral sinonasal symptoms for over 3 months, purulence on nasal endoscopy, and overt dental pathology on computed tomography (CT). Subjective foul smell, and maxillary sinus cultures demonstrating anaerobes and α-streptococci (viridans group) may be more specific to ODS. For endodontic evaluations, cold pulp testing and cone-beam CT imaging are most optimal for confirming pulpal and periapical disease.

CONCLUSION

Diagnosing ODS requires collaboration between otolaryngologists and dental specialists. Clinicians should suspect ODS when patients present with unilateral sinonasal symptoms, especially foul smell. Patients will generally have purulent drainage on nasal endoscopy, and both sinus opacification and overt dental pathology on CT. However, some patients will have subtle or absent dental pathology on CT. For suspected endodontic disease, endodontists should be consulted for at least cold pulp testing, and ideally cone-beam CT.