Macrophage polarization in human periapical lesions in relation to histopathological diagnosis, clinical features and lesion volume: An ex vivo study

AIM

To evaluate M1 and M2 macrophage polarization in radicular cysts and periapical granulomas through an immunohistochemical analysis and the correlation between macrophage polarization and histopathological diagnosis, clinical characteristics and lesion volume using cone-beam computed tomography.

METHODOLOGY

Periapical biopsies diagnosed as radicular cysts (n = 52) and periapical granulomas (n = 51) were analysed by immunohistochemical method. Teeth with periapical lesion with no history of root canal treatment (primary lesion) and lesions persistent to root canal treatment (persistent lesions) were included. Pathological diagnosis, patients' age, gender and clinical characteristics were obtained from treatment records. A cone-beam computed tomographic periapical volume index (CBCTPAVI) score was assigned to each periapical lesion based on the volume of the lesion. Immuno-expressions of CD68 and CD163 were quantified. The CD68/CD163 ratio was adopted to represent M1 or M2 macrophage polarization. Mann-Whitney U test was used to determine the different CD68/CD163 ratio between groups of radicular cyst and periapical granuloma. Spearman's correlation test was performed to assess the correlation between the CD68/CD163 ratio and lesion volume and CBCTPAVI score.

RESULTS

Radicular cysts and periapical granulomas had CD68/CD163 median of 2.05 (IQR = 1.33) and 1.26 (IQR = 0.81), respectively. A significantly higher CD68/CD163 ratio was observed in radicular cysts (p < .001). In contrast, periapical granulomas had significantly lower median of CD68/CD163 ratio. Larger lesions had a higher median of CD68/CD163 ratio, while smaller lesions had lower median of CD68/CD163 ratio (p = .007, rs = .262). CD68/CD163 ratio was significantly correlated with the CBCTPAVI score in the overall periapical lesions (p = .002, rs = .306). The higher CD68/CD163 ratio in larger lesions indicated a higher degree of M1 polarization compared to smaller lesions. Regarding the pathological diagnosis, there was a significant positive correlation between CBCTPAVI score and CD68/CD163 ratio in periapical granulomas (p < .001, rs = .453), whereas the negative correlation was observed for radicular cysts (p < .001, rs = -.471).

CONCLUSIONS

Periapical granulomas are characterized by a M2-dominant macrophage polarization, while radicular cysts have significantly higher M1 macrophages. The higher degree of M1 macrophage polarization was significantly correlated with larger volume and higher CBCTPAVI scores of overall periapical lesion and periapical granuloma.

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.

Is a Pre-Existent Cone-Beam Computed Tomography Able to Detect Metal Dental Posts?

(1) Background: In this study, the efficacy of cone-beam computed tomography (CBCT) in detecting dental posts was compared to periapical radiography. (2) Methods: A retrospective evaluation of 53 patients' periapical radiographs and CBCT images was performed. The presence and type of the intra-canal dental post were initially determined on the periapical images (PA) radiographs' examination and were then compared to the observer's ability to detect the dental post on a CBCT image. The effect of the post's type (metal cast or prefabricated) on its detection on CBCT images was determined. (3) Results: 10.5% of teeth that were identified as having a post on a PA radiograph were not identified as having a post on the CBCT examination (p < 0.05). Approximately 17.6% of teeth that were identified as not having a post on a PA radiograph were identified as having a post on the CBCT examination (p < 0.05). Moreover, 16.3% and 50% of teeth with a prefabricated or cast posts on PA radiographs were falsely identified on the CBCT examination, respectively (p < 0.05). (4) Conclusions: A CBCT image is an insufficient tool for the identification of metal prefabricated and cast posts. A PA image is the recommended radiographic tool for achieving information about the post-endodontic restoration status of teeth candidates for endodontic retreatment in patients with a former CBCT scan.

The trend of radiographic healing after root canal treatment in teeth with apical periodontitis based on cone-beam computed tomography: A 4-year longitudinal study

OBJECTIVES

The aim of this study was to observe the radiographic healing of periapical lesions after root canal treatment via volumetric measurements based on cone-beam computed tomography (CBCT) over 4 years.

METHODS

In total, 162 single-root teeth from patients with chronic periapical periodontitis who underwent primary root canal treatment were included in this retrospective study. Follow-up visits were scheduled at 1, 2, and 4 years after treatment. The volume of radiolucency at pretreatment and follow-up were measured, and the radiographic outcomes were classified into 4 categories: absence, reduction, uncertain or enlargement. Reduction or enlargement was considered when the volumetric change in radiolucency was 20 % or more.

RESULTS

During the 4-year follow-up period, 128 teeth were reviewed at least once, including 3 extracted teeth. Of the remaining 125 teeth, the volume of radiolucency was reduced in 116 teeth (90.6 %), uncertain in 5, and enlarged in 4 teeth during 1 to 4 years after treatment. Among the 43 teeth with reduced radiolucency at 1 year after treatment, 42 (97.7 %) had continuing reduced lesions at 4 years. In the 2 teeth with enlarged radiolucency at 1 year, the volume of radiolucency doubled at 4 years. Cox regression analysis revealed that the preoperative radiolucency size was a risk factor for persistent periapical radiolucency.

CONCLUSIONS

The efficacy of root canal treatment for apical periodontitis was predictable. When the radiolucency changed by 20 % or more in volume on CBCT scans at 1 year after treatment, reversal of the radiographic healing tendency was rare.

CLINICAL SIGNIFICANCE

The volumetric changes in radiolucency on CBCT could reflect trends in the healing process and may foster early clinical decision-making.

Outcome of Contemporary Nonsurgical Endodontic Retreatment: A Systematic Review of Randomized Controlled Trials and Cohort Studies

INTRODUCTION

The success rates of NS-ReTx have varied across decades of prior research. Nonetheless, recent endodontic advances have substantially enhanced case management. This systematic review aimed to identify rigorous studies on contemporary NS-ReTx, investigating both periapical healing-evaluated strictly for complete resolution or loosely for size reduction of periapical radiolucency-and success, denoting clinical normalcy combined with periapical healing.

METHODS

We systematically searched MEDLINE, Embase, Web of Science, the Cochrane Library, and gray literature from January 1988 to December 2022. Article selection and data extraction were independently conducted by 3 reviewers. Selected studies underwent risk of bias assessment, and evidence quality using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analysis and meta-regression established pooled outcome rates, 95% confidence intervals (CIs), and significant clinical prognostic factors (P < .05).

RESULTS

Twenty-nine articles were included. Pooled periapical healing rates using strict and loose criteria were 78.8% (95% CI: 75.2-82.4) and 87.5% (95% CI: 83.8-91.2), respectively. Pooled success rates using strict and loose criteria were 78.0% (95% CI: 74.9-81.2) and 86.4% (95% CI: 82.6-90.1), respectively. Meta-regression analyses revealed significant influences on NS-ReTx outcomes (P < .05), including periapical status, lesion size, apical root filling extent, and follow-up duration.

CONCLUSIONS

Contemporary NS-ReTx shows encouraging outcomes, achieving periapical healing and success rates ranging from approximately 78% (strict criteria) to 87% (loose criteria). The absence of or smaller preoperative lesions, adequate root filling length, and extended follow-ups significantly improve NS-ReTx outcomes. Integrating these factors into treatment planning is pivotal for optimizing the outcome of NS-ReTx.

Current Management of Dens Evaginatus Teeth Based on Pulpal Diagnosis

INTRODUCTION

Dens evaginatus (DE) is a dental anomaly with a supernumerary tubercle projection that typically contains dentin and pulp tissue. However, the tubercle projection can fracture, exposing the dentin and potentially the dental pulp, which induces pulpal diseases. Managing DE should be primarily based on the clinical diagnosis of the pulp.

METHODS

The literature search in prevalence, prophylaxis, and management of dens evaginatus was performed in PubMed database as well as by manual search, in which the related contents were collected and descriptively analyzed.

RESULTS

Of the 264 searched literatures, 62 articles were included for this scoping review. The prophylactic management of the tubercle of DE teeth with a normal pulp should be performed as early as possible by the prep-and-fill technique or the reinforcement technique to preserve tooth vitality and continued root development, with the former reported to be superior compared with the latter. Furthermore, DE teeth with reversible pulpitis should be managed with the prep-and-fill technique. For DE teeth with irreversible pulpitis, vital pulp therapy, ie, partial or full/coronal pulpotomy, should be considered when the pulpal inflammation is limited to the coronal pulp to preserve the vitality of the radicular pulp that induces apexogenesis. A pulpectomy should be performed if the pulpal inflammation has progressed into the radicular pulp. For DE teeth with pulpal necrosis (or after pulpectomy) and immature roots, mineral trioxide aggregate apexification or regenerative endodontic procedures are the treatment options. For DE teeth with pulpal necrosis and complete root formation, nonsurgical root canal treatment is the treatment of choice. A flow chart of the decision-making for managing DE teeth based on pulpal diagnosis is proposed.

CONCLUSION

DE teeth should be properly managed, by prophylaxis or treatment, depending on pulpal diagnosis and related factors.

Current Trends in Intentional Replantation Treatment Among Endodontists and Postgraduate Students in India, the United States of America, and the United Kingdom: A Cross-Sectional Study

Objective This study aimed to investigate the knowledge, attitude, and practices (KAP) of intentional replantation among postgraduate students and endodontists in India, the United States of America, and the United Kingdom. Materials and methods The sample size was estimated using G*Power. Based on the pilot study done before with 60 participants, a sample size of 928 was obtained. The survey consisted of 22 questions, which were finalized after content validation by two endodontic experts. It was circulated through multiple online social platforms such as Instagram, Facebook, WhatsApp, and other online dental communities/channels. The respondents were questioned about the case selection, extraction methods, antibiotic therapy, patient acceptance level, operator preference, prognostic indicator, and various other steps in the intentional replantation treatment modality. The data for this KAP survey were organized in an Excel sheet, and statistical analysis was done using the Chi-squared test. Analysis of descriptive and inferential statistics was conducted using SPSS version 20.0 (IBM Inc., Armonk, New York). A p-value of <0.05 was considered significant. Results A strong statistical difference was found in the KAP of the practitioners in different countries. The vast majority (72.7%) considered intentional replantation as an adjunct treatment modality rather than a last resort. A total of 76.5% of the respondents preferred replantation of the tooth into the socket within 15 minutes, and 86.4% of the participants regarded replantation as the most cost-effective treatment modality. Ultrasonics (76.8%) was most commonly chosen for retrograde preparation, and Biodentine (60.1%; Septodont, Saint-Maur-des-Fossés, France) as root-end filling material. Conclusion It can be concluded that a broad majority of practitioners in different countries view intentional replantation as an adjunct treatment modality rather than a last resort. Thus, intentional replantation seems to be a promising option for preserving the natural dentition of teeth with high survival rates and better outcomes.

Single versus multiple visits for endodontic treatment of permanent teeth

BACKGROUND

Root canal treatment (RoCT), or endodontic treatment, is a common procedure in dentistry. The main indications for RoCT are irreversible pulpitis and necrosis of the dental pulp caused by carious processes, coronal crack or fracture, or dental trauma. Successful RoCT is characterised by an absence of symptoms (i.e. pain) and clinical signs (i.e. swelling and sinus tract) in teeth without radiographic evidence of periodontal involvement (i.e. normal periodontal ligament). The success of RoCT depends on a number of variables related to the preoperative condition of the tooth, as well as the endodontic procedures. RoCT can be carried out with a single-visit approach, which involves root canal system obturation (filling and sealing) directly after instrumentation and irrigation, or with a multiple-visits approach, in which the treatment is completed in two or more sessions and obturation is performed in the last session. This review updates the previous versions published in 2007 and 2016.

OBJECTIVES

To evaluate the benefits and harms of completion of root canal treatment (RoCT) in a single visit compared to RoCT over two or more visits, with or without medication, in people aged over 10 years.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 25 April 2022.

SELECTION CRITERIA

We included randomised controlled trials and quasi-randomised controlled trials in people needing RoCT comparing completion of RoCT in a single visit compared to RoCT over two or more visits.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. tooth extraction and 2. radiological failure after at least one year (i.e. periapical radiolucency). Our secondary outcomes were 3. postoperative and postobturation pain; 4. swelling or flare-up; 5. analgesic use and 6. presence of sinus track or fistula after at least one month. We used GRADE to assess certainty of evidence for each outcome. We excluded five studies that were included in the previous version of the review because they did not meet the current standard of care (i.e. rubber dam isolation and irrigation with sodium hypochlorite).

MAIN RESULTS

We included 47 studies with 5805 participants and 5693 teeth analysed. We judged 10 studies at low risk of bias, 17 at high risk of bias and 20 at unclear risk of bias. Only two studies reported data on tooth extraction. We found no evidence of a difference between treatment in one visit or treatment over multiple visits, but we had very low certainty about the findings (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.09 to 2.50; I2 = 0%; 2 studies, 402 teeth). We found no evidence of a difference between single-visit and multiple-visit treatment in terms of radiological failure (RR 0.93, 95% CI 0.81 to 1.07; I2 = 0%; 13 studies, 1505 teeth; moderate-certainty evidence). We found evidence of a higher proportion of participants reporting pain within one week in single-visit groups compared to multiple visit groups (RR 1.55, 95% CI 1.14 to 2.09; I2 = 18%; 5 studies, 638 teeth; moderate-certainty evidence).  We found no evidence of a difference in the proportion of participants reporting pain until 72 hours postobturation (RR 0.97, 95% CI 0.81 to 1.16; I2 = 70%; 12 studies, 1329 teeth; low-certainty evidence), pain intensity until 72 hours postobturation (mean difference (MD) 0.26, 95% CI -4.76 to 5.29; I2 = 98%; 12 studies, 1258 teeth; low-certainty evidence) or pain at one week postobturation (RR 1.05, 95% CI 0.67 to 1.67; I2 = 61%; 9 studies, 1139 teeth; very low-certainty evidence). We found no evidence of a difference in swelling or flare-up incidence (RR 0.56 95% CI 0.16 to 1.92; I2 = 0%; 6 studies; 605 teeth; very low-certainty evidence), analgesic use (RR 1.25 95% CI 0.75 to 2.09; I2 = 36%; 6 studies, 540 teeth; very low-certainty evidence) or sinus tract or fistula presence (RR 1.00, 95% CI 0.24 to 4.28; I2 = 0%; 5 studies, 650 teeth; very low-certainty evidence). Subgroup analysis found no differences between single-visit and multiple-visit RoCT for considered outcomes other than proportion of participants reporting post-treatment pain within one week, which was higher in the single-visit groups for vital teeth (RR 2.16, 95% CI 1.39 to 3.36; I2 = 0%; 2 studies, 316 teeth), and when instrumentation was mechanical (RR 1.80, 95% CI 1.10 to 2.92; I2 = 56%; 2 studies, 278 teeth).

AUTHORS' CONCLUSIONS

As in the previous two versions of the review, there is currently no evidence to suggest that one treatment regimen (single-visit or multiple-visit RoCT) is more effective than the other. Neither regimen can prevent pain and other complications in the 12-month postoperative period. There was moderate-certainty evidence of higher proportion of participants reporting pain within one week in single-visit groups compared to multiple-visit groups. In contrast to the results of the last version of the review, there was no difference in analgesic use.

Factors related to apical periodontitis in a southern Brazilian population: a multilevel analysis

The aim of this cross-sectional study was to evaluate the effects of individual-level and tooth-level factors on apical periodontitis (AP) in an urban population in southern Brazil. A random sample of digital panoramic radiographs (n = 545) from a dental school database was evaluated. The diagnosis of AP was determined by using a dichotomous scale (yes/no). AP was assessed according to gender, age, presence and quality of endodontic treatment (ET), presence of an intracanal post, coronal condition, and dental group. Data were analyzed descriptively and through multilevel Poisson regression analysis, considering teeth characteristics (level 1) nested in individuals (level 2). In this sample of 545 participants, the prevalence of AP was 49.5% (n =2 70) and ET was 43.5% (n = 237). Considering 13,595 teeth, AP was identified in 596 (4.4%) and ET in 617 (4.5%). Of the teeth with ET, 153 (24.8%) presented AP. Among individual-level factors, the disease was not significantly associated with gender or age. For tooth-level factors, AP was significantly associated with ET quality: teeth with short fillings (< 3 mm) and teeth with over-fillings had 2.77 (CI: 1.95-3.94, p < 0.001) and 1.08 (CI: 0.39-2.98, p < 0.001) higher prevalence of AP, respectively. There was no association between AP and age, gender, dental group, coronal condition, or the presence of an intracanal post. AP was highly prevalent in this population, and multilevel analysis indicated a significant association with ET quality.

Outcomes reporting in systematic reviews on surgical endodontics: A scoping review for the development of a core outcome set

BACKGROUND

Evidence-informed decision-making in healthcare relies on the translation of research results to everyday clinical practice. A fundamental requirement is that the validity of any healthcare intervention must be supported by the resultant favourable treatment outcome. Unfortunately, differences in study design and the outcome measures evaluated often make it challenging to synthesise the available research evidence required for secondary research analysis and guideline development. Core outcome sets (COS) are defined as an agreed standardised set of outcomes which should be measured and reported as a minimum in all clinical trials on a specific topic. The benefits of COS include less heterogeneity, a reduction in the risk of reporting bias, ensuring all trials contribute data to facilitate meta-analyses, and given the engagement of key stakeholders, it also increases the chances that clinically-relevant outcomes are identified. The recognition of the need for COS for assessing endodontic treatment outcomes lead to the development of Core Outcome Sets for Endodontic Treatment modalities (COSET) protocol, which is registered (No. 1879) on the Core Outcome Measures in Effectiveness Trials (COMET) website.

OBJECTIVES

The objectives of this scoping review are to: (1) identify the outcomes assessed in studies evaluating surgical endodontic procedures; (2) report on the method of assessment used to measure the outcomes; (3) and assess selective reporting bias in the included studies. The data obtained will be used to inform the development of COS for surgical endodontics.

METHODS

A structured literature search of electronic databases and the grey literature was conducted to identify systematic reviews on periradicular surgery (PS), intentional replantation (IR) and tooth/root resection (RR), published between January 1990 and December 2020. Two independent reviewers were involved in the literature selection, data extraction and the appraisal of the studies identified. The type of intervention, outcomes measured, type of outcomes reported (clinician- or patient-reported), outcome measurement method, and follow-up period, were recorded using a standardised form.

RESULTS

Twenty-six systematic reviews consisting of 19 studies for PS, three studies for IR and four studies for RR were selected for inclusion. Outcome measures identified for PS and IR included pain, swelling, mobility and tenderness, outcomes related to periodontal/soft tissue healing (including sinus tract), periradicular healing, tooth survival, life impact (including Oral-Health-Related-Quality-of-Life), resource use and/or adverse effects. For RR, in addition to tooth survival, endodontic complications, and adverse effects, the outcome measures were primarily periodontal-related, including pocket depth reduction, attachment gain, periodontal disease, and periodontic-endodontic lesions. The majority of outcome measures for PS, IR, and RR were assessed clinically, radiologically and/or via patient history. Specific tools such as rating scales (Visual Analog Scale, Verbal rating Scale, Numerical Rating Scale, and other scales) were used for the assessment of pain, swelling, and tenderness, and validated questionnaires were used for the assessment of oral health-related quality of life. The range of follow-up periods were variable, dependent on the outcome measure and the type of intervention.

CONCLUSIONS

Outcome measures, method of assessment and follow-up periods for PS, IR and RR were identified and categorised to help standardise the reporting of outcomes for future research studies. Additional outcome measures that were not reported, but may be considered in the COSET consensus process include loss of root-end filling material, number of clinic visits, surgery-related dental anxiety and muco-gingival aesthetic-related measures, such as scarring, black triangles, root surface exposure, and tissue discolouration.

Outcomes of Primary Root Canal Therapy: An updated Systematic Review of Longitudinal Clinical Studies Published between 2003 and 2020

Background

A comprehensive effort to evaluate outcomes of primary root canal therapy (RCT) between 1966 and 2002 was published by Ng et al. (2007, International Endodontic Journal, 40, 921; 2008, International Endodontic Journal, 41, 6). Changes in endodontic materials and treatment methods warrant an updated analysis of outcomes.

Objectives

This study aimed to (1) quantify the success rates of primary RCT published between 2003 and 2020; and (2) investigate the influence of some characteristics known/suspected to be associated with treatment outcomes.

Methods

An electronic search was performed in the following databases (01‐01‐2003 to 12‐31‐2020): Pubmed, Embase, CINHAL, Cochrane and Web of Science. Included study designs were longitudinal clinical studies (randomized control trials, cohort studies, retrospective observational studies). Studies with at least twelve‐months of post‐operative review and success rates based on clinical and radiographic criteria were analysed. The terms ‘strict’ (complete resolution of periapical lesion) or ‘loose’ (reduction in size of existing periapical lesion) were used to describe the outcome criteria. Weighted, pooled success rates were calculated. Random effects meta‐regression models were used to investigate potential sources of statistical heterogeneity. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate for quality assessment of the included studies.

Results

Forty‐two studies were included in the review. Meta‐analyses showed that the weighted pooled success rates were estimated to be 92.6% (95% CI: 90.5%–94.8%) under ‘loose criteria’ and 82.0% (95% CI: 79.3%–84.8%) under ‘strict’ criteria. The most significant areas of study heterogeneity were year of publication and qualification of operator. The majority (64.29%) of studies were considered to be of low quality of evidence.

Discussion

Biological factors continue to have the most significant impact on RCT outcomes. The technological method of instrumentation had no significant effect. The quality of evidence was based primarily on study design and only randomized control trials were considered to be ‘high’ quality of evidence.

Conclusions

The reported success rates show improvement over time. Weighted success rates for studies with a minimum of four‐years follow‐up had better outcomes, compared to those with less than four years, when ‘strict criteria’ were used.

Registration

PROSPERO database (CRD42021226311).

Psycho-social perspectives of nonsurgical versus surgical endodontic interventions in persistent endodontic disease

INTRODUCTION

Patients' experiences related to dental treatment could influence care-seeking behaviour and engender personal bias. Although endodontic retreatment and apical surgery are procedures often performed to manage previously treated teeth with persistent disease, there is lack of information regarding psycho-social perspectives of patients who undergo these treatments. Our aim was to compare experiences of patients who received these two treatment modalities using a qualitative approach.

METHODS

A purposive sample of patients was taken from our previous study utilizing the Oral Health Impact Profile to compare oral health-related quality of life of 150 patients who received retreatment and apical surgery. Patients who reported impact and no impact were invited to participate in focus group discussions (FGDs). Eighteen patients from the retreatment group and 15 patients from the surgical group participated in six FGDs. Thematic analysis was conducted to identify key themes.

RESULTS

Four themes emerged: (1) psycho-social disability associated with dental procedures, (2) physical disability associated with dental problems, (3) reliance on dentist's advice for treatment and (4) self-management to preserve treated teeth. Patients undergoing endodontic retreatment reported significant time loss from work and were less informed of alternative treatment options. However, they were pleased with the aesthetics of their teeth, especially if new crowns were made. Patients undergoing surgery experienced anxiety related to loss of control during surgery and apprehension on visualizing the wound post-surgery. They reported more impact on their diet, social interaction and sleep quality and some felt self-conscious due to post-treatment gingival recession. Patients in both groups placed great trust in professional advice and expressed a clear desire to maintain their natural dentition. There was low awareness regarding long-term care and future sequelae of their treated tooth.

CONCLUSIONS

Patients reported different psycho-social and physical impacts following endodontic retreatment and apical surgery. Patients undergoing endodontic retreatment were more satisfied with aesthetic outcomes but experienced greater impact related to complexities and length of time taken for treatment. Patients undergoing surgery were better informed of treatment options but experienced greater physical and psycho-social disability during the recovery phase. Clinicians could consider incorporating findings from this study into the patient-dentist discussion.

Evaluation of irrigation techniques in the removal of root canal filling material: Micro-CT and SEM study

Background/Aim: This study aimed to compare the different irrigation activation methods in retreatment of oval-shaped root canals. Material and Methods: Forty distal canals from mandibular molars were filled. After the removal of filling material, specimens were assigned to four groups as follows; control, passive ultrasonic irrigation (PUI), self-adjusting file (SAF), and XP-endo Finisher (XPF). The amount of residual filling material was assessed by micro-computed tomography (micro-CT) and root canal walls were examined by using scanning electrom microscopy (SEM). Data were analyzed using the Kruskal-Wallis and Dunn test. Results: None of the activation techniques removed root canal remnants completely. The amount of filling material significantly decreased in all activation techniques compared to the control group (p<0.05). There was no significant difference between the PUI, SAF, and XPF groups in the micro-CT analysis (p>0.05). SEM evaluation showed higher scores in the apical region in all groups (p<0.05). Conclusions: The use of activation methods reduces the amount of residual filling material.

Is Coronal Restoration a Predictor of Posttreatment Apical Periodontitis?

Objectives  To investigate the posttreatment apical periodontitis (AP) in endodontically treated teeth through a multivariate approach and to analyze the relative importance of quality and type of coronal restoration as predictors of periapical disease.

Materials and Methods  The present study sample was drawn within 2-year period from the 1,072 consecutive patients older than 18 years, first time attending the Dental Clinic of the Clinical Hospital Center Rijeka, Croatia. A total of 1,350 endodontically treated teeth were included in the study. For each tooth, the periapical status, root filling quality, intracanal post, separated file presence, marginal bone loss, and quality and type of coronal restoration were recorded.

Statistical Analysis  Chi-square tests were used to analyze the variations in the periapical status, quality of root canal filling, and quality of coronal restoration in different tooth types. The effect of explanatory variables on periapical status was explored using univariate and multivariate logistic regression models. The outcome variable was set as the presence versus absence of AP in the tooth.

Results  Multivariate logistic regression analysis revealed statistically significant associations and increased risk for AP presence in molars (odds ratio [OR] = 2.15; p  < 0.001), teeth positioned in mandible (OR = 1.49; p  = 0.007), teeth with short length of root filling (OR = 4.08; p  < 0.001), overfilled teeth (OR = 2.99; p  = 0.001), and teeth with inadequate density of root filling (OR = 4.14; p  < 0.001). Considering variables related to coronal restoration, neither coronal restoration type nor quality was found to be predictive for posttreatment AP. Merely, the presence of intracanal post significantly increased the odds of AP presence (OR = 1.57; p  = 0.009).

Conclusion  The results of the present study did not indicate that type or quality of coronal restoration may be predictors of posttreatment AP. Periapical disease was significantly associated with molars, mandibular teeth, substandard quality of root fillings, and intracanal post presence.

The effect of retrograde material type and surgical techniques on the success rate of surgical endodontic retreatment: systematic review of prospective randomized clinical trials

Background

Endodontic surgical procedures, when performed, require retrograde filling materials that are biocompatible, non-toxic, non-irritant, dimensionally stable, and ideally promote bone formation. Precise evaluation of retrograde filling materials in clinical trials is necessary to give holistic view for properties of material and potential outcome from its use. The purpose of this review is to evaluate the effect of retrograde material type and surgical techniques on the success rate of surgical endodontic retreatment.

Methods

An electronic search was performed in the time frame between 1st of January 2000 to 1st of September 2020 using database.

Sources

Web of Science, PubMed and redundant hand searches through their references. Seven inclusion–exclusion criteria were set for the selection and identification of relevant articles. Risk of bias was conducted for the included studies.

Results

Nine randomized clinical trials (RCTs) fulfilled the inclusion criteria for this systematic review. The outcome of this review revealed that none of the reviewed trials totally-fulfilled CONSORT 2010 criteria.

Conclusions

In light of the outcome of this review, there is no enough evidence to support the superiority of certain retrograde filling material or surgical technique over another in the success rate of surgical endodontics retreatment. The variety of methodologies and strategies, such as patient selection, the method of treatment and study analysis, led to doubtful credibility of the obtained clinical evidence. Further prospective randomized controlled clinical trials evaluating the specific effect of the various used materials are needed.

Effect of prosthetic restorations and root canal fillings on periapical health in a selected patient group

Aims To examine the effect of the quality of root canal fillings and prosthetic restorations on the frequency of apical periodontitis (AP).Methodology A total of 200 radiographs of 1,098 teeth with indirect restorations were selected. Each case was documented by age, sex, tooth location, tooth type, restoration type and presence of root canal treatment (RCT). Teeth were categorised as healthy or diseased considering periapical health. The quality of RCT and prosthetic restorations was categorised by radiographic and clinical examinations. Data were analysed using chi-squared test and logistic regression.Results Inadequate prosthetic restorations were found to be less healthy than the adequate ones. Statistical significance was found in teeth with RCT, which had a higher rate of AP (15.8%). Root-filled teeth categorised as inadequately treated (24.1%) were significantly unhealthier than the adequately root-filled teeth. Teeth with inadequate prosthetic restorations and RCT had an increase in AP risk of 6.41 and 20.74 times, respectively (p <0.05).Conclusions Results showed that AP risk was increased by both inadequate RCT and prosthetic restorations. Quality of RCT significantly affected periapical health more than the quality of prosthetic restorations. Not only radiographic but also clinical examination of restorations is required for successful evaluation.

Microsurgical endodontic treatment of the upper molar teeth and their relationship with the maxillary sinus: a retrospective multicentric clinical study

PURPOSE

To assess the clinical and radiographic success rate of microsurgical endodontic treatment of upper molar teeth in relationship with the maxillary sinus, with 12 months follow-up.

METHODS

Patients treated with microsurgical endodontic treatment of upper molar teeth in the period between 2017 and 2019 were recruited from two dental clinics according to specific selection criteria. The outcomes were determined based on clinical and radiographic results taken three, six and 12 months post-operatively, compared with those taken immediately before and after surgery. Clinical and radiographic outcomes were recorded. The distance between the most apical part of the root and of the lesion to the maxillary sinus was measured on CBCT images before the surgery. Patient-related outcomes were recorded.

RESULTS

Out of 35 patients evaluated, 21 were selected according with the selection criteria for a total of 27 roots and 29 canals treated. After 12 months, 18 patients showed a complete healing whereas three demonstrated incomplete healing. Consequently, the success rate in this study was 85.7% after one year. In 28.5% (6 patients) there was a perforation of the Schneiderian membrane that didn't seem to affect the outcome. All patients kept the molar one year later. The pain level decreased significantly over the time during the first week after surgery.

CONCLUSION

Microsurgical Endodontic treatment of the upper molar teeth should be considered a valid and predictable treatment option even in case of Schneiderian membrane perforation. Future clinical studies with a larger sample size are needed to compare the results obtained.

Nonsurgical endodontic management of mandibular first premolar with incomplete root-end resection

The complexity of the nonsurgical endodontic retreatment should be weighed against the benefit of surgical approach. This case report describes uncommon diagnosis and successful nonsurgical endodontic management of mandibular first premolar with a previous history of failed apicoectomy and incomplete root-end resection using mineral trioxide aggregate and cone-beam computed tomography.

Comparative Evaluation of Fracture Resistance of Endodontically Treated Teeth Restored with Different Core Build-up Materials: An In Vitro Study

The aim is to evaluate the fracture resistance of endodontically treated teeth restored with posterior direct composite (PRC) resin, bulk-fill composite resin, dual-cure composite (DCC) resin, and short fiber-reinforced composite (SFC) resin material.

Histological and Radiological Features of a Four-Phase Injectable Synthetic Bone Graft in Guided Bone Regeneration: A Case Report

BACKGROUND AND OBJECTIVE

Injectable synthetic bone grafts (ISBG) are widely used biomaterials for regeneration purposes. The aim of this case report was to examine the efficacy of ISBG in the management of buccal fenestration in the case of a 25-year-old female.

CASE REPORT

After a traumatic tooth extraction, the defect was filled with ISBG and covered with a resorbable membrane. The ISBG showed easy handling and the patient had no complications during healing. Six months after augmentation, a bone biopsy was taken during implant bed preparation. The histological results showed good integration of ISBG into the newly formed bone and no signs of tissue inflammation. Additionally, a CBCT (cone beam computed tomography) analysis was performed to support the histological results.

CONCLUSION

The use of the examined ISBG led to successful treatment of the buccal fenestration defect.

Four-year Outcome of Nonsurgical Root Canal Retreatment Using Cone-beam Computed Tomography: A Prospective Cohort Study

INTRODUCTION

The purpose of this prospective study was to investigate the 4-year outcome and prognostic factors of nonsurgical root canal retreatment determined by measuring the volumetric change of periapical radiolucencies on cone-beam computed tomographic (CBCT) scans.

METHODS

Ninety-seven endodontically treated teeth from 80 patients diagnosed as apical periodontitis and indicated for root canal retreatment were included. Retreatment was performed by 7 endodontic specialists using a standardized treatment protocol. The teeth were reexamined clinically and radiographically 48-67 months after retreatment. The volume of preoperative and postoperative periapical radiolucencies on CBCT images was independently measured by 2 examiners. Radiographic outcome is presented in 4 categories: absence, reduction, enlargement, or unchanged. Reduction or enlargement was determined when the volumetric change of radiolucency was 20% or more. Multivariate logistic regression was performed for predictor analysis.

RESULTS

Sixty-two teeth (63.9%) from 50 patients returned for follow-up. Fifty-eight teeth were included in the prognostic analysis, all of which were symptom free. The 4 remaining teeth that had been extracted because of fracture were excluded. The total volume of periapical radiolucencies at 4 years postoperatively decreased by 94.6% compared with that preoperatively (P < .001), with an average reduction of 83.4% (95% confidence interval, 69.2%-97.5%). The periapical radiolucencies were determined as absence in 44 teeth (75.9%), reduction in 10 teeth (17.2%), unchanged in 1 tooth (1.7%), and enlargement in 3 teeth (5.2%). Tooth type was identified as an outcome predictor (P < .05).

CONCLUSIONS

The 4-year outcome of endodontic retreatment is predictable, with a significant volumetric reduction in periapical radiolucencies.

Radiographic and Clinical Findings of Single-Visit Root Canal Treatments with Apical Enlargement in Necrotic Teeth: A Retrospective Cohort Study

This study evaluated the long-term clinical outcomes of single-visit root canal treatments with apical enlargement on patients with necrotic pulp tissue retrospectively. A total of 137 teeth with necrotic pulp tissue which underwent single-visit root canal treatments were included. The root canals were shaped up until the apical constriction, which was determined by an apex locator. The outcomes were evaluated by two independent and calibrated endodontists clinically and radiographically. Teeth were dichotomized into healed (PAI ≤ 2, no signs or symptoms) and nonhealed (PAI > 2, with/without signs or symptoms) groups. Each patients' preoperative PAI and lesion size were recorded to evaluate the preoperative periapical status as well as several other prognostic factors. Statistical analyses were performed (p = 0.05) on ninety teeth. The mean observation time was 60 months. Out of ninety teeth, 87 (96.7%) were healed and 3 (3.3%) were nonhealed. No correlations were found between the prognostic factors and the outcomes (p > 0.05). Cohen's kappa and Gwet's agreement coefficient scores between the preoperative PAI scores and preoperative lesion sizes showed good agreements, with values of 0.834 and 0.898, respectively. Apical enlargement is a viable treatment option for single-visit root canal treatments.

Intentional replantation - a clinical review of cases undertaken at a major UK dental school

Introduction Intentional replantation (IR) may offer a solution for persistent periapical lesions associated with endodontically treated teeth in select cases. This case series demonstrates the use of IR as an alternative treatment approach to both orthograde and surgical endodontic retreatment. The indications, contraindications, benefits and risks of IR are discussed, and the clinical procedure is outlined.Setting Restorative Department, University Dental Hospital of Manchester, UK.Case reports Of the 13 cases presented, the follow-up period before discharge ranged from 3-28 months. Only one tooth which presented intra-operative challenges required extraction three months after IR due to post-operative mobility.Conclusion In select cases, IR may provide a simple, less invasive and cost-effective alternative to both endodontic retreatment and extraction alone following appropriate training.

A Rare Case of Single-Rooted Mandibular Second Molar with Single Canal

The root canal anatomy of mandibular second molar teeth is known to be highly variable. Whilst the most frequently seen configuration is two mesial canals and one distal canal, other variations such as four canals, two canals, and C-shaped canal system do also exist. This case report describes the diagnosis and management of unusual root canal configuration of a mandibular second molar, with one canal in a single conical root, using the contemporary advancements in endodontics. Following clinical and radiographic examinations of the case, a diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis of tooth #47 was established, and root canal treatment followed by composite buildup and crown were planned. Clinicians should be aware of the different anatomic variants each tooth may exhibit. Furthermore, clinicians need to possess the proper knowledge and skills that allow them to utilize the diagnostic and therapeutic tools available at their disposal in order to optimize the quality of care provided to their patients.

Clinical guideline and treatment planning decisions of single-tooth implants versus preserving natural teeth with nonsurgical endodontic therapy

The outcomes of both dental implants and endodontically treated teeth have been extensively studied. An assessment of whether to rehabilitate a tooth requiring endodontic treatment or to replace it with a dental implant can often involve a challenging and complex decision making process for clinicians now a days. This review describes practical criteria and a systematic process to aid the treatment planning decision of whether to preserve teeth by root canal treatment (RCT) or extract and provide an implant. This article reviews the benefits and disadvantages of both treatment options and discusses success vs. survival outcomes.

Cytocompatibility of 3D printed dental materials for temporary restorations on fibroblasts

Background

Three-dimensional (3D) printing is widely used in the fabrication of dental prostheses; however, the influence of dental materials used for 3D printing on temporary restoration of fibroblasts in tissues is unclear. Thus, the influence of different dental materials on fibroblasts were investigated.

Methods

Digital light processing (DLP) type 3D printing was used. Specimens in the control group were fabricated by mixing liquid and powder self-curing resin restoration materials. The temporary resin materials used were Model, Castable, Clear-SG, Tray, and Temporary, and the self-curing resin materials used were Lang dental, Alike, Milky blue, TOKVSO CUREFAST, and UniFast III. Fibroblast cells were cultured on each specimen and subsequently post-treated for analysis. Morphology of the adhered cells were observed using a confocal laser scanning microscope (CLSM) and a scanning electron microscope (SEM).

Results

CLSM and SEM cell imaging revealed that the 3D printed material group presented better cell adhesion with well-distributed filopodia compared to that in the conventional resin material group. Cell proliferation was significantly higher in the 3D printing materials.

Conclusion

Superior cytocompatibility of the specimens fabricated through 3D printing and polishing process was demonstrated with the proof of better cell adhesion and higher cell proliferation.

The association between clinical diagnostic factors and the prevalence of vertical root fracture in endodontic surgery

BACKGROUND/PURPOSE

Diagnosis of vertical root fractures (VRFs) can often be challenging due to the similarity of signs and symptoms with other common dental infectious diseases. This study was aimed at evaluating the potential relationship between VRFs and commonly used clinical diagnostic factors.

METHODS

330 root-filled teeth with endodontic failures were subjected to endodontic microsurgery over a six-year period. VRFs were identified in 61 teeth. A randomly age- and sex-matched retrospective case-control study was conducted on a subset of 59 root-filled teeth with VRFs (cases) and 177 root-filled teeth without VRFs (controls). The strength of association between preoperative signs and radiographic findings and VRFs was evaluated using logistic regression model.

RESULTS

Sinus tract, periodontal pocket depth ≥5 mm, periodontal swelling or abscess, and radiological image of J-shaped or "halo" radiolucency were significantly more frequent in cases than in controls (p < 0.05). With regard to logistic regression analysis, J-shaped or "halo" radiolucency demonstrated the greatest association with VRF, followed by periodontal pocket depth ≥5 mm, sinus tract, and periodontal swelling or abscess. Approximately 70% of cases manifested themselves as combinations of at least two of these factors. Teeth having two and three or four of these factors had 3.14 times and 11.64 times higher risks for the presentations of VRFs, respectively (p < 0.001).

CONCLUSION

The major risk for VRFs was represented by those presenting radiological image of J-shaped or "halo" radiolucency, periodontal pocket depth ≥5 mm, sinus tract, and periodontal swelling or abscess simultaneously.

Post-treatment apical periodontitis related to the technical quality of root fillings and restorations in Thai population

The aim of this study was to investigate the post-treatment apical periodontitis in endodontically treated teeth related to the technical quality of root fillings and restorations in Thai population. Full-mouth periapical radiographs from Thai patients attending the Faculty of Dentistry, Mahidol University, Thailand were examined. The periapical status, quality of root fillings and coronal restorations, existence of intraradicular post and its relationship to the root fillings were evaluated. Among 1586 patients, 37.4% presented endodontically treated teeth. The total number of endodontically treated teeth was 1511, and 35% presented apical periodontitis. Combined data for root filling and coronal restoration qualities revealed significantly better outcome in teeth with adequate qualities of both parameters than the other combinations (P < 0.001). The prevalence of post-treatment apical periodontitis among Thai population was relatively high and significantly associated with substandard technical quality of root fillings and restorations.

The use of Bioceramics as root-end filling materials in periradicular surgery: A literature review

Introduction

Periradicular surgery involves the placement of a root-end filling following root-end resection, to provide an apical seal to the root canal system. Historically several materials have been used in order to achieve this seal. Recently a class of materials known as Bioceramics have been adopted. The aim of this article is to provide a review of the outcomes of periradicular surgery when Bioceramic root-end filling materials are used on human permanent teeth in comparison to "traditional" materials.

Methods & results

An electronic literature search was performed in the databases of Web of Science, PubMed and Google Scholar, between 2006 and 2017, to collect clinical studies where Bioceramic materials were utilised as retrograde filling materials, and to compare such materials with traditional materials. In this search, 1 systematic review and 14 clinical studies were identified. Of these, 8 reported the success rates of retrograde Bioceramics, and 6 compared treatment outcomes of mineral trioxide aggregate (MTA) and traditional cements when used as root-end filling materials.

Conclusion

Bioceramic root-end filling materials are shown to have success rates of 86.4-95.6% (over 1-5 years). Bioceramics has significantly higher success rates than amalgam, but they were statistically similar to intermediate restorative material (IRM) and Super ethoxybenzoic acid (Super EBA) when used as retrograde filling materials in apical surgery. However, it seems that the high success rates were not solely attributable to the type of the root-end filling materials. The surgical/microsurgical techniques and tooth prognostic factors may significantly affect treatment outcome.

Single versus multiple visits for endodontic treatment of permanent teeth

BACKGROUND

Root canal treatment (RoCT), or endodontic treatment, is a common procedure in dentistry. The main indications for RoCT are irreversible pulpitis and necrosis of the dental pulp caused by carious processes, tooth cracks or chips, or dental trauma. Successful RoCT is characterised by an absence of symptoms (i.e. pain) and clinical signs (i.e. swelling and sinus tract) in teeth without radiographic evidence of periodontal involvement (i.e. normal periodontal ligament). The success of RoCT depends on a number of variables related to the preoperative condition of the tooth, as well as the endodontic procedures. This review updates the previous version published in 2007.

OBJECTIVES

To determine whether completion of root canal treatment (RoCT) in a single visit or over two or more visits, with or without medication, makes any difference in term of effectiveness or complications.

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 14 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 5), MEDLINE Ovid (1946 to 14 June 2016), and Embase Ovid (1980 to 14 June 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 14 June 2016. We did not place any restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of people needing RoCT. We excluded surgical endodontic treatment. The outcomes of interest were tooth extraction for endodontic problems; radiological failure after at least one year, i.e. periapical radiolucency; postoperative pain; swelling or flare-up; painkiller use; sinus track or fistula formation; and complications (composite outcome including any adverse event).

DATA COLLECTION AND ANALYSIS

We collected data using a specially designed extraction form. We contacted trial authors for further details where these were unclear. We assessed the risk of bias in the studies using the Cochrane tool and we assessed the quality of the body of evidence using GRADE criteria. When valid and relevant data were collected, we undertook a meta-analysis of the data using the random-effects model. For dichotomous outcomes, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). For continuous data, we calculated mean differences (MDs) and 95% CIs. We examined potential sources of heterogeneity. We conducted subgroup analyses for necrotic and vital teeth.

MAIN RESULTS

We included 25 RCTs in the review, with a total of 3780 participants, of whom we analysed 3751. We judged three studies to be at low risk of bias, 14 at high risk, and eight as unclear.Only one study reported data on tooth extraction due to endodontic problems. This study found no difference between treatment in one visit or treatment over multiple visits (1/117 single-visit participants lost a tooth versus 2/103 multiple-visit participants; odds ratio (OR) 0.44, 95% confidence interval (CI) 0.04 to 4.78; very low-quality evidence).We found no evidence of a difference between single-visit and multiple-visit treatment in terms of radiological failure (risk ratio (RR) 0.91, 95% CI 0.68 to 1.21; 1493 participants, 11 studies, I² = 18%; low-quality evidence); immediate postoperative pain (dichotomous outcome) (RR 0.99, 95% CI 0.84 to 1.17; 1560 participants, 9 studies, I² = 33%; moderate-quality evidence); swelling or flare-up incidence (RR 1.36, 95% CI 0.66 to 2.81; 281 participants, 4 studies, I² = 0%; low-quality evidence); sinus tract or fistula formation (RR 0.98, 95% CI 0.15 to 6.48; 345 participants, 2 studies, I² = 0%; low-quality evidence); or complications (RR 0.92, 95% CI 0.77 to 1.11; 1686 participants, 10 studies, I² = 18%; moderate-quality evidence).The studies suggested people undergoing RoCT in a single visit may be more likely to experience pain in the first week than those whose RoCT was over multiple visits (RR 1.50, 95% CI 0.99 to 2.28; 1383 participants, 8 studies, I² = 54%), though the quality of the evidence for this finding is low.Moderate-quality evidence showed people undergoing RoCT in a single visit were more likely to use painkillers than those receiving treatment over multiple visits (RR 2.35, 95% CI 1.60 to 3.45; 648 participants, 4 studies, I² = 0%).

AUTHORS' CONCLUSIONS

There is no evidence to suggest that one treatment regimen (single-visit or multiple-visit root canal treatment) is better than the other. Neither can prevent all short- and long-term complications. On the basis of the available evidence, it seems likely that the benefit of a single-visit treatment, in terms of time and convenience, for both patient and dentist, has the cost of a higher frequency of late postoperative pain (and as a consequence, painkiller use).

Endodontic procedures for retreatment of periapical lesions

BACKGROUND

When primary root canal therapy fails, periapical lesions can be retreated with or without surgery. Root canal retreatment is a non-surgical procedure that involves removal of root canal filling materials from the tooth, followed by cleaning, shaping and obturating of the canals. Root-end resection is a surgical procedure that involves exposure of the periapical lesion through an osteotomy, surgical removal of the lesion, removal of part of the root-end tip, disinfection and, commonly, retrograde sealing or filling of the apical portion of the remaining root canal. This review updates one published in 2008.

OBJECTIVES

To assess effects of surgical and non-surgical therapy for retreatment of teeth with apical periodontitis.To assess effects of surgical root-end resection under various conditions, for example, when different materials, devices or techniques are used.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Trials Register (to 10 February 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1), MEDLINE Ovid (1946 to 10 February 2016) and Embase Ovid (1980 to 10 February 2016). We searched the US National Registry of Clinical Trials (ClinicalTrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials (to 10 February 2016). We placed no restrictions regarding language and publication date. We handsearched the reference lists of the studies retrieved and key journals in the field of endodontics.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving people with periapical pathosis. Studies could compare surgery versus non-surgical treatment or could compare different types of surgery. Outcome measures were healing of the periapical lesion assessed after one-year follow-up or longer; postoperative pain and discomfort; and adverse effects such as tooth loss, mobility, soft tissue recession, abscess, infection, neurological damage or loss of root sealing material evaluated through radiographs.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from included studies and assessed their risk of bias. We contacted study authors to obtain missing information. We combined results of trials assessing comparable outcomes using the fixed-effect model, with risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, and 95% confidence intervals (CIs). We used generic inverse variance for split-mouth studies.

MAIN RESULTS

We included 20 RCTs. Two trials at high risk of bias assessed surgery versus a non-surgical approach: root-end resection with root-end filling versus root canal retreatment. The other 18 trials evaluated different surgical protocols: cone beam computed tomography (CBCT) versus periapical radiography for preoperative assessment (one study at high risk of bias); antibiotic prophylaxis versus placebo (one study at unclear risk); different magnification devices (loupes, surgical microscope, endoscope) (two studies at high risk); types of incision (papilla base incision, sulcular incision) (one study at high risk and one at unclear risk); ultrasonic devices versus handpiece burs (one study at high risk); types of root-end filling material (glass ionomer cement, amalgam, intermediate restorative material (IRM), mineral trioxide aggregate (MTA), gutta-percha (GP), super-ethoxy benzoic acid (EBA)) (five studies at high risk of bias, one at unclear risk and one at low risk); grafting versus no grafting (three studies at high risk and one at unclear risk); and low energy level laser therapy versus placebo (irradiation without laser activation) versus control (no use of the laser device) (one study at high risk).There was no clear evidence of superiority of the surgical or non-surgical approach for healing at one-year follow-up (RR 1.15, 95% CI 0.97 to 1.35; two RCTs, 126 participants) or at four- or 10-year follow-up (one RCT, 82 to 95 participants), although the evidence is very low quality. More participants in the surgically treated group reported pain in the first week after treatment (RR 3.34, 95% CI 2.05 to 5.43; one RCT, 87 participants; low quality evidence).In terms of surgical protocols, there was some inconclusive evidence that ultrasonic devices for root-end preparation may improve healing one year after retreatment, when compared with the traditional bur (RR 1.14, 95% CI 1.00 to 1.30; one RCT, 290 participants; low quality evidence).There was evidence of better healing when root-ends were filled with MTA than when they were treated by smoothing of orthograde GP root filling, after one-year follow-up (RR 1.60, 95% CI 1.14 to 2.24; one RCT, 46 participants; low quality evidence).There was no evidence that using CBCT rather than radiography for preoperative evaluation was advantageous for healing (RR 1.02, 95% CI 0.70 to 1.47; one RCT, 39 participants; very low quality evidence), nor that any magnification device affected healing more than any other (loupes versus endoscope at one year: RR 1.05, 95% CI 0.92 to 1.20; microscope versus endoscope at two years: RR 1.01, 95% CI 0.89 to 1.15; one RCT, 70 participants, low quality evidence).There was no evidence that antibiotic prophylaxis reduced incidence of postoperative infection (RR 0.49, 95% CI 0.09 to 2.64; one RCT, 250 participants; low quality evidence).There was some evidence that using a papilla base incision (PBI) may be beneficial for preservation of the interdental papilla compared with complete papilla mobilisation (one RCT (split-mouth), 12 participants/24 sites; very low quality evidence). There was no evidence of less pain in the PBI group at day 1 post surgery (one RCT, 38 participants; very low quality evidence).There was evidence that adjunctive use of a gel of plasma rich in growth factors reduced postoperative pain compared with no grafting (measured on visual analogue scale: one day postoperative MD -51.60 mm, 95% CI -63.43 to -39.77; one RCT, 36 participants; low quality evidence).There was no evidence that use of low energy level laser therapy (LLLT) prevented postoperative pain (very low quality evidence).

AUTHORS' CONCLUSIONS

Available evidence does not provide clinicians with reliable guidelines for treating periapical lesions. Further research is necessary to understand the effects of surgical versus non-surgical approaches, and to determine which surgical procedures provide the best results for periapical lesion healing and postoperative quality of life. Future studies should use standardised techniques and success criteria, precisely defined outcomes and the participant as the unit of analysis.

A clinical study on single-visit root canal retreatments on consecutive 173 patients: frequency of periapical complications and clinical success rate

OBJECTIVES

This study assessed the outcome measures of single-visit root canal retreatments and frequency of periapical complications considering preoperative, intraoperative and postoperative factors.

MATERIALS AND METHODS

Between November 2011 and December 2012, in 173 patients, a total of 234 endodontically treated teeth were retreated in a single appointment by one experienced endodontist. Five teeth were extracted and 119 teeth were lost to follow-up yielding to 110 teeth (47 %) to be examined by two calibrated examiners for the outcome of healing (periapical index score-PAI ≤2; no signs or symptoms) or non-healing (presence of apical periodontitis-PAI >2; signs or symptoms). Preoperative, intraoperative and postoperative factors were evaluated for their association with the outcome. Data were analysed using Fisher's exact and Fisher-Freeman Halton tests for bivariate analysis to identify potential outcome predictors. Logistic regression models were used for multivariate analysis to determine significant outcome predictors.

RESULTS

Mean observation time was 29 months. Follow-up assessment revealed 100 teeth (90.9 %) as healed and 10 teeth (9.1 %) non-healed. Age, gender, tooth type and preoperative (pain, periodontal defects, root filling density and length), intraoperative (sealer extrusion) and postoperative (type of coronal restorations) factors did not significantly affect the outcome (p > 0.05). Preoperative periradicular lesions with diameters less than 5 mm presented significantly better outcome than larger lesions (p < 0.05; odds ratio (OD) 6; 95 % CI 1.45-24.85). Logistic regression model showed an increased risk of non-healing for the parameter of preoperative periradicular lesions with diameters larger than 5 mm (OD 6.42; 95 % CI 1.51-27.27).

CONCLUSIONS

Single-appointment root canal retreatments presented a favourable success rate. Only preoperative lesion size had a significant effect on the outcome where the lesions smaller than 5 mm performed significantly better healing.

CLINICAL RELEVANCE

Single-appointment root canal retreatments could be considered as a viable treatment option for orthograde retreatment cases with periradicular lesion size smaller than 5 mm.

Photodynamic Antimicrobial Chemotherapy for Root Canal System Asepsis: A Narrative Literature Review

Aim. The aim of this comprehensive literature review was to address the question: Does photodynamic therapy (PDT) improve root canal disinfection through significant bacterial reduction in the root canal system? Methodology. A comprehensive narrative literature review was performed to compare PDT effect with sodium hypochlorite as the comparative classical irrigant. Two reviewers independently conducted literature searches using a combination of medical subject heading terms and key words to identify relevant studies comparing information found in 7 electronic databases from January 2000 to May 2015. A manual search was performed on bibliography of articles collected on electronic databases. Authors were contacted to ask for references of more research not detected on the prior electronic and manual searches. Results. The literature search provided 62 titles and abstracts, from which 29 studies were related directly to the search theme. Considering all publications, 14 (48%) showed PDT to be more efficient in antimicrobial outcome than NaOCl (0.5-6% concentration) used alone and 2 (7%) revealed similar effects between them. Toluidine blue and methylene blue are the most used photosensitizers and most commonly laser has 660 nm of wavelength with a 400 nm diameter of intracanal fiber. Conclusions. PDT has been used without a well-defined protocol and still remains at an experimental stage waiting for further optimization. The level of evidence available in clinical studies to answer this question is low and at high risk of bias.

Oral surgery: part 2. Endodontic surgery

In the past, the interaction between dentoalveolar surgery and restorative dentistry has been limited to the removal of teeth with pulp and/or periradicular disease or those that were unrestorable. However, with the increasing dental awareness of the population and the retention of teeth into later life, the interaction between dentoalveolar surgery and restorative dentistry is becoming a fundamental aspect of clinical practice. Indeed, endodontic and implant surgery are core activities that facilitate the retention of a functional dentition.

Effectiveness of rotatory and reciprocating movements in root canal filling material removal

The purpose of this study was to compare the efficacy of reciprocating and rotary techniques for removing gutta-percha and sealer from root canals. Forty straight and oval single-rooted premolars were prepared up to size 30, filled with gutta-percha and sealer, and then randomly allocated to two experimental retreatment groups: ProTaper Retreatment System (PTRS) and WaveOne System (WS). Procedural errors, time of retreatment and apically extruded material were recorded for all the roots. The roots were radiographed after retreatment. The percentage of residual material was calculated using image analysis software. The data were analyzed by Kolmogorov-Smirnov and t tests, with a significance level set at 5%. No system completely removed the root filling material from the root canal. No significant differences were observed between the systems, in terms of residual filling material in any tested third (p > 0.05). WS was faster in removing filling material than PTRS (p < 0.05). Extrusion was observed in 4 cases in PTRS and in 5 cases in WS. No procedural errors were observed in either group. It can be concluded that although no differences were observed in the efficacy of PTRS and WS for removing root filling material, WS was faster than PTRS.