The diagnostic accuracy of laser Doppler flowmetry in assessing pulp blood flow in permanent teeth: A systematic review

Analysis of the Pulpal Blood Flow Microdynamics during Prosthetic Tooth Preparation Using Diamond Burs with Different Degrees of Wear

Pulpal modifications taking place during prosthetic tooth preparation using worn-out burs may represent a risk for the vitality of the dental pulp. The aim of this in vivo study was to evaluate whether the wear of diamond burs has an influence on the vascular microdynamics at the level of the dental pulp, during vertical preparation for zirconia crowns. The study was performed with a split-mouth design and included 32 vital permanent monoradicular teeth (20 maxillary and 12 mandibular), from six subjects, aged between 20 and 50 years. The teeth were randomly assigned to two study groups of 16 teeth each. For prosthetic preparation, new burs were used in the first group, and burs at their 5th use were used in the second group. Four consecutive determinations of the pulpal blood flow by Laser Doppler flowmetry (LDF-laser Doppler MoorLab instrument VMS-LDF2, Moor Instruments Ltd., Axminster, UK) were taken for each tooth included in the study: before the preparation (control values), immediately, at 24 h, and at 7 days after the prosthetic preparation. A four-way ANOVA statistical analysis was applied to analyze the effect of four considered factors (bur wear degree, time of measurement, tooth number, and tooth location) on the pulpal blood flow (PBF). A significant increase in pulpal blood flow compared to the baseline was recorded immediately after preparation (p < 0.01), at 24 h (p < 0.01), and at 7 days (p < 0.05) in both groups, but more pronounced in the case of burs at the 5th use. The blood flow was significantly higher in upper jaw teeth, irrespective of the measurement time. In conclusion, the use of worn-out diamond burs produces lasting modifications in the pulpal blood flow of teeth that undergo prosthetic crown preparation. ISRCTN registry: ISRCTN49594720.

Blood pH Changes in Dental Pulp of Patients with Pulpitis

The severity of pulpitis is a crucial factor in determining the suitable treatment. There are no clear objective indicators to assess the stage of pulp inflammation that could be used in clinical practice. The change in blood pH of the pulp during the inflammatory phase could hypothetically serve as an indicator of the pulp inflammation severity. The aim of this study was to assess the pH values in the pulpal blood of mature teeth in patients with symptomatic pulpitis, in comparison with the healthy controls. The study included patients with symptoms of pulpitis in premolar or molar teeth (Test group; n = 24, mean age 36.04, SD 7.10), and healthy controls (Control group, n = 6, mean age 24.5, SD 5.94) referred for extraction of premolars or third molars, for orthodontic reasons. The pulpal blood was taken at the opening of the endodontic access cavity, and the pH value was measured in both groups. Statistical analysis was performed using the SPSS 27.0 program with a significance level of p ≤ 0.05. The Mann-Whitney test for dependent samples was performed to evaluate the statistical difference between the groups. The patients with symptomatic pulpitis had significantly decreased pulpal blood pH compared to the healthy controls (p ≤ 0.05). The mean pulpal blood pH was 7.27 (SD 0.06) and 7.40 (SD 0.02) in Test and Control groups, respectively. In the Test group, the pulpal blood pH values were significantly lower in the patients who had symptoms for 3 days or more (7.25, SD 0.05) than in those who had symptoms for up to 3 days (7.33, SD 0.03) (p < 0.001). The pH value of the pulpal blood gradually declines in cases of symptomatic pulpitis, along with increasing duration of the symptoms.

Pulp regeneration treatment using different bioactive materials in permanent teeth of pediatric subjects

Background and Objectives

The present systematic review aims to assess the success rate of the pulp regeneration treatment, according to the American Association of Endodontists (AAE) criteria, using different bioactive materials in permanent teeth of pediatric subjects (6-17 years of age).

Materials and Methods

The study protocol was registered on PROSPERO and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The question formulation was accomplished using the PICO model, and an electronic search was carried out on Scopus, MEDLINE/PubMed, Web of Science, and Cochrane databases till April 1, 2023. A total of 30 studies were established to fulfill the inclusion criteria of this systematic review.

Results

A total of 273 teeth have been treated with pulp regeneration treatment. By comparing different biomaterials and the success criteria defined by the AAE, the material associated with a higher success rate was found to be the white mineral trioxide aggregate. However, the overall success rate of pulp regeneration treatment was reported for 248 out of 273 teeth (91.20%).

Conclusions

Data obtained support the potential that regenerative endodontics aids in continuing root development in permanent immature teeth. Further studies are needed for a more extensive evaluation of the use of different biomaterials and the success rate in regenerative endodontics.

The influence of immediate intraoperative loading with a splinting component on supporting tissues during a one-stage implant

OBJECTIVE

Aim: To study the specifics of the impact of immediate intraoperative loading with a splinting component on supporting tissues during a one-stage implantation protocol.

PATIENTS AND METHODS

Materials and Methods: In the course of the study, orthopedic treatment was carried out for 55 patients aged 29 to 60 years. The following were performed: cone-beam computed tomography, software planning and intraoral scanning with an optical scanner, one-stage implantation protocol, assessment of implant stability with the Osstell ISQ device, microcirculation study in the peri-implant area using laser Doppler flowmetry (LDF).

RESULTS

Results: It was established that around loaded implants there is an increase in blood flow and vasomotor activity of the microcirculatory channel of the supporting tissues, an increase in the volume of bone tissue and an increase in torque, which is the optimal forecast for the acceleration of the pace of osseointegration.

CONCLUSION

Conclusions: The use of a splinting component during immediate intraoperative functional masticatory load accelerates the dynamics of bone tissue remodeling processes around the implant, which is an optimal prediction of osseointegration rates in various dental implantation protocols and is consistent with high values of the implant stability coefficient.

Effectiveness of endodontic tissue engineering in treatment of apical periodontitis: A systematic review

BACKGROUND

Regenerative endodontics has evolved in recent years with tissue engineering concepts in particular appearing promising. Endodontic tissue engineering (ETE) describes the various approaches based on the orthograde introduction of scaffolds or biomaterials (with or without cells) into the root canal to achieve pulp tissue regeneration. There are currently no systematic reviews investigating whether ETE is a suitable method for the treatment of endodontic disease in both mature and immature permanent teeth.

OBJECTIVES

The purpose of this systematic review was to determine the effectiveness of ETE in permanent teeth with pulp necrosis in comparison with conventional endodontic treatment.

METHODS

We searched MEDLINE, Embase and the Cochrane Library for published reports as well as Google Scholar for grey literature up to November 2021. Included were studies of patients with permanent immature or mature teeth and pulp necrosis with or without signs of apical periodontitis (P) comparing ETE (I) with calcium hydroxide apexification, apical plug and root canal treatment (C) in terms of tooth survival, pain, tenderness, swelling, need for medication (analgesics and antibiotics), radiographic evidence of reduction in apical lesion size, radiographic evidence of normal periodontal ligament space, function (fracture and restoration longevity), the need for further intervention, adverse effects (including exacerbation, restoration integrity, allergy and discolouration), oral health-related quality of life (OHRQoL), presence of sinus tract and response to sensibility testing (O). An observation period of at least 12 months was mandatory (T) and the number of patients in human experimental studies or longitudinal observational studies had to be at least 20 (10 in each arm) at the end (S). Risk of bias was appraised using the Cochrane risk-of-bias (RoB 2) tool. Two authors independently screened the records, assessed full texts for eligibility and evaluated risk of bias. Heterogeneity of outcomes and limited body of evidence did not allow for meta-analysis.

RESULTS

Two randomized clinical trials investigating cell transplantation approaches with a total of 76 participants (40 treated immature teeth and 36 treated mature teeth) were included for qualitative analysis. Both studies had moderate concerns in terms of risk of bias. Due to the lack of homogeneity a meta-analysis was not possible. Tooth survival for ETE, root canal treatment and apexification was 100% after 12 months. Teeth treated with ETE showed a higher number of cases with positive pulpal responses to sensitivity tests and with blood perfusion compared with root canal treatment or apexification.

DISCUSSION

This systematic review highlights that there is limited evidence for ETE approaches. Even though the results of this review suggest a high survival with ETE in mature and immature teeth, there is a moderate risk of bias due to methodological limitations in the included studies, so the overall results should be interpreted with caution. Lack of a robust control group was a common problem during literature screening, and outcomes besides dental survival were reported inconsistently. Future clinical trials need to address methodical as well as assessment concerns and report long-term results.

CONCLUSION

The benefits and high survival rates reported for ETE techniques suggest that this procedure might be an alternative to conventional procedures for permanent teeth with pulpal necrosis. However, more appropriate studies are needed to derive clinical recommendations.

REGISTRATION

PROSPERO (CRD42021266350).

Effectiveness of diagnosing pulpitis: A systematic review

BACKGROUND

The diagnosis of the status of the inflamed pulp is essential in clinical diagnosis and treatment provision. There are a limited number of well-designed and well-executed clinical trials on the diagnosis of the true status of the pulp.

OBJECTIVES

Three PICO questions were formulated and agreed a priori by the European Society of Endodontology to evaluate the clinical tests for sensibility testing, determination of biomarkers and pulp bleeding with regard to their suitability to correctly diagnose the condition of the pulp tissue for the development of S3-Level guidelines.

METHODS

A literature search was conducted using PubMed, Clarivate Analytics' Web of Science, Scopus, Google Scholar and Cochrane Central Register of Controlled Trials from inception to 21 January 2022. Additionally, a hand search was performed, and the contents of the major subject journals were also examined. Eligibility criteria followed the proposed PICO questions. Two independent reviewers were involved in study selection, data extraction and appraising the included studies; disagreements were resolved by a third reviewer. The risk of bias was assessed by the QUADAS-2 tool for diagnostic accuracy studies, the Newcastle-Ottawa scale for noncomparative, nonrandomized studies and the Newcastle-Ottawa Quality Assessment scale adapted for cross-sectional studies.

RESULTS

In total, 28 studies out of 29 publications were considered eligible and were included in the review. Twelve studies were identified to investigate the diagnostic accuracy of the pulp vitality. Ten studies fulfilled the criteria to evaluate the diagnostic accuracy of the pulpal conditions, while 6 studies investigating the expression of biomarkers were eligible. Three studies addressing the prognostic factors and therapeutic interventions relating to pulpal status were included.

DISCUSSION

The core problem in pulp diagnostics is that a reliable reference standard is lacking under clinical conditions. Based on limited evidence, the most promising current approach seems to define a combination of different clinical tests and symptoms, probably in future including molecular diagnosis ("diagnostic package") will be required to ascertain the best possible strategy to clinically diagnose true pulpal conditions.

CONCLUSIONS

The effectiveness of diagnosing pulpitis is low due to limited scientific evidence regarding the accuracy and reproducibility of diagnostic tests. There is a lack of evidence to determine the true status of the pulp or to identify prognostic indicators allowing for a reliable pre-operative estimation of the outcome of vital pulp treatment.

REGISTRATION

PROSPERO database (CRD42021265366).

New Methodology of Human Health Express Diagnostics Based on Pulse Wave Measurements and Occlusion Test

Nowadays, with the increase in the rhythm of life, the relevance of using express diagnostics methods for human health state estimation has significantly increased. We present a new express diagnostics method based on non-invasive measurements (the pulse wave shape, heart rate, blood pressure, and oxygen saturation of blood vessels and tissues). A feature of these measurements is that they can be carried out both in the hospital and at home. The new compact and portable optical hardware–software complex has been developed to measure tissue oxygen saturation. This complex makes it possible to reduce the measurement time from 60 min to 7–8 min, which reduces the likelihood of artifacts in the measurement process and increases its reliability. A new technique has been developed to carry out these measurements. A new optical sensor based on a line of charge-coupled devices has been developed to register a pulse wave in the far peripheral zone. The developed new technique for processing the pulse waveform and data on the oxygen saturation of hemoglobin in the blood and tissues allows a person to obtain additional information about their state of health independently. It will help to make conclusions about taking the necessary measures. This additional information allows the attending physician to provide more effective control over the course of treatment of the patient at any time since the methods of express diagnostics proposed by us have no restrictions on the number of applications. The functional state of more than 300 patients was studied. The results of various measurements are presented.

EVALUATION OF DYNAMIC CHANGES IN THE MICROCIRCULATION OF THE MUCOSA IN THE ZONE OF DENTAL IMPLANTATION WITH IMMEDIATE INTRAOPERATIVE LOAD

OBJECTIVE

The aim: Study of the dynamics of changes in the average values of the index of mucosal microcirculation after dental implantation with immediate intraoperative prosthetics.

PATIENTS AND METHODS

Materials and methods: In clinical conditions, 55 patients aged from 29 to 60 years with a diagnosis of partial absence of teeth requiring orthopedic treatment using implants on the lower jaw were treated and examined. In the course of the latest achievements, the following methods were used: clinical protocol of immediate implantation with Solidum and Simplex implants of the «ART IMPLANT» system on the lower jaw by the one-stage implantation method, with immediate intraoperative loading and the manufacture of a temporary non-removable dental prosthesis, determination of the microcirculation index in dynamics using the laser Doppler method flowmetry, statistical analysis.

RESULTS

Results: The obtained results indicate a pronounced reaction of microcirculation up to the 3rd day after surgery, an increase in blood perfusion of the mucous membrane by 2.7 times while maintaining vasomotor activity, which indicates adaptation to the injury and immediate loading of the denture in the postoperative period. 3 months after dental surgery and immediate intraoperative prosthetics, all indicators of microcirculation approach the initial values before surgery.

CONCLUSION

Conclusions: With the help of laser Doppler flowmetry, the fact of a sharp restoration of microcirculation after dental implantation surgery with immediate intraoperative prosthetics is confirmed.

A miniaturized ultrasound transducer for monitoring full-mouth oral health: a preliminary study

OBJECTIVE

To customize a miniaturized ultrasound transducer to access full-mouth B-mode, color Doppler, and spectral Doppler imaging for monitoring oral health.

METHODS

A customized periodontal ultrasound transducer SS-19-128 (19 MHz, 128 channels) 1.8-cm wide and 1-cm thick was developed and connected to a data acquisition (DAQ) system. B-mode, color Doppler, and spectral Doppler data could all be collected with SS-19-128. The imaging resolution and penetration capacity of SS-19-128 were characterized on phantoms. The gingival thickness was measured on 11 swine teeth by SS-19-128 for comparison with conventional transgingival probing via Bland-Altman analysis and Pearson correlation. Five human subjects were then recruited to demonstrate B-mode and Doppler imaging by SS-19-128.

RESULTS

The axial and lateral spatial resolution at 5.5 mm depth is 102.1 µm and 142.9 µm, respectively. The penetration depth in a tissue-mimicking phantom is over 30 mm. In vivo B-mode imaging of all 28 teeth was demonstrated on one human subject, and imaging of tooth #18 was accessed on five human subjects. Gingival thickness measurement compared with transgingival probing showed a bias of -0.015 mm and SD of 0.031 mm, and a r = 0.9235 (p < 0.0001) correlation. In vivo color and spectral Doppler imaging of the supraperiosteal artery in human gingiva was performed to generate hemodynamic information.

CONCLUSIONS

The small size of SS-19-128 offers important advantages over existing ultrasound technology-more specifically, whole-mouth scanning/charting reminiscent of radiography. This is nearly a two-fold increase in the number of teeth that can be assessed versus conventional transducers.

Diagnosis of Skin Vascular Complications Revealed by Time-Frequency Analysis and Laser Doppler Spectrum Decomposition

Nowadays, photonics-based techniques are used extensively in various applications, including functional clinical diagnosis, progress monitoring in treatment, and provision of metrological control. In fact, in the frame of practical implementation of optical methods, such as laser Doppler flowmetry (LDF), the qualitative interpretation and quantitative assessment of the detected signal remains vital and urgently required. In the conventional LDF approach, the key measured parameters, index of microcirculation and perfusion rate, are proportional to an averaged concentration of red blood cells (RBC) and their average velocity within a diagnostic volume. These quantities compose mixed signals from different vascular beds with a range of blood flow velocities and are typically expressed in relative units. In the current paper we introduce a new signal processing approach for the decomposition of LDF power spectra in terms of ranging blood flow distribution by frequency series. The developed approach was validated in standard occlusion tests conducted on healthy volunteers, and applied to investigate the influence of local pressure rendered by a probe on the surface of the skin. Finally, in limited clinical trials, we demonstrate that the approach can significantly improve the diagnostic accuracy of detection of microvascular changes in the skin of the feet in patients with Diabetes Mellitus type 2, as well as age-specific changes. The results obtained show that the developed approach of LDF signal decomposition provides essential new information about blood flow and blood microcirculation and has great potential in the diagnosis of vascular complications associated with various diseases.

Laser Er:YAG-Assisted Debonding May Be a Viable Alternative to the Conventional Method for Monocrystalline Ceramic Brackets

In orthodontic practice, due to the increased interest among patients in smile aesthetics, different types of brackets are now being used, with those most frequently applied being ones made of polycrystalline and monocrystalline ceramic. The aim of this study was to evaluate the laser Er:YAG-assisted debonding technique compared to conventional methods for removing monocrystalline ceramic brackets from human teeth. The study sample included 60 vital teeth (frontals of the upper jaw) from 10 patients who had monocrystalline ceramic brackets and were in the final phase of orthodontic treatment. The debonding procedure was carried out following a split-mouth study design, using either the conventional technique or laser Er:YAG 2940 nm radiation. For each tooth, three variables were evaluated: the patient's sujective tooth sensitivity associated with the debonding, the time required for debonding, and pulp blood flow microdynamics after the debonding. Three evaluation instruments were used to assess and quantify the treatment effects: (i) the Wong-Baker FACES Pain Rating Scale for pain assessment; (ii) a digital stopwatch/timer to measure the time required to remove the bracket; and (iii) laser Doppler flowmetry (LDF) for recording the pulp blood flow evolution. The statistical analysis of the recorded data showed a statistically significant difference between the two debonding methods regarding the tooth sensitivity during the debonding and the time required for the procedure. The subjective tooth sensitivity was reduced from a mean ± standard deviation of 3.07 ± 1.46 to 0.47 ± 0.86 on the Wong-Baker FACES scale (Wilcoxon signed rank, p < 0.001). The necessary time for debonding was reduced by 0.697 ± 0.703 s per tooth (paired t-test, p < 0.001). There was no difference in the blood microdynamics between the two debonding techniques. According to the results of this study, the laser Er:YAG-assisted debonding technique may be a viable alternative to the conventional method for monocrystalline ceramic brackets.

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.

Efficacy assessment of laser Doppler imager in diagnosing the pulp vitality after dental trauma

Background/purpose

This is the first paper evaluating the efficacy of laser Doppler imager in diagnosis of pulpal vitality. The purpose of this study was to evaluate and compare the diagnostic benefits of laser Doppler imaging and electric pulp test (EPT) in dental trauma.

Materials and methods

Seven patients were selected for pulp vitality evaluation in Kaohsiung Medical University Hospital between 2018 and 2019. EPT and laser Doppler imager evaluation were performed for patients with traumatic injury to teeth. Statistical methods included the Kappa consistency test and the chi-square test. In addition, the receiver operating characteristic (ROC) curve, and the area under the curve (AUC) were used.

Results

There was a significant difference in Doppler flow values between the severe trauma group and the mild trauma group, regardless of patient self-reported symptoms (P = 0.043) or physicians' diagnostic classification (P = 0.018). For an EPT instrument, the Kappa coefficient was 0.67 and 1-year pulpal status findings were highly consistent (P < 0.001). Using a Doppler instrument, the Kappa coefficient was 0.85. According to the ROC curve, the AUC for EPT was 0.94, the AUC for Doppler was 1, and the optimal cut-off value was 31.55, indicating that both were superior diagnostic tools.

Conclusion

Both laser Doppler imager and EPT can be used as tools for diagnosing traumatic pulp necrosis. Doppler imaging instruments allow for a more timely and accurate assessment of pulp vitality in dental trauma. In the future, ongoing research and related training are necessary for interpretation of Doppler data.

Multiple Laser Doppler Flowmetry Probes Increase the Reproducibility of Skin Blood Flow Measurements

Cutaneous microcirculatory perfusion is commonly measured using laser Doppler flowmetry (LDF) probes, which provide a continuous, non-invasive quantification of skin blood flow (SkBF). However, inhomogeneities in the skin’s microvasculature density contribute to a decrease in reproducibility whenever an LDF probe is removed and replaced, as is the case during pre- and post-intervention or between-day measurements. Therefore, this study aimed to determine whether increasing the total number of individual LDF probes in a localized area improves the reproducibility of the measurement. Seven laser Doppler probes were secured in a custom-made acrylic holder designed to attach to the skin’s surface easily. SkBF, local skin temperature (Tsk), and blood pressure (BP) were assessed in 11 participants (6 M, 5 F, 42 ± 15 years). SkBF and Tsk were measured from the dorsal forearm (arm trial) for 5 min. Next, the multi-laser device was moved to the lateral side of the calf (leg trial), and measurements were obtained for 5 min. Each arm and leg trial was cyclically repeated three times, and all trials were separated by intermissions lasting 10–15 min. The average SkBF and the cutaneous vascular conductance (CVC) from all possible LDF probe combinations were not statistically different across the three arm and leg trials. Two-way mixed-effects models with absolute agreement were used to compute the intraclass correlation coefficient (ICC) for CVC, and the minimum ICC increased with the addition of LDF probes. The ICC of the average CVC from seven LDF probes was 0.96 between the arm trials and 0.91 between the leg trials, which suggests that there is excellent reliability and little difference between trials following the removal and replacement of the device. Moreover, all individual ICC values from ≥3 LDF probe combinations were greater than 0.70 (i.e., good reliability). These data suggest that SkBF measurements with multiple laser Doppler probes in a custom-made holder have excellent reproducibility after replacing the probes within the same participant. Therefore, this application could provide more reproducible assessments between repeated measurements (e.g., before and after exercise or clinical procedures) where the LDF probes must be removed and replaced within the same location.

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.

Kovanaze Intranasal Spray vs Traditional Injected Anesthetics: a Study of Pulpal Blood Flow Utilizing Laser Doppler Flowmetry

OBJECTIVE

An ideal local anesthetic would be effective, minimally reduce pulpal blood flow (PBF), and not require injection. This study compared the effects of 3% tetracaine plus 0.05% oxymetazoline nasal spray (Kovanaze; KNS) and injections using 2% lidocaine with 1:100,000 epinephrine (LE) or 3% mepivacaine plain (MP) on PBF, anesthetic efficacy, and participant preference.

METHODS

In a double-blind cross-over design, 20 subjects randomly received a test anesthetic and placebo at each of 3 visits (KNS/mock infiltration; mock nasal spray/LE; or mock nasal spray/MP). Nasal sprays and infiltration apical to a maxillary central incisor were delivered ipsilaterally. PBF was evaluated by laser Doppler flowmetry, and local anesthetic success was assessed with electric pulp testing. Postoperative pain levels, participant preference, and adverse events were also assessed.

RESULTS

LE injections demonstrated significant reductions in PBF at all time intervals compared with baseline (P < .05), whereas KNS and MP did not. Pulpal anesthesia success rates were higher for LE (85%) compared with MP (35%) and KNS (5%). Participants reported significantly higher postoperative pain levels for KNS compared with LE and MP. Additionally, KNS was the least preferred of the anesthetics administered and resulted in more reported adverse events.

CONCLUSION

Although KNS showed no significant effect on PBF, it was not effective in achieving pulpal anesthesia as used in this study.

Pulp changes from rapid maxillary expansion: A systematic review

INTRODUCTION

This study aimed to systematically review the current evidence on the occurrence of pulp changes as side effects from orthopaedic rapid maxillary expansion (ORME) or surgically assisted rapid maxillary expansion (SARME).

METHODS

An electronic search was performed in eleven databases. The eligibility criteria included clinical studies assessing vitality, sensibility or dimensions of the pulp chamber of permanent teeth before and after ORME or SARME, without restrictions on publication year or language. The risk of bias was analysed with the NIH 'Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group' and the 'JBI for quasi-experimental studies' tool. The GRADE tool was used to assess the certainty of evidence.

RESULTS

The initial search resulted in 1,197 records, from which only seven before-after studies were included. There was a change in the pulpal blood flow (PBF) of maxillary incisors and canines up to 5 days after SARME, which gradually returned after 7 days to 3 months. After ORME, one study observed an increased PBF and one study observed a reduced PBF, which gradually returned after the end of expansion. Two studies observed that both ORME and SARME caused temporary changes in pulp sensibility. Three studies observed a significant reduction in the pulp chamber after ORME or SARME. The outcomes presented a very low certainty of evidence.

CONCLUSIONS

Although limited, the evidence shows that ORME and SARME caused temporary changes in pulp vitality and sensibility, with the possibility of inducing a reduction in pulp chamber dimensions.

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.

Present status and future directions: Endodontic management of traumatic injuries to permanent teeth

The prognosis of traumatized teeth depends largely on the fate of the pulp and its treatment. This review aims to update the present status on the endodontic management of traumatic injuries to permanent teeth and to identify relevant research areas that could contribute to an improvement in diagnosis and treatment of traumatized permanent teeth. Future research should pay greater attention to (1) diagnostic methods to assess the perfusion of the pulp and enhance detection of tooth cracks and initial signs of root resorption; (2) improved materials for vital pulp treatment; (3) studies focusing on type and duration of splinting after root fractures; (4) antiresorptive intracanal medication in case of posttraumatic pulp necrosis and infection-related resorption and (5) long-term data on the apical barrier technique compared to revitalization.

European Society of Endodontology position statement: endodontic management of traumatized permanent teeth

This position statement represents a consensus of an expert committee convened by the European Society of Endodontology (ESE) on the endodontic management of traumatized permanent teeth. A recent comprehensive review with detailed background information provides the basis for this position statement (Krastl et al. 2021, International Endodontic Journal, https://doi.org/10.1111/iej.13508). The statement is based on current scientific evidence as well as the expertise of the committee. Complementing the recently revised guidelines of the International Association of Dental Traumatology, this position statement aims to provide clinical guidance for the choice of the appropriate endodontic approach for traumatized permanent teeth. Given the dynamic nature of research in this area, this position statement will be updated at appropriate intervals.

Laser Doppler for Accurate Diagnosis of Oehler’s Type III Dens Invaginatus: A Case Report

In vital pulp therapy, pulp testing aids in the differential diagnosis and influences the treatment plan. Different from previous doppler flowmetry studies that only recorded waves and data, we report the first time, the use of a laser doppler blood flow monitor and imager with a colored image to present pulp vitality information in the dental field. We report here a case of Oehlers type IIIa dens invaginatus of the right upper lateral incisor in a 31-year-old girl, with the opening of the invagination near CDJ and a peri-invagination lesion sized 8 × 9 mm2. Cone beam computed tomography was used to verify specific spatial and stereoscopic data. After removing the source of infection, mineral trioxide aggregate was selected to fill the invagination. Laser doppler was scheduled for further assessment. After three years of regular follow-up, the patient’s clinical condition improved, the peri-invagination lesion healed, and the laser doppler and electric pulp test both showed a positive reaction. Laser doppler has successfully improved the diagnostic accuracy Thus, unnecessary interventions can be avoided while reducing the treatment time by preserving the vitality. However, further work is needed to resolve the limitations of laser doppler.

Endodontic management of traumatized permanent teeth: a comprehensive review

The pulp plays a key role in the treatment of traumatic dental injuries (TDIs) and is strongly associated with the outcome, particularly in severe cases. A correct pulp diagnosis is essential as it forms the basis for developing the appropriate management strategy. However, many TDIs are complex, and their treatment requires a profound knowledge of the physiological and pathological responses of the affected tissues. This comprehensive review will look at the dentine-pulp complex and its interaction with the surrounding tissues following TDIs. The literature up to 2020 was reviewed based on several searches on PubMed and the Cochrane Library using relevant terms. In addition to the recently revised guidelines of the International Association of Dental Traumatology, this article aims to provide background information with a focus on endodontic aspects and to gather evidence on which a clinician can make decisions on the choice of the appropriate endodontic approach for traumatized permanent teeth.

Pulse Oximetry as a Diagnostic Tool to Determine Pulp Vitality: A Systematic Review

Pulse oximetry (PO) can be used as a technique to assess vascularization. Although it is commonly used in the field of medicine, it still has limited use in dentistry. The aim of this study is to evaluate, by means of a systematic review, if pulse oximetry is a viable and effective system to determine pulp vitality and assess the clinical criteria for its use. A literature search was performed in Medline, Scopus, Embase, and Web of Science databases. Clinical studies using pulse oximetry as a tool to determine pulp vitality in permanent teeth were eligible. Quality assessment of the included studies was performed following the Quality Assessment for Diagnostic Accuracy Studies (QUADAS-2) guidelines. A total of 24 articles were included in the review. The subjective test most compared to PO was the cold test. PO has shown a good sensibility and specificity, and it has been used in different clinical situations. Pulse oximetry has a high potential as a tool for the diagnosis of pulp vitality. However, the absence of a specific pulse oximeter for a dental practice, among other limitations, added to the lack of evidence on how different systemic and oral pathologies may affect the pulp’s oxygen saturation levels, which hinders its clinical use.

Guidelines for the orthodontic management of the traumatised tooth

Dental trauma is common in the UK, with more than one in ten children having experienced some form of dental trauma. In addition, one in ten patients have been reported to have experienced dental trauma before orthodontic treatment. A recent survey of orthodontists’ knowledge and experience of orthodontic management of traumatised teeth has highlighted large inconsistencies in management of traumatised teeth among UK orthodontists, highlighting the need for further information or training on orthodontic management of traumatised teeth.

Therefore, the following guidelines have been developed in order to provide an evidence-based approach to treat this cohort of patients. The following guidance is based on the available literature, expert opinion and UK orthodontists’ consensus drawn from a recent survey.

Using Laser-Doppler Flowmetry to Evaluate the Therapeutic Response in Dentin Hypersensitivity

Dentin hypersensitivity (DH) is a common medical condition with underreported prevalence and it is difficult to quantify. This study aimed to investigate whether assessing dental pulp vascular micro-dynamics by laser-Doppler flowmetry (LDF) would be functional for therapeutic evaluation, in contrast to a verbal rating scale (VRS). A split-mouth single-blind randomized study was conducted on seven patients and a total of 36 teeth. Two DH therapeutic methods were employed: (i) fluoride gel; (ii) Nd:YAG radiation combined with fluoride gel. For each tooth, five consecutive LDF determinations of pulp blood flow were made (before and immediately after desensitizing treatment, then after 24 h, 7 days, and 1 month), and the VRS was applied each time. Spearman’s correlation was applied for concurrent validation. Two-way (treatment and patient) repeated measures ANOVA full factorial was applied, followed by Tukey’s post-hoc comparisons and Pillai’s trace multivariate statistic. While VRS scores had moderate reliability, LDF could objectively estimate treatment effects. Based on partial eta-squared values, treatment and patient characteristics were estimated to explain about 84% and 50% of the variability, respectively. In conclusion, LDF is an objective technique that can quantitatively assess DH evolution, and it is effective in reliably monitoring oral health therapeutic interventions.

How to measure retinal microperfusion in patients with arterial hypertension

PURPOSE

Assessment and monitoring of changes in microcirculatory perfusion, perfusion dynamic, vessel structure and oxygenation is crucial in management of arterial hypertension. Constant search for non-invasive methods has led the clinical focus towards the vasculature of the retina, which offers a large opportunity to detect the early phase of the functional and structural changes in the arterial hypertension and can reflect changes in brain vasculature. We review all the available methods of retinal microcirculation measurements including angiography, oximetry, retinal vasculature assessment software, Optical Coherence Tomography Angiography, Adaptive Optics and Scanning Laser Doppler Flowmetry and their application in clinical research.

MATERIALS AND METHODS

To further analyse the applicability of described methods in hypertension research we performed a systematic search of the PubMed electronic database (April 2020). In our analysis, we included 111 articles in which at least one of described methods was used for assessment of microcirculation of the retina in hypertensive individuals.

RESULTS

Up to this point, the methods most commonly published in studies of retinal microcirculation in arterial hypertension were Scanning Laser Doppler Flowmetry followed shortly by Optical Coherence Tomography Angiography and retinal vasculature assessment software.

CONCLUSIONS

While none of described methods enables the simultaneous measurement of all microcirculatory parameters, certain techniques are widely used in arterial hypertension research, while others gain popularity in screening.

Evidence mapping and quality assessment of systematic reviews in dental traumatology

BACKGROUND/AIMS

Evidence mapping of systematic reviews (SRs) systematically and comprehensively identifies, organizes, and summarizes the distribution of scientific evidence in a field. The aims of this study were to delineate domains in dental traumatology (DT), evaluate the existing SRs within the domains, and identify the paucity of evidence for future research.

METHODS

Domains and sub-domains of DT were established according to the methods of qualitative research. The protocol for evidence mapping was prepared as per the guidelines of GEM and PRISMA. The search strategy was formulated using words and MeSH terms in eight databases without restriction of languages and year of publication. Gray literature, protocol registries, and references of selected articles were also searched. Duplicates were removed, and the final selection of SRs was completed. Data extraction and quality analysis using the ROBIS tool and the PRISMA checklist were performed.

RESULTS

The overall search resulted in 64 SRs from 1999 to 2020 with 44 published in last six years. The highest number of SRs had been performed in the Prognostic domain (n = 19) followed by the domains of Epidemiology (n = 15), Therapeutics (n = 10), Oral Biology (n = 7), Diagnostics (n = 6), Preventive (n = 5), and Research Methods (n = 2). Within each domain, there were variabilities in the number of reviewers, a priori protocols, search limitations, risk of bias methods, and meta-analysis. Of the SRs, including 4 Cochrane reviews, 28.4% were inconclusive. A low risk of bias was found in 48.4% of the SRs. Among the registered and ongoing SRs, six were from the domain of epidemiology, two in the domain of therapeutics, five from prognostics, and one each in the domains of prevention and research methods.

CONCLUSION

The SRs in DT could be mapped in seven domains with variabilities in the methods. The majority had an a priori registered protocol and a low risk of reporting errors. Within the Epidemiology and Preventive domains, SRs were present in all the sub-domains with the majority demonstrating low-risk of bias (ROB). The domain of prognosis had SRs in most sub-domains but with a high ROB. Insufficient numbers of SRs were present in most sub-domains of the Diagnostics, Therapeutics, Research Methods and Oral Biology domains.

Cell-Based Regenerative Endodontics for Treatment of Periapical Lesions: A Randomized, Controlled Phase I/II Clinical Trial

A randomized controlled phase I/II clinical trial was designed to evaluate the safety and efficacy of encapsulated human umbilical cord mesenchymal stem cells in a plasma-derived biomaterial for regenerative endodontic procedures (REPs) in mature permanent teeth with apical lesions. The trial included 36 patients with mature incisors, canines, or mandibular premolars showing pulp necrosis and apical periodontitis. Patients were randomly and equally allocated between experimental (REP) or conventional root canal treatment (ENDO) groups. On the first visit, cavity access and mechanical preparation of the root canal were performed. Calcium hydroxide medication was used, and the cavity was sealed. Three weeks later, patients were treated following their assigned protocol of ENDO or REP. Clinical follow-up examinations were performed at 6 and 12 mo. Categorical variables were evaluated by Fisher's exact test. Quantitative variables were compared using the Mann-Whitney test. The evolution over time of the percentage of perfusion units and the dimensions of lesion and cortical compromise were explored. After the 12-mo follow-up, no adverse events were reported, and the patients showed 100% clinical efficacy in both groups. Interestingly, in the REP group, the perfusion unit percentage measured by laser Doppler flowmetry revealed an increase from 60.6% to 78.1% between baseline and 12-mo follow-up. Sensitivity tests revealed an increase of the positive pulp response in the REP group at 12-mo follow-up (from 6% to 56% on the cold test, from 0% to 28% on the hot test, and from 17% to 50% on the electrical test). We present the first clinical safety and efficacy evidence of the endodontic use of allogenic umbilical cord mesenchymal stem cells encapsulated in a plasma-derived biomaterial. The innovative approach, based on biological principles that promote dentin-pulp regeneration, presents a promising alternative for the treatment of periapical pathology (ClinicalTrials.gov NCT03102879).

Revitalisation endodontic treatment of traumatised immature teeth: a prospective long-term clinical study

PURPOSE

Continuation of root development following revitalisation endodontics (RET) has been shown to be unpredictable with lower success rates in traumatised teeth. This study reports the outcomes for RET in traumatised teeth over a review period of 4 years.

METHODS

A prospective uncontrolled study, where RET was performed on traumatised upper immature anterior teeth with necrotic pulps in 15 children (mean age = 8.3 years), was conducted. Patients were reviewed at 3, 9, 12, 24, and 48 months, where clinical and radiographic assessments were performed. At the last review appointment, patients and parents answered questions assessing their perception and acceptance of tooth colour change over time. McNemar's Exact test and linear mixed model assessment were used to assess changes in pulpal electrical response and radiographic evidence of continuation of root development over time, respectively.

RESULTS

There was 83.3% healing with no significant changes in EPT responses, and no significant changes in root lengths, while significant changes in root widths (p < 0.05) and root apex widths (p < 0.001) were found over time. Twenty-five percent of patients and 33% of parents felt that there were changes in tooth colour following RET over time.

CONCLUSION

Within the limitations of this study, traumatised teeth treated using RET showed no significant root lengthening, however, acceptable periapical healing, slow thickening of root dentinal walls, and rapid development of apical closure were evident over a period of 43 months. Using Portland cement and omitting minocycline, did not eliminate crown colour change following RET.

Microbiological aspects of traumatic injuries

After traumatic injuries to teeth, microorganisms may invade the compromised pulp tissue and initiate pulp infection and periapical inflammation. In addition to bone resorption that typically accompanies pulp necrosis, root resorption frequently occurs. Root resorption has several variants that may occur shortly after the trauma or at a later stage. The pathological changes seen after traumatic injuries to teeth are invariably linked to the presence of microbial irritants. The presence of bacterial biofilms in the dental pulp space can be treated with regenerative or therapeutic endodontic procedures. However, necrosis of periodontal ligament is usually terminal for the tooth involved. In this review, the sources of bacteria after traumatic injuries are discussed. The types and role of microorganisms involved in the pathogenesis of endodontic pathosis after traumatic injuries are presented, and contemporary approaches for the management of these conditions are reviewed. Contemporary antimicrobial strategies are discussed. The rationale for the use of systemic and topical antimicrobials is presented. Finally, novel approaches to the use of antimicrobial therapies, particularly in regenerative procedures, are reviewed.