The detection of periapical pathoses using digital periapical radiography and cone beam computed tomography in endodontically retreated teeth - part 2: a 1 year post-treatment follow-up

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

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

Outcome of nonsurgical management of large cyst-like periapical lesions using a modified apical negative pressure irrigation system: a case series study

OBJECTIVE

To assess the effectiveness of a self-constructed modified apical negative pressure irrigation (ANPI) system employing commonly used clinical instruments in nonsurgical root canal therapy (NSRCT) for large cyst-like periapical lesions (LCPLs).

METHODS

From 2017 to 2022, 35 patients diagnosed with LCPLs (5-15 mm) via preoperative clinical and radiographic evaluations of endodontic origin underwent NSRCT combined with ANPI. These patients were subjected to postoperative clinical and radiographic follow-up at 3 months, 6 months, 1 year, 2 years, 3 years, and 4 years, with a CBCT scan specifically conducted at 6-month follow-up. Through the reconstruction of three-dimensional cone beam computed tomography (CBCT) data, an early prognosis was facilitated by monitoring changes in lesion volume. Various treatment predictors-including sex, type of treatment, lesion size, preoperative pain, jaw, type of teeth involved, sealer extrusion, and the number of root canals-were meticulously analyzed. The evaluation of post-treatment outcomes leveraged both clinical observations and radiographic data collected during the follow-up periods. The Kruskal‒Wallis test and one-way ANOVA were also conducted to determine the independent factors influencing treatment outcomes. A significance level of 5% was established.

RESULTS

Thirty-five teeth from 35 patients with a median age of 28 years (range 24-34) were treated; the median follow-up duration was 19 months (range 12-26). The overall success rate was 91.4%, with a median lesion reduction of 77.0% (range 54.2-96.4%) at 6 months. Patients under 30 years of age exhibited a significantly greater success rate than older patients did (100.0% vs. 80.0%, p = 0.037). Other factors, such as sex, jaw, treatment type, preoperative pain, cyst size, tooth location, sealer extrusion, and the number of roots, did not significantly impact treatment outcomes.

CONCLUSIONS

Despite limitations related to the observational case-series study design and relatively small sample size, our findings suggest that utilizing the ANPI in the NSRCT for LCPLs may hold promise. The notably higher success rate in patients younger than 30 years is worth noting.

The outcome of combined use of iRoot BP Plus and iRoot SP for root-end filling in endodontic microsurgery: a randomized controlled trial

OBJECTIVES

Root-end filling is important for the clinical outcome of endodontic microsurgery. Our previous study showed that combined application of iRoot BP Plus Root Repair Material (BP-RRM) and iRoot SP Injectable Root Canal Sealer (SP-RCS) in root-end filling exhibited better apical sealing as compared to the application of BP-RRM alone. The aim of this randomized controlled clinical trial was to evaluate the effect of the combined use of BP-RRM and SP-RCS on the prognosis of teeth with refractory periapical diseases after endodontic microsurgery.

MATERIALS AND METHODS

240 teeth with refractory periapical diseases scheduled for endodontic microsurgery were randomly divided into BP-RRM/SP-RCS group (n = 120) and BP-RRM group (n = 120). The patients were followed up at 3 months, 6 months, and 12 months after endodontic microsurgery. Pre- and post-operative clinical and radiographic examinations were performed to evaluate the treatment outcome. The 1-year success rate of endodontic microsurgery in BP-RRM/SP-RCS and BP-RRM groups was compared by Chi-square test. Factors that might impact the prognosis were further analyzed using Chi-square test or Fisher's exact test.

RESULTS

A total of 221 teeth completed the 12-month follow-up. The 1-year success rates of the BP-RRM/SP-RCS and BP-RRM groups were 94.5% (104/110) and 92.8% (103/111), respectively. The combined use of BP-RRM and SP-RCS achieved a clinical outcome comparable to BP-RRM alone (P = 0.784). Tooth type (P = 0.002), through-and-through/apico-marginal lesion (P = 0.049), periodontal status (P < 0.0001), and Kim's lesion classification (P < 0.0001) were critical factors associated with the 1-year success of endodontic microsurgery.

CONCLUSIONS

The combined use of BP-RRM and SP-RCS is a practicable method for root-end filling in endodontic microsurgery with a satisfactory 1-year clinical outcome.

CLINICAL RELEVANCE

The combined application of BP-RRM and SP-RCS in EMS is an effective root-end filling method with a satisfactory 1-year clinical outcome.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100052174).

Outcome of root canal retreatment filled with gutta-percha techniques: A systematic review and meta-analysis

OBJECTIVE

The present systematic review and meta-analysis aimed to evaluate the success rate of root canal retreatment filled with gutta-percha and the variables related to retreatment success.

DATA

The PRISMA guidelines were followed for the present review. The study protocol was registered in the International Prospective Database of Systematic Reviews (PROSPERO CRD42021283134). Risk assessment was performed using the Newcastle-Ottawa scale. Funnel plots were used to detect publication bias and asymmetry was assessed using Egger's tests.

SOURCES

PubMed, Scopus, ScienceDirect, Cochrane, and additional sources were searched.

STUDY SELECTION

Studies published until 10 December 2022. Clinical studies evaluating the success of root canal retreatment filled with gutta-percha with at least a 1-year follow-up were selected.

RESULTS

Ten studies and one unpublished study fulfilled the inclusion criteria for quantitative analysis. The success rate of non-surgical root canal retreatment was 71% (95% CI: 66%-76%) with strict criteria and 87% (79% - 93%) with loose criteria for 1-3 years of follow-up, and 77% (66% - 86%) with strict criteria for a 4-5 years of follow-up. Endodontically retreated teeth with periapical lesions had a lower success rate under strict criteria. The tooth type, dental arch, initial periapical index (PAI) score, and the number of visits also affected the treatment success rate under strict criteria. For the loose criteria, teeth with larger periapical lesions and higher initial PAI scores had a lower success rate.

CONCLUSIONS

According to the present systematic review and meta-analysis, non-surgical root canal retreatment results in favourable outcomes. The presence of a periapical radiolucency, periapical lesions >5mm, a higher initial PAI score, multiple-visit retreatments, and mandibular and molar teeth resulted in a lower success rate.

CLINICAL SIGNIFICANCE

Non-surgical root canal retreatment filled with gutta-percha techniques is a relatively predictable procedure with a high success rate. Several variables can affect retreatment success, mainly the presence and size of a periapical lesion and the type of tooth.

Predictors of periapical bone healing associated with teeth having large periapical lesions following nonsurgical root canal treatment or retreatment: A cone beam computed tomography-based retrospective study

AIM

Several factors influence the condition of the periapical tissues associated with root filled teeth. The primary objective of this study was to retrospectively evaluate the extent and speed of bone healing of large periapical lesions associated with nonsurgical root canal treatment or retreatment. The secondary objective was to analyse the relationship between the time to complete healing when analysed using cone beam computed tomography (CBCT) and other possible predictors that affect healing.

METHODOLOGY

Seventy-nine patients were treated during the years 2013-2020 with large periapical lesions of endodontic origin (10-15 mm) as observed on intraoral periapical radiographs (IOPAR) were included. IOPAR and CBCT were available before treatment and during the follow-up (IOPAR every 6 months and CBCT every 12 months). The volume of periapical lesions was calculated by OsiriX Lite software. Variables such as initial volume of the lesion, age, gender, type of treatment or type of root canal filling were compared to identify the differences between healed and unhealed lesions. Pearson's Chi-square test was used for categorical variables, the t-test for age and the Wilcoxon test for initial volume of the lesion. The association between time to healing and the variables was assessed using univariate analysis and multivariate analysis. The Wilcoxon test was used to observe the association of healing time with categorical variables and the correlation index was measured with the quantitative variables.

RESULTS

Of the 79 cases analysed, 60 lesions (76%) were completely healed as verified by CBCT in a mean healing time of 19 months, of which 60% healed fully between 12 and 18 months. Increase in age of patient and larger initial volume of the lesion were associated with a significantly longer healing time (p < .001). Gender, filling material and type of treatment did not have a significant effect on the healing process (p > .05).

CONCLUSIONS

Clinicians should be aware that periapical lesions in older patients and larger areas of bone loss take longer to heal. CBCT monitoring of large periapical lesions is critical and it can help clinicians in the decision-making process.

Cost-effectiveness analysis of full versus selective root canal retreatment

AIM

Selective root-canal retreatment has been proposed as an alternative to full retreatment in multirooted, root-canal-filled teeth with evidence of apical pathology, where only the affected root(s) is retreated. Whilst this option may save costs initially, failures and retreatments may compensate for these initial savings. We assessed the cost-effectiveness of full versus selective root-canal retreatment using data from a recent clinical pilot study, employing a modelling approach.

METHODOLOGY

A Markov model was constructed to follow up a previously root-canal treated maxillary molar with apical pathology on a single root (mesio-buccal), receiving either selective or full root-canal retreatment. A private-payer perspective in Dutch health care was adopted. Permanent molar teeth with apical lesions on the mesial root were simulated over the lifetime of initially 50-year-old patients. Teeth could have endodontic complications and require interventions such as retreatment or tooth extraction and replacement. Costs were calculated based on the Dutch dental fee catalogues. Monte-Carlo microsimulations were performed to assess lifetime costs and effectiveness (measured as tooth retention time), and the resulting cost-effectiveness. Probabilistic joint uncertainty and sensitivity analyses were performed, and cost-effectiveness at different willingness-to-pay-thresholds was evaluated.

RESULTS

In the base-case scenario, selective retreatment was less costly (2137; 2.5%-97.5% percentiles: 1944-2340 Euro) and more effective (19.6; 18.3-20.8 Years) than full retreatment (2495; 2305-2671 Euro; 16.5; 15.2-17.9 Years) in 100% of the simulations and regardless of the willingness-to-pay threshold. Only in a worst case scenario was selective retreatment more costly, but remained more effective.

CONCLUSIONS

Selective retreatment, when clinically applicable, is likely to be more cost-effective than full retreatment in endodontically treated molars with persistent apical periodontitis. Our results should be interpreted with caution because the quality of the underlying data is limited.

The Effect of Unintentional AH-Plus Sealer Extrusion on Resolution of Apical Periodontitis After Root Canal Treatment and Retreatment-A Retrospective Case-control Study

INTRODUCTION

This study aimed to investigate the effect of unintentional AH Plus sealer extrusion on the outcome of nonsurgical root canal treatment and retreatment in teeth with apical periodontitis (AP) compared to teeth with AP and no sealer extrusion at the 1-year follow-up.

METHODS

In a retrospective case-control study conducted from September 2016 to September 2021, teeth presenting clinical and radiographic signs of AP prior to treatment were included. The study comprised 2 groups: AH Plus sealer extrusion group (n = 60): initial root canal treatment or nonsurgical retreatment with unintentional apical extrusion of AH Plus sealer; and no AH Plus sealer extrusion group (n = 60): underwent the same treatment types without sealer extrusion. Additional factors, including sex, age, tooth type, tooth location, and treatment type, were recorded as potential outcome predictors. At 1-year follow-up, teeth were evaluated clinically and radiographically, and outcomes were classified as favorable (healed/healing) or unfavorable (uncertain/non-healing). Statistical analyses, such as the χ2 test, logistic regression, and Mann-Whitney U test, were employed for data analysis.

RESULTS

A favorable outcome was observed in 88.4% and 85% of the cases of the AH Plus sealer extrusion and no AH Plus sealer extrusion groups, respectively. There was no statistically significant difference between the groups in terms of outcomes (P > .05) when analyzed categorically or ordinally. Of independent variables, nonsurgical retreatment showed lower healing of AP in both groups.

CONCLUSIONS

Unintentional AH Plus sealer extrusion did not affect the healing of AP. However, initial root canal treatment showed better healing of AP than nonsurgical retreatment in the presence of AH Plus sealer extrusion. The analyzed outcome predictors had no effect on treatment outcome.

Outcome of non-surgical root canal retreatment procedures obturated with warm gutta-percha techniques: A longitudinal clinical study

OBJECTIVE

To evaluate the success rate of non-surgical root canal retreatment at the 2- to 3-year follow-up and identify the possible prognostic factors.

METHODS

Patients who underwent root canal retreatment at a university dental clinic were contacted for clinical and radiographic follow-up. The retreatment outcomes in these cases were based on clinical signs, symptoms, and radiographic criteria. Inter- and intra-examiner concordance were calculated using Cohen's kappa coefficient. The retreatment outcome was dichotomized into success or failure according to strict and loose criteria. The radiographic success criteria consisted of complete resolution or absence of a periapical lesion (strict criteria) or a reduction in the size of an existing periapical lesion at recall (loose criteria). χ² tests were used to evaluate possible variables associated with retreatment outcomes (age, sex, tooth type, location, contact points, periapical status, quality of previous and final root canal filling, previous and final restoration, number of visits, and complications).

RESULTS

Overall, 129 teeth (113 patients) were included in the final evaluation. The success rate was 80.6% under strict criteria and 93% under loose criteria. Molars, teeth with an initially higher periapical index (PAI) score, and teeth with > 5 mm periapical radiolucency had a lower success rate according to the strict criteria model (p < 0.05). When the loose success criteria were used, teeth with larger (> 5 mm) periapical lesions and those that had been perforated during retreatment showed a lower success rate (p < 0.05).

CONCLUSIONS

The present study demonstrated that non-surgical root canal retreatment is a highly successful procedure after an observation period of 2-3 years. Treatment success is primarily affected by the presence of periapical lesions.

Outcome of selective root canal retreatment-A retrospective study

AIM

Selective root canal retreatment is when the treatment is limited to root(s) with radiographic evidence of periapical pathosis. The goals of this retrospective study were as follows: (i) evaluate the clinical and radiographic (periapical radiographs [PR] or cone-beam computerized tomographs [CBCT]) outcome of selective root canal retreatment after ≥12 months follow-up; (ii) evaluate the periapical status of the unretreated roots; and (iii) assess tooth survival.

METHODOLOGY

A retrospective study (January 2018 to April 2021) was conducted to identify permanent multirooted teeth that underwent selective root canal retreatment. Clinical records, PR and CBCT were examined to ascertain variables of interest. Outcomes (per root and per tooth) were classified into 'favourable' or 'unfavourable' using well-established clinical and radiographic healing criteria. Treatment outcomes for the whole tooth and per root were compared as well as bivariate associations between the treatment outcome of the retreated roots and the treatment-related parameters (quality of root filling, sealer extrusion, iatrogenic mishaps and type of restoration) were analysed using Fisher's exact test (α = .05). Survival was recorded in months.

RESULTS

A total of 75 teeth (195 roots) in 75 subjects were available for outcome analysis. The favourable outcome per tooth was 86.7%. At follow-up, 92.6% of the retreated roots had a favourable outcome. From the unretreated roots, 3.5% showed radiographic signs of an emerging periapical lesion. No statistical difference was shown between the outcomes per root and per tooth between both groups. None of the treatment-related parameters had a direct influence on the outcome of the retreated roots. The survival rate at 12-48 months after retreatment was 91.5%.

CONCLUSIONS

Selective root canal retreatment is associated with a favourable outcome in a majority of cases. Unretreated roots rarely developed radiographic signs of a new periapical lesion at follow-up. Future high-quality clinical trials with larger sample sizes and longer follow-up periods are required to confirm these findings.

Outcome and associated predictors for nonsurgical management of large cyst-like periapical lesions: A CBCT-based prospective cohort study

AIM

The aim of this cone-beam computed tomography (CBCT)-based study was to evaluate the outcome of nonsurgical root canal treatment (RCT) performed for the management of large cyst-like periapical lesions (LCPL) and to identify the predictive factors affecting healing.

METHODOLOGY

Fifty-four subjects (77 permanent maxillary anterior teeth) with LCPL (>10 mm) of endodontic origin were included. A single operator performed standardized multi-visit RCT. Patients were clinically and radiographically examined at 6, 12 months, and a CBCT scan was taken at 24 months. Two independent blinded evaluators measured the pre- and postoperative volume of periapical lesions on CBCT scans using ITK snap software (version 3.8.0-beta-20181028-win64). The outcome was assessed as a percentage change in lesion volume and dichotomized as success (resolved/reduced) or failure (unchanged/enlarged). Ten preoperative (gender; age; intraoral draining sinus, soft tissue swelling, tooth discoloration, pulp canal obliteration, open apex, root resorption, cortical bone defect and lesion volume) and four intraoperative (apical extent and density of root filling; number of treatment visits and type of root filling) predictive factors were observed. Bivariate and stepwise multivariable linear regression analysis was performed to identify independent predictors affecting treatment outcomes. The significance level was set at 5%.

RESULTS

A recall rate of 88% was achieved. The success rate of RCT was 82.2% (8.9% resolved, 73.3% reduced). Median lesion volume reduction was 75% (IQR 61%-93%). No pre- or intra-operative factors were related to treatment failure. However, presence of preoperative cortical bone defect (palatal versus no cortical defect, β = -51.5; 95% CI: -86.9 to -16, p = .006) and apical extent of obturation (long versus flush, β = -27.2; 95% CI: -53.8 to -0.6, p = .04) were negatively associated with reduction in lesion volume (%).

CONCLUSION

Large cyst-like periapical lesions may be successfully managed with RCT. Preoperative cortical bone defect and apical extent of obturation may negatively influence osseous healing.

The influence of patient race on the outcome of endodontic treatments: a pooled analysis of one-year recall data from four cone beam computed tomography outcome studies

Objectives The aim of this pooled data analysis was to establish if there is an association between a patient's race and the proportion of successful outcomes of endodontic treatments, and if so, what factors may determine this association.Methodology Data collected from four prospective clinical outcome studies were pooled. Patients were recalled 12 months after the completion of the treatment. Treatment outcome was determined by clinical findings and cone beam computed tomography examination. Statistical analysis included the description of categorical and continuous variables and simple binary logistic regression models, chi-squared tests and Kruskal-Wallis tests.Results Data from 301 patients were available. Of these patients, 43 were Black (14.3%), 50 were from a Non-Black Minority Ethnic (NBME) group (16.6%) and 208 were white (69.1%). The risk of an unfavourable outcome was higher in teeth with short root canal fillings (OR = 3.36; p = 0.002), when a preoperative radiolucency was present (OR = 2.59; p = 0.019) and when an intra-operative root canal perforation was detected (OR = 5.25; p = 0.016).Multiple regression models showed that Black (OR = 2.28; p = 0.05) and NBME patients (OR = 3.07; p = 0.008) had a higher risk of an unfavourable result compared to white patients.Conclusions Black and NBME patients had a significantly higher failure rate of root canal treatments compared to white patients. All other known pre-, intra- and post-operative risk factors for root canal treatment failure were present in similar proportions in BME and white patients.

Influence of cone beam computed tomography on endodontic treatment planning: A systematic review

OBJECTIVES

The aim of this systematic review was to evaluate how treatment plans changed when cone beam computed tomography (CBCT) imaging was used in endodontic treatment decision-making.

DATA

Studies examining changes in clinicians' treatment plans with and without the use of CBCT were included. Risk of bias assessment was completed using a modification of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool.

SOURCES

A systematic search was performed in PubMed, Embase, Scopus, Cochrane databases from inception to 14 September 2021.

STUDY SELECTION

The initial search identified 3379 titles and abstracts; 20 articles fulfilled inclusion and exclusion criteria for full text review. An additional three articles were identified through citation searching. Sixteen studies met inclusion and exclusion criteria for data extraction and analysis. Fifteen studies reported changes in treatment plan with CBCT imaging. Five studies reported changes in 45 - 66.7% of the cases but did not mention specific treatment options. Of the 11 remaining studies, 10 studies reported changes in 24.3 - 56% of cases and changes in treatment options, while one study reported no significant change in treatment plan after CBCT imaging was introduced. With CBCT imaging, clinicians were more likely to prescribe further intervention that included endodontic treatment and extractions.

CONCLUSION

Although the current evidence was heterogeneous, it was clear that CBCT offered more information than periapical radiography. This influenced endodontic treatment decision-making and in more complex cases, led to further intervention including non-surgical and surgical endodontic treatment and extractions.

CLINICAL SIGNIFICANCE

Additional information from CBCT imaging influenced endodontic treatment decision-making in the following situations: high difficulty cases, diagnosis of symptomatic teeth after failed root canal treatment, evaluation of periapical healing, pre-surgical treatment planning, and management of traumatised immature teeth and external cervical resorption.

The Assessment of Quality of the Root Canal Filling and the Number of Visits Needed for Completing Primary Root Canal Treatment by Operators with Different Experience

The main goal of root canal treatment (RCT) is to eradicate or essentially diminish the microbial population within the root canal system and to prevent reinfection by a proper chemo-mechanical preparation and hermetic final obturation of the root canal space. The aim of this study was to assess the quality of the root canal filling and the number of visits needed for completing RCT by operators with different experience, including dentistry students (4th and 5th year), general dental practitioners (GDPs), and endodontists. Data from medical records of 798 patients were analyzed, obtaining 900 teeth and 1773 obturated canals according to the inclusion and exclusion criteria. A similar number of teeth was assessed in each group in terms of density and length of root canal filling and number of visits. The larger number of visits and the lower quality of treatment was observed for 4th year students than for other groups (p < 0.05); in contrast, the endodontists needed the lowest number of visits to complete RCT and more often overfilled teeth than other operator groups (p < 0.05). Interestingly, no statistical difference in quality of root canal filling was noted between 5th year students, GPDs and endodontists. The treatment of lower teeth demanded statistically more visits than that of upper teeth (p < 0.05). The results of the study emphasize that most of the root canal filling performed by operators was considered adequate, regardless of tooth type, files used and number of visits.

The outcome of endodontic treatment using an enhanced infection protocol in specialist practice

Objectives This study aims to determine the outcome of primary root canal treatment with specific enhanced infection control protocol. The secondary aim was to compare percentages of successful outcomes in this study with a previous study undertaken by the same operator using both periapical radiograph (PR) and cone beam computed tomography (CBCT).Materials and methods Root canal treatment of 110 teeth in 95 patients carried out by a single operator using an enhanced infection control procedure (disinfection of gutta percha before obturation, changing of gloves after each intraoperative radiograph and also before the start of the root canal obturation). PR and CBCT scans of 94 teeth in 87 patients were assessed 12 months after completion of primary root canal treatment and compared with their respective pre-treatment (diagnostic) PR and CBCT scans. Healing was assessed by a consensus panel consisting of two calibrated examiners. Comparison of the PR and CBCT images for 'healed' and/or 'healing' outcomes was performed using McNemar's test.Results The 'healed' rate (absence of periapical radiolucency) was 89.4% using PR and 78.7% for CBCT (p <0.046). This rate increased to 95.7% for PR and 92.6% for CBCT when the 'healing' group (reduced size of periapical radiolucency) was included (p <0.046).Conclusion The frequent changing of gloves during the course of endodontic treatment and disinfection of gutta percha points before obturation, together with the use of contemporary rotary files, resulted in a high success rate of primary root canal treatment compared to similar clinical studies conducted previously.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Outcome of single-visit- versus two-visit root canal retreatment in teeth with periapical lesions: a randomized clinical trial

AIM

To evaluate the clinical and radiographic outcome of single-visit root canal retreatment and to compare the results with conventional two-visit root canal retreatment as control group.

METHODOLOGY

One hundred root canal-treated, single-rooted asymptomatic teeth with periapical lesion were retreated by one operator. Fifty of the teeth were randomly assigned to the single-visit group and the others were treated in two-visits. In both groups, root canal filling material was removed, and re-instrumentation of the root canal was performed using step-back technique with hand files using 2.5% NaOCl and 5% EDTA as irrigants. In the single-visit group 5 ml 2% chlorhexidine (CHX) were applied as the final irrigation and in the two-visit group, calcium hydroxide paste was placed into the root canal as an interappointment dressing. All root canal obturations were performed with lateral compaction. All patients were followed up for 24 months. Success was determined depending on both healed and healing cases. The chi-square or Fisher's Exact test was used to analyse the differences between the groups for success rates and the factors affecting the outcome.

RESULTS

The recall rate was 89 (89%). At 24 months, 39 teeth (88.6%) were considered as healed, 3 teeth (6.8%) as healing, and 2 teeth (4.5%) were identified as failed in the single-visit group, while in the two-visit group 39 teeth (86.7%) had healed, 2 teeth (4.4%) were scored as healing, and 4 teeth (8.9%) as failed. There was no statistically significant difference in the success rates between the two groups (P > 0.05). Size of the lesion and the preoperative length of root canal filling had a statistically significant impact on the outcome (P < 0.05).

CONCLUSION

No statistically significant difference was observed in terms of healing in 24-month follow-up of retreatments completed in single-visit or two-visits in asymptomatic teeth with periapical lesions. Size of the periapical lesion and initial apical level of root canal filling have affected the outcome of root canal retreatment.

A Scoping Review of Four Decades of Outcomes in Nonsurgical Root Canal Treatment, Nonsurgical Retreatment, and Apexification Studies: Part 3-A Proposed Framework for Standardized Data Collection and Reporting of Endodontic Outcome Studies

INTRODUCTION

Despite initiatives to standardize and improve reporting of rapidly growing endodontic outcome research studies, issues related to missing and ambiguous information are still of great concern. In this article, we propose a framework for standardized data collection and a compiled checklist for reporting of various study designs on endodontic outcome.

METHODS

A comprehensive search was carried out to locate randomized controlled trials, cohorts, case-control studies, or case series of >100 patients that reported on endodontic outcomes. We reviewed these articles to develop a Data Collection Template and compiled a checklist for reporting of future endodontic outcome research.

RESULTS

Out of 354 eligible articles previously reported in our scoping review on endodontic outcome studies, 109 articles were selected and screened for study variables or levels of categorization. Our complied Data Collection Template was developed in 19 domains to highlight important demographic, preoperative, intraoperative, and postoperative variables. Because of the specific needs for endodontic outcome literature, we also proposed a compiled checklist (consisting of 4 main domains) to facilitate the reporting of various study designs on endodontic outcome studies. This checklist included simple descriptions of the required items and examples on reporting from published endodontic studies.

CONCLUSIONS

By facilitating the collection and reporting of relevant research data by investigators in private practice and academia, we hope that the proposed Data Collection Template and reporting guideline can highlight the importance of standardization among clinicians and researchers while producing valid scientific information that will support evidence-based treatment decisions.

A prospective cohort study evaluating the outcome of root canal retreatment in symptomatic mandibular first molars with periapical lesions

AIM

To evaluate the impact of various predictors on the outcome of root canal retreatment in symptomatic mandibular first molars with periapical lesions after a minimum of 2 years.

METHODOLOGY

One hundred and twenty previously root canal treated symptomatic mandibular first molars with periapical lesions which were diagnosed as symptomatic apical periodontitis or acute apical abscess with localized intraoral swelling were included. Root canal retreatment was performed by an experienced endodontist using a standardized treatment protocol. The teeth were followed up clinically and radiographically and the radiographic outcome was assessed using a modified periapical index scale (PAI). The cumulative success proportion and the influence of predictors on the outcome of the root canal retreatment were analysed using Kaplan-Meier analyses and log-rank tests, and the hazard ratios for the predictors were also investigated using Univariate Cox Proportional Hazard regression analysis at a significance level of 5%.

RESULTS

Of the 120 teeth, 103 teeth were re-examined with an 85% recall rate. The cumulative success rate was 88% in which 64% were healed and 24% were healing, and failure rate was recorded as 12%. None of the preoperative predictors, including age, gender, soft tissue tenderness, intraoral swelling, size of the lesion, PAI score, apical level and density of root canal filling before root canal retreatment, nor intraoperative predictors, such as active exudate drainage, density of root canal filling after root canal retreatment and restoration type had an influence on the outcome of root canal retreatment (p > .05). The only factor that significantly reduced the success rate of root canal retreatment was the apical level of the root canal filling; when it was more than 2 mm short of the radiographic apex in teeth where apical patency was not established, the success was significantly lower (p = .023).

CONCLUSIONS

Root canal retreatment in symptomatic mandibular first molars with periapical lesions resulted in a success rate of 88%. None of the predictors had a significant influence on the outcome, except for the apical level of the root canal filling after root canal retreatment with short root fillings being associated with significantly more post-treatment endodontic disease.

Patterns of Cone-Beam Computed Tomography (CBCT) Utilization by Various Dental Specialties: A 4-Year Retrospective Analysis from a Dental and Maxillofacial Specialty Center

The study aimed to analyze the uses of cone-beam computed tomography (CBCT) in the diagnosis and treatment in various dental specialties. This 4-year cross-sectional study analyzed the records of 1409 individuals who underwent a CBCT at the Oral and Maxillofacial Center at Sheba Medical Center, Israel. The average age of the patients was 27.9 ± 11.5 (range: 9-86 years). Patients were referred for CBCT by the following departments: Oral and Maxillofacial Surgery (1063; 75.5%), Endodontics (182; 12.9%), Periodontology (122; 8.6%) and Orthodontics (42; 3.0%). Most CBCT radiographs evaluated the maxilla (774; 55.0%), followed by the mandible (481; 34.1%) and both (154; 10.9%). The target anatomical structures included: bone (694; 49.3%), teeth (307; 21.7%), and both jaws (408; 29.0%). The main indications for CBCT use were: assessment of anatomical structures and implant sites (787; 55.9%), determine root canals morphology (182; 12.9%), visualization of impacted teeth, tooth alignment, and localization (177; 12.6%), suspected cysts or tumors (148; 10.5%), evaluation of Temporomandibular joint disorders (106; 7.5%) and other reasons (9; 0.6%). In 279 (19.8%) of cases, the diagnosis changed following CBCT, mainly in Orthodontics tooth analysis (28 (66.7%); p < 0.001). Practitioners and health authorities should be aware of this baseline information regarding CBCT use in the diagnosis and assessment of various oral and maxillofacial pathologies, anomalies and tooth position relative to anatomic structures. Continuing research and publications of CBCT utilization and guidelines are recommended.

The impact of an enhanced infection control protocol on molar root canal treatment outcome - a randomized clinical trial

AIM

To evaluate the effect of an enhanced infection control protocol on root canal treatment outcomes and on microbial load within root canals after chemomechanical preparation.

METHODOLOGY

A total of 144 molar teeth from 139 healthy patients receiving primary root canal treatment were block randomized to a standard protocol (StP) or an enhanced infection control protocol (EnP). Both treatment arms adhered to current best practice recommendations, while the EnP comprised additional steps that included replacing rubber dams, gloves, files, all instruments and surface barriers at the time of canal filling to reduce the chances of iatrogenic contamination. Patients and radiographic examiners were blinded to the protocol used. Intracanal microbial samples were taken at baseline (S1) and after completion of chemomechanical preparation (S2). Microbial 16S rDNA copy numbers were enumerated by quantitative polymerase chain reaction (qPCR). Cone beam computed tomography (CBCT) scans were taken before treatment and at one-year follow-up. The outcome was assessed clinically and radiographically using CBCT by logistic regression modelling.

RESULTS

At one-year follow-up, 115 teeth were analysed (54 in StP and 61 in EnP). The percentage of favourable outcomes assessed by CBCT was 85.2% in the EnP and 66.7% in the StP. The odds of 12-month success was three times higher in the EnP group compared with the StP group (OR=2.89; p=0.022, CI: 1.17 - 7.15). The median bacterial reads were reduced from 8.1×10³ in S1 samples to 3.5×10³ in the StP group and from 8.6×10³ to 1.3×10³ in the EnP group. The enhanced protocol significantly reduced bacterial counts in pre-canal filling samples when compared to the standard protocol (p=0.009).

CONCLUSIONS

The implementation of a facile, enhanced infection control protocol in primary root canal treatment resulted in less detectable bacterial DNA before canal filling and significantly more successful outcomes at one year.

Comparison of the diagnostic efficacy of 2D radiography and cone beam computed tomography in persistent apical periodontal disease: A PRISMA-DTA systematic review and meta-analysis

OBJECTIVE

The objective of this study was to answer the question: Do conventional radiographs (periapical/panoramic) afford better diagnostic outcomes than cone beam computed tomography (CBCT) as a complement for clinical diagnosis of apical lesions with persistent apical periodontitis or disease after root canal treatment?

STUDY DESIGN

Five electronic databases were searched and provided information to enable construction of a table to determine primary diagnostic measures and secondary parameters. The evidence was appraised with the Quality Assessment of Diagnostic Accuracy Studies tool and GRADEpro software.

RESULTS

Twenty-seven articles (9903 diagnostic images) were included. The pooled sensitivity, specificity, area under the receiver operating characteristic curve (AUC_ROC), positive predictive value, negative predictive value, negative likelihood ratio, and accuracy were 0.58, 1, 0.77, 1, 0.68, 0.45, and 0.79, respectively.

CONCLUSIONS

Moderate certainty evidence suggested that conventional radiographs showed poor sensitivity and excellent specificity but good diagnostic performance in terms of AUC_ROC and accuracy. Sensitivity, AUC_ROC, and negative likelihood ratio values could be reduced if the time elapsed to diagnosis after root canal treatment exceeded 5 years. The use of CBCT with a reduced field of view or a 2D radiographic technique should be weighed considering patient-specific and indication-oriented criteria as taking precedence over the therapeutic goal.

Endodontic disease detection: digital periapical radiography versus cone-beam computed tomography-a systematic review

Purpose: To assess the comparative diagnostic performance of digital periapical (PA) radiography and cone-beam computed tomography (CBCT) imaging on endodontic disease detection and to provide study methodology and design recommendations for future studies comparing the diagnostic performance of imaging modalities on endodontic disease detection. Approach: A search of the Medline, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials databases was conducted. Studies that compared the performance of CBCT to digital PA radiography for detecting endodontic disease had an independent reference standard determining the presence of endodontic disease and conducted data analysis including either sensitivity, specificity, receiver operating characteristic (ROC) analysis or free response operating characteristic analysis were included. Of the 20,530 identified studies, only 3 fulfilled the inclusion criteria. Results: Most studies assessed for eligibility were excluded due to limitations and biases in study design-15 of 18 studies had no reference standard. Only one retrospective clinical study reported on the diagnostic performance of CBCT and showed a sensitivity of 86% and specificity of 26%. Two cadaver studies reported sensitivity ranging from 60% to 100%, specificity ranging from 79% to 100%, and an area under the ROC curve of 0.943 for CBCT. The reported sensitivity for digital PA radiography ranged from 27% to 60%, specificity was 99%, and the area under the ROC curve was 0.629. Conclusions: There is a lack of quality evidence and insufficient data to compare diagnostic performance of digital PA and CBCT imaging. This emphasizes the need for well-designed studies to inform clinicians about the relative diagnostic performance of these imaging modalities.

Guidelines for reporting on CBCT scans

The aim of a radiographic report is to provide an accurate interpretation of images to facilitate the diagnostic process, and when indicated prompt the appropriate management for the patient. It is part of the patient's clinical records. This paper describes the imaging chain involved in the cone beam computed tomography (CBCT) workflow from referring to reporting on a CBCT scan. It provides guidelines on the essential information required before and immediately after a CBCT scan is taken, and optimizing the viewing conditions. Finally, it describes a framework for a systematic, comprehensive and tailored CBCT radiographic report. It is aimed at endodontists, clinicians and radiologists reporting on CBCT scans of the dentoalveolar region.

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.

Rapid Chairside Microbial Detection Predicts Endodontic Treatment Outcome

Background. The aim of this longitudinal, one-year cohort study was to explore the hypothesis that fluorescence sampling of the root canal space prior to obturation could predict the outcome of root canal treatment (RCT). Methods. Sixty-five teeth underwent primary RCT and were followed up clinically and radiographically. The outcome was determined radiographically with periapical radiographs (PR) and cone beam computed tomography (CBCT) scans. Results. Success at 12 months was predictable based on the fluorescence score. When the fluorescence score (defined as the percentage of signal over total signal including background) was lower than 67, there was a 4.5 times (Odds ratio (OR) = 0.028; 95% confidence interval (CI): 0.003, 0.291, p = 0.001) greater chance of success (90% overall). When the readings were above this threshold, the success rate was 20%. Conclusion. A chairside sampling method is able to predict the outcome of RCT, through the use of paper point sampling and fluorescence staining. This has reduced the prevalence of persistent infections by guiding the optimum time for obturation. ClinicalTrials.gov trial NCT03660163.

Postendodontic Pain after Pulpotomy or Root Canal Treatment in Mature Teeth with Carious Pulp Exposure: A Multicenter Randomized Controlled Trial

This equivalence, randomized, clinical trial aimed to compare the postoperative pain of root canal therapy (RCT) with pulpotomy with mineral trioxide aggregate (PMTA) or calcium-enriched mixture (PCEM) in permanent mature teeth. In seven academic centers, 550 cariously exposed pulps were included and randomly allocated into PMTA (n = 188), PCEM (n = 194), or RCT (n = 168) arms. Preoperative “Pain Intensity” (PI) on Numerical Rating Scale and postoperative PIs until day 7 were recorded. Patients' demographic and pre-/intra-/postoperative factors/conditions were recorded/analysed. The arms were homogeneous in terms of demographics. The mean preoperative PIs were similar (P=0.998), the mean sum PIs recorded during 10 postoperative intervals were comparable (P=0.939), and the trend/changes in pain relief were parallel (P=0.821) in all study arms. The incidences of preoperative moderate-severe pain in RCT, PMTA, and PCEM arms were 56.5%, 55.7%, and 56.7%, which after 24 hours considerably decreased to 13.1%, 10.6%, and 12.9%, respectively (P=0.578). The time span of endodontic procedures was statistically different; RCT = 69.73, PMTA = 35.37, and PCEM = 33.62 minutes (P < 0.001). Patients with greater preoperative pain, symptomatic apical periodontitis, or presence of PDL widening suffered more pain (P=0.002, 0.035, and 0.023, resp.); however, other pre-/intra-/postoperative factors/conditions were comparable. Pulpotomy with MTA/CEM and RCT demonstrate comparable and effective postoperative pain relief.

Cone-beam Computed Tomographic Analysis to Detect the Association between Primary and Secondary Endodontic Infections and Mucosal Thickness of Maxillary Sinus

INTRODUCTION

This retrospective study used cone-beam computed tomographic (CBCT) imaging to evaluate the differences in the mucosal thickness of the Schneiderian membrane in primary and secondary endodontic lesions.

METHODS

A total of 121 CBCT scans were analyzed. Clinical features such as sex, age, size and volume of the periapical lesion, dimension of the bone, morphology, and relationship between the roots and the mucosal thickness were recorded and analyzed in primary and secondary endodontic lesions in CBCT sagittal and coronal planes. Data were analyzed using the chi-square test, the Mann-Whitney U test, and multiple logistic regression (P < .05).

RESULTS

Statistical analysis revealed no significant differences in membrane thickness between the primary and secondary lesions in the sagittal and coronal planes (P = .08 and .06). Differences between age groups were statistically significant in both groups (P < .05). The volume of the periapical lesions of the secondary endodontic lesions were statistically greater than that of the primary lesions (P < .05). Mucosal thickness prevalence increased when the volume of the lesion was greater, and the bone dimension was narrower in maxillary second premolars and first and second molars. Teeth with 2 or more affected roots were directly related to increased sinus mucosa thickening.

CONCLUSIONS

CBCT images showed no differences in mucosal thickening between primary and secondary endodontic lesions.

European Society of Endodontology position statement: Use of cone beam computed tomography in Endodontics: European Society of Endodontology (ESE) developed by

This Position Statement represents a consensus of an expert committee convened by the European Society of Endodontology (ESE) on the use of Cone Beam Computed Tomography (CBCT) in Endodontics. This paper is an update of the ESE CBCT position statement which was published in 2014 (European Society of Endodontology 2014, https://doi.org/10.1111/iej.12267). Recent review articles provide more detailed background information and the basis for this position statement. It is intended that this position statement will be updated at least every 4-5 years to keep abreast of relevant research. The aim of this paper is to provide clinicians with evidence-based guidance on the application of CBCT in Endodontics. Since 2014, there has been an increase in the number of clinical studies confirming the positive impact of CBCT on treatment planning, decision-making when reviewing cases and reduced practitioner stress levels.

Comparison of diagnostic accuracy between periapical and panoramic radiographs and cone beam computed tomography in measuring the periapical area of teeth scheduled for periapical surgery. A cross-sectional study

BACKGROUND

The aim of the study was compare the sensitivity and measurements obtained from teeth with apical lesions scheduled for periapical surgery using three different diagnostic methods: periapical radiography (Gendex Expert DC), panoramic radiography (Planmeca® Promax 3D Classic) and cone beam computed tomography (CBCT) (Planmeca® Promax 3D Classic).

MATERIAL AND METHODS

This cross-sectional study involved 35 patients (45 teeth) scheduled for periapical surgery in which periapical radiographs, panoramic radiographs and CBCT scans had been obtained. The images were used to analyze the maximum vertical and horizontal dimension and the resulting areas of the periapical lesions based on the three diagnostic methods.

RESULTS

The two-dimensional techniques (periapical radiography and panoramic radiography) yielded a sensitivity of 82% versus 100% in the case of CBCT. The mean vertical dimension of the apical areas was 5.48 mm with periapical radiography and 5.04 mm with panoramic radiography - the difference with respect to CBCT being statistically significant (6.36 mm for the coronal sections). There were no significant differences among the three techniques in terms of horizontal dimension (p>0.05) or lesion area.

CONCLUSIONS

The sensitivity of periapical radiolucencies detected using CBCT was significantly greater than with the two-dimensional imaging techniques. Significant differences between the latter and CBCT were only observed in the case of the vertical measurements. Key words:Periapical lesion, apicoectomy, CBCT, periapical radiography, panoramic radiography.

Comparison of Two-Dimensional and Three-Dimensional Radiographs Using Clinically Relevant Parameters

This work compared the assessment of clinically relevant parameters by two-dimensional, that is, full-mouth intraoral radiograph (I-O) and panoramic radiograph (OPT), and three-dimensional, that is, cone beam computed tomography (CBCT), imaging methods. Different radiographic images (CBCT, I-O and OPT) were available for a 53-year-old female patient with dental and periodontal problems. A total of 14 dental and periodontal parameters were assessed by two independent examiners and compared among the three radiographic imaging modalities. For 10 parameters (71%), the CBCT images were superior to both I-O and OPT images. In contrast, CBCT demonstrated an inferior performance compared to I-O and OPT in the assessment of caries and dental restorations. Compared to OPT, I-O provided more clinically relevant findings for 10 out of 14 parameters (71%). Agreement between I-O and OPT was found with respect to dehiscence, fenestration, the number of bone walls and the root canal cross-section. Differences between the radiographic images were more likely to be detected when maxillary teeth rather than mandibular teeth were assessed with regard to furcation involvement, root proximity and root fusion.

Cone beam computed tomography in Endodontics - a review of the literature

The use of cone beam computed tomography (CBCT) in the diagnosis and/or management of endodontic problems is increasing and is reflected in the exponential rise in publications on this topic in the last two decades. The aim of this paper is to: (i) Review current literature on the endodontic applications of CBCT; (ii) Based on current evidence make recommendations for the use of CBCT in Endodontics; (iii) Highlight the areas in which more research is required.

Self-Limiting versus Conventional Caries Removal: A Randomized Clinical Trial

A single-blind randomized controlled clinical trial in patients with deep caries and symptoms of reversible pulpitis compared outcomes from a self-limiting excavation protocol using chemomechanical Carisolv gel/operating microscope (self-limiting) versus selective removal to leathery dentin using rotary burs (control). This was followed by pulp protection with mineral trioxide aggregate (MTA) and restoration with glass ionomer cement and resin composite, all in a single visit. The pulp sensibility and periapical health of teeth were assessed after 12 mo, in addition to the differences in bacterial tissue concentration postexcavation. Apical radiolucencies were assessed using cone beam computed tomography/periapical radiographs (CBCT/PAs) taken at baseline 0 mo (M0) and 12 mo (M12). In total, 101 restorations in 86 patients were placed and paired subsurface, and deep (postexcavation) dentin samples were obtained. DNA was extracted and bacteria-specific 16S ribosomal RNA gene quantitative polymerase chain reaction was performed. No significant difference was found in bacterial copy numbers normalized to mass of dentin (“bacterial tissue concentration”) between the self-limiting (96.3% reduction) and control protocols (97.1%, P = 0.33). The probability of 12-mo success was 4 times (odds ratio [OR] = 4.33; confidence interval [CI], 1.2–15.6; P = 0.025) higher in the self-limiting protocol compared to the control (conventional excavation technique), with pulp survival rates of 73.3% and 90%, respectively ( P = 0.049). Molars had a 4 times higher probability of success compared to premolars (OR, 4.17; CI, 1.17–14.9; P = 0.028), and symptom severity did not statistically predict outcome (OR, 0.41; CI, 0.12–13.9, P = 0.153). CBCT detected significantly more periapical (PA) lesions than PA radiographs at the baseline visit ( P < 0.001). In conclusion, the self-limiting caries excavation protocol under magnification increased pulp survival rate compared to rotary bur excavation ( ClinicalTrials.gov NCT03071588).

Clinical and Patient-centered Outcomes of Nonsurgical Root Canal Retreatment in First Molars Using Contemporary Techniques

INTRODUCTION

There have been many recent technical advances in modern endodontics that have the potential to affect treatment outcomes. Reports on treatment outcomes using contemporary techniques are relatively scarce, especially in the field of nonsurgical retreatment. The purpose of this study was to determine the success of nonsurgical root canal retreatment in molars using contemporary endodontic techniques.

METHODS

Sixty-three patients referred for retreatment in first molars were enrolled in the study. The retreatment procedures were performed by endodontic residents using a semistandardized treatment protocol. Patients were followed-up at 6, 12, and 24 months. Treatment outcomes were categorized into healed, healing, or nonhealing based on clinical and radiographic criteria. Healed and healing were considered as successes, and nonhealing was considered a failure. Outcomes were also evaluated using patient-centered criteria that included oral health-related quality of life scores and subjective chewing ability.

RESULTS

Fifty-two of the 63 patients were available for final analysis. Five cases (9.6%) were determined to be nonhealing at the last follow-up with new or persistent periapical lesions. Thirty-seven (71.2%) patients had complete resolution of apical periodontitis, and the remaining 10 (19.2%) remained asymptomatic and showed radiographic evidence of healing. Oral health-related quality of life scores and chewing ability improved significantly over time (P < .05), with the biggest increase observed within the first week of treatment completion.

CONCLUSIONS

This study showed that endodontic retreatment using contemporary techniques significantly improved patients' quality of life and chewing ability over time, with a success rate of 90.4% after 2 years.

Influence of patient position and other inherent factors on image quality in two different cone beam computed tomography (CBCT) devices

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Patient head position can affect the image quality in CBCT-examinations.

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CNR values can be used to evaluate image quality.

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Inherent factors influence effective dose variations between CBCT-devices.

Objectives

The aim of this in vitro study was to evaluate how a deviation from the horizontal plane, affects the image quality in two different CBCT-devices.

Methods

A phantom head SK150 (RANDO, The Phantom Laboratory, Salem, NY, USA) was examined in two CBCT-units: Accuitomo 80 and Veraviewepocs 3D R100 (J. Morita Mfg. Corp. Kyoto, Japan). The phantom head was placed with the hard palate parallel to the horizontal plane and tilted 20 ° backwards. Exposures were performed with different field of views (FOVs), voxel sizes, slice thicknesses and exposure settings. Effective dose was calculated using PCXMC 2.0 (STUK, Helsinki, Finland). Image quality was assessed using contrast-to-noise-ratio (CNR). Region of interest (ROI) was set at three different levels of the mandibular bone and soft tissue, uni- and bilaterally in small and large FOVs, respectively. CNR values were calculated by CT-value and standard deviation for each ROI. Factor analysis was used to analyze the material.

Results

Tilting the phantom head backwards rendered significantly higher mean CNR values regardless of FOV. The effective dose was lower in small than in large FOVs and varied to a larger extent between CBCT-devices in large FOVs.

Conclusions

Head position can affect the image quality. Tilting the head backward improved image quality in the mandibular region. However, if influenced by other variables e.g. motion artifacts in a clinical situation, remains to be further investigated.

Advances in knowledge

Image quality assessed using CNR values to investigate the influence of different patient positions and FOVs.

Management of Dens Invaginatus Type II Associated with Immature Apex and Large Periradicular Lesion Using Platelet-rich Fibrin and Biodentine

Dens invaginatus (DI) poses peculiar challenges in endodontic treatment of teeth because of distortion of pulpal space. A case of Oehlers type II DI with open apex and large periapical lesion is reported. The case was managed using cone-beam computed tomography (CBCT), operating microscope, platelet-rich fibrin (PRF), and Biodentine. A 15-year-old male patient presented with palatal swelling. Pulp sensibility testing of right maxillary lateral incisor was negative. Intraoral periapical digital radiograph revealed an Oehlers type II DI with open apex and periapical radiolucency. A CBCT scan was performed to study the anatomy, determine the true extent of the periapical lesion, and form a treatment plan. A diagnosis of Oehlers type II DI with pulp necrosis and acute periapical abscess was made. Two-visit endodontic treatment was performed. In the first visit, the invaginated central mass was removed under operating microscope, chemo-mechanical preparation was done, and double antibiotic paste dressing was placed. In the second visit, the canal was sealed with apical matrices of PRF and Biodentine as filling material. The patient was asymptomatic and radiographs revealed continued healing of the osseous defect at follow-up visits. A CBCT scan at 30 months showed complete continuity of periodontal ligament space, healing of labial and palatal cortical plates, and formation of intercortical bone. The advances in endodontic armamentarium and technology, like CBCT and operating microscope, have made successful treatment of challenging cases possible. PRF and Biodentine as apical matrices and filling material, respectively, proved to be effective in the present case.