Pulp sensibility and vitality tests for diagnosing pulpal health in permanent teeth: a critical review

Dental Pulp Vascular Response to Early Stages of Caries

OBJECTIVES

During caries progression, dental pulp is increasingly pathologically affected. Since the accurate assessment of pulp is of vital importance in clinical decision-making, this study aimed to evaluate pulpal condition in the early stages of caries via laser Doppler (LD) flowmetry and histologic analysis and determine their agreement.

METHODS

Fourteen patients with severe dental crowding were included. Prior to extractions and orthodontic treatment, dental pulp condition of 52 premolars was evaluated via LD flowmetry. Teeth were assessed for the presence of caries and lesions were graded according to the International Caries Detection and Assessment System (ICDAS). After extractions, teeth were split and histologically stained for endothelial cells with anti-von Willebrand factor and Movat pentachrome for collagen. Volume densities of vessels (Vvasc) and collagen were calculated.

RESULTS

There was a significant negative correlation between LD flow and Vvasc of the dental pulp with ICDAS grade. Pulpal LD flow and Vvasc in teeth with the initial lesion were increased, decreasing with progressing stages of caries. A significant positive correlation between the the pulpal LD flow and Vvasc, and a negative correlation of LD flow with collagen fibre density were noted.

CONCLUSIONS

Caries affects the physiology of the dental pulp, initially with increasing vascularity, and decreasing vascularity at later stges of caries progression. Collagen contents increase with grades of ICDAS. LD flow shows good agreement with the histologic constitution of the dental pulp. Use of clinical measurements of pulpal LD flow could provide a good noninvasive indication of pulpal vascular state and its health.

Photobiomodulation therapy on puncture-associated pain: A controlled randomized double-blind clinical trial

Dental fear and phobia are prevalent worldwide, with local anesthesia being the most feared procedure. This study aimed to determine whether photobiomodulation therapy (PBMT), used as a pre-anesthetic, could modulate puncture pain and enhance the effectiveness of local anesthesia. In this controlled, randomized, double-blind study, 49 participants were divided into an experimental group (n = 24), which received infrared laser therapy (100 mW, at 808 nm, 8 J, 80 s at a single point) immediately before standard anesthesia; and control group (n = 25), which received the standard anesthetic technique and sham laser. Pain levels were measured using the visual analog scale, and anesthetic efficacy was assessed through electrical tests (latency), percentage of failures, and cartridge usage. Anxiety levels were evaluated using the Beck Anxiety Inventory. Cardiovascular parameters were evaluated through blood pressure, oxygen levels, and heart rate. This randomized, double-blind study found no difference between groups in these experimental conditions. The bias toward a positive PBMT result was sufficiently removed. Autonomic responses of the PBMT group were maintained stable during the procedure.

Peri-implant medication-related osteonecrosis of the jaw mimicking endodontic disease in a cancer patient: A case report

Medication-related osteonecrosis of the jaw (MRONJ) is a progressive condition that can cause significant bone loss and its diagnosis can be challenging. A 68-year-old man with a diagnosis of hepatocellular carcinoma, undergoing treatment with atezolizumab, bevacizumab and zoledronic acid, complained of spontaneous pain in the right lower second premolar. Oral examination revealed no dental changes and implants in the right jaw. A patient history and thorough clinical and radiographic examinations mimic endodontic disease. The implant crowns were removed, bleeding on probing, and peri-implant pockets were observed. The main hypothesis was MRONJ Stage 2, and the surgical treatment was performed. The pain ceased and signs of MRONJ were not observed within 3 months. MRONJ should be considered as a hypothesis in the case of odontalgia and a patient's history of antiresorptive and antiangiogenic therapies. Furthermore, monitoring patients with dental implants in the mandible through detailed clinical and imaging evaluation is required.

Thermosensing ability of TRPC5: current knowledge and unsettled questions

Our understanding of how the mammalian somatosensory system detects noxious cold is still limited. While the role of TRPM8 in signaling mild non-noxious coolness is reasonably understood, the molecular identity of channels transducing painful cold stimuli remains unresolved. TRPC5 was originally described to contribute to moderate cold responses of dorsal root ganglia neurons in vitro, but mice lacking TRPC5 exhibited no change in behavioral responses to cold temperature. The question of why a channel endowed with the ability to be activated by cooling contributes to the cold response only under certain conditions is currently being intensively studied. It seems increasingly likely that the physiological detection of cold temperatures involves multiple different channels and mechanisms that modulate the threshold and intensity of perception. In this review, we aim to outline how TRPC5 may contribute to these mechanisms and what molecular features are important for its role as a cold sensor.

Applications of smart materials in minimally invasive dentistry - some research and clinical perspectives

OBJECTIVES

Dental caries is one of the most prevalent bacteria-induced non-communicable diseases globally. It is known to be the top oral health burden in both developing and developed nations. There is substantial literature on the disease process and there is still debate on the extent of caries removal needed and the adequacy of the materials available to restore the lost tooth structure. The current review discusses the disease process together with the contemporary management of the carious lesion and also presents substantial evidence on novel materials and techniques that make minimally invasive dentistry predictable.

METHODS

The written work presented shows the most relevant literature for the management of dental caries focusing on novel materials used in minimally invasive dentistry.

RESULTS

There is still much to learn about specific antimicrobial and caries prevention mechanisms of novel materials. Materials that respond to a single or a few stimuli remain "weakly intelligent" in the face of the complex microenvironment in the oral cavity. Engineered systems that combine artificial intelligence and chemical engineering, are expected to possess higher intelligence, self-healing capabilities as well as environmental adaptability, and may be future promising research directions.

SIGNIFICANCE

The targeted approach in managing dental caries will hopefully have a better clinical outcome. The strategies discussed are alternatives to the contemporary approach and will improve the clinical management.

Clinical and patient-level predictors of procedure and tooth survival after direct pulp capping

BACKGROUND

Historical reports of unpredictable outcomes associated with vital pulpal therapies, particularly direct pulp capping (DPC), have contributed to clinicians' skepticism of the procedure. Contemporary reports highlight more predictable outcomes of vital pulpal therapies, inclusive of DPC. There is a dearth of reported patient-centered outcomes of these procedures.

METHODS

Insurance claims were used in an observational, retrospective cohort study to evaluate outcomes of DPC performed on permanent teeth. Statistical analyses included Kaplan-Meier survival estimates and Cox proportional hazards regression. Log-rank tests were used to evaluate unadjusted differences in survival. Cox proportional hazard regression was used to evaluate the adjusted hazard of adverse event occurrence.

RESULTS

The analytic cohort included 4,136 teeth from 3,716 patients. DPC procedures were identified in public-payer (85.5%) and private-payer (13.4%) insurance claims databases. After DPC, procedure survival rate was 83% and tooth survival rate was 93% during a mean follow-up time of 52 months. Molar tooth type, same-day permanent restoration placement, and amalgam restoration type were significant positive predictors of procedure (DPC) survival. Age was not a statistically significant predictor of procedure survival after controlling for tooth type, gender, time to restoration, and restoration type. Nonmolar tooth type and younger age were significant positive predictors of tooth survival after DPC. Failures were most likely to occur within the first year.

CONCLUSIONS

DPC has favorable patient-centered outcomes and contributes to long-term tooth survival.

PRACTICAL IMPLICATIONS

The favorable patient-centered outcomes of DPC bolster calls to consider cost-effectiveness and access to care for endodontic procedures.

Exploring approaches to pulp vitality assessment: A scoping review of nontraditional methods

INTRODUCTION

Diagnostic procedures for pulp vitality assessment are a crucial aspect of routine dental practice. This review aims to provide a comprehensive overview of nontraditional techniques and methodologies for assessing pulp vitality, specifically exploring promising approaches that are currently not used in dental practice.

METHODS

The study protocol was registered a priori (https://osf.io/3m97z/). An extensive electronic search was conducted across multiple databases, including MEDLINE via PubMed, Scopus, Web of Science, and Embase. Inclusion criteria were guided by the research question based on the PCC model as follows: "What are the potential nontraditional techniques (Concept) for assessing pulp vitality (Population) in the field of endodontics or clinical practice (Context)?" Studies were included that explored possible approaches to pulp vitality assessment, utilizing a range of techniques, whilst any studies using traditional pulp tests (cold, heat, and electric stimulation) or well-known methods (pulse oximetry and laser Doppler flowmetry) were excluded. Reviewers independently screened articles and extracted data. A patent search was also performed.

RESULTS

Of 3062 studies, 65 were included that described nontraditional approaches for assessing pulp vitality. These included a range of optical diagnostic methods, ultrasound Doppler flowmetry (UDF), magnetic resonance imaging (MRI), terahertz imaging, tooth temperature measurements, as well as invasive methodologies, including 133xenon washout, radioisotope-labelled tracers, hydrogen gas desaturation, intravital microscopy and fluorescent microspheres isotope clearance. The patent search included artificial intelligence and biomarkers methods.

CONCLUSIONS

This review provides details for potential innovative tests that may directly describe pulp vitality. Importantly, these methods range from clinically impractical through to promising methods that may transform clinical practice. Several nontraditional techniques have the potential to enhance diagnostic accuracy and could provide valuable insights into the assessment of pulp vitality in challenging clinical scenarios.

Referred pain is associated with greater odontogenic spontaneous pain and a heightened pain sensitivity in patients with symptomatic irreversible pulpitis

BACKGROUND

Symptomatic irreversible pulpitis often results in heightened reactions to thermal stimuli such as pain evoked by a cold stimulus, and spontaneous odontogenic pain (unprovoked pain).

OBJECTIVE

This study primarily compared the clinical manifestations of odontogenic spontaneous pain and pain provoked by cold stimulus specifically focusing on their sensory discriminative characteristics (intensity, duration and quality) between symptomatic irreversible pulpitis patients with and without referred pain.

METHODS

Twenty-three patients with symptomatic irreversible pulpitis with referred pain and 12 patients without referred pain were included in this cross-sectional study. The following outcomes were assessed: odontogenic spontaneous pain and its descriptors; pain evoked by cold stimulus and qualitative sensory testing before and after local anaesthesia; referred pain location; use of analgesic medication; complementary anaesthesia efficacy. T-test, chi-squared and McNemar tests were applied to the data (p < .50).

RESULTS

Patients with referred pain presented a greater odontogenic pain intensity (p < .05) when considered the average of the last 24 h. These patients also showed higher pain rating and pain descriptors (p < .05). Intensity and duration of the pain evoked by cold stimulus in the non-affected contralateral tooth at baseline were higher for patients with referred pain (p < .05).

CONCLUSION

Symptomatic irreversible pulpitis patients with referred pain present greater odontogenic spontaneous pain and a heightened pain sensitivity. Therefore, patients with referred pain seem more complex from a pain severity perspective, supporting the clinical utility of discriminating symptomatic irreversible pulpitis with and without referred pain.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

AIM

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Management of luxation injuries in line with International Association of Dental Traumatology guidelines - Two case reports

Luxation injuries represent significant traumatic events for permanent teeth. This article presents the management of intrusive and extrusive luxation injuries, following the International Association of Dental Traumatology (IADT) guidelines, through two case reports. The first case involves a 30-year-old female with an intruded maxillary left central incisor, managed through surgical extrusion, stabilization, and endodontic treatment. The second case features a 15-year-old female with an extruded maxillary left central incisor, repositioned and splinted. Follow-up examinations revealed the resolution of symptoms in both cases. These cases highlight the efficacy of IADT guidelines in diagnosing and treating luxation injuries, resulting in favorable outcomes.

A Scientometric Study of Saudi PubMed-Indexed Endodontic Research

Scientometric studies play a crucial role in quantitatively assessing the impact and quantity of scholarly articles, providing a basis for policy-making and informed decision-making processes. Given the ongoing transformation within the Saudi scientific community across various domains, it is essential to establish a baseline for high-quality endodontic research. A comprehensive search in the PubMed database, using the keywords ["Saudi" OR "Saudi Arabia"] within the time frame of 2014 to 2021. The screening process involved evaluating the title and abstract of each article, with only those classified as endodontic articles included for analysis in this study. The analysis included factors such as the type of paper, the authors, the citations, and the year of publication. Featuring one or more authors affiliated with a Saudi dental institution, 70 papers were specifically categorized as endodontic papers. The most prevalent type of paper was case reports, accounting for 27 articles (28%), followed by literature reviews with 13 articles (18%). The number of authors ranged from one to ten, with a general trend of increasing publication rates over the years. In terms of citations, only four papers received more than 20 citations, while the majority of papers garnered between one and ten citations. Most articles in the field of endodontics exhibited low-level evidence. Therefore, it is recommended that the quality of research output and evidence be enhanced.

The Impact of the Gender on the Pulp Vitality Testing for the Various Types of the Conducting Media: An Original Research

Introduction

To identify gender-based differences in pulpal sensory thresholds in human teeth utilizing various conducting media.

Materials and Methods

The study involved 50 participants of both genders equally distributed. The maxillary central incisors were the teeth selected for the intervention. The three conducting media that were put to the test were Colgate Sensitive Pro-Relief Enamel Repair Toothpaste (CS), Himalaya herbals sensitivity toothpaste (HS), and Lignox 2% gel (LG). Subject's sensory threshold readings as well as the Visual analogue scale (VAS) scores were noted at the tiniest sensation they experienced. Following an ANOVA, a post hoc analysis was performed to confirm the significance between the three media.

Results

Lox 2% Jelly significantly reduced sensory threshold values compared to the other conducting media (P < 0.001). Comparing the sensory threshold values of the sexes showed that men have greater values. Male and female readings differed significantly in the Lox 2% Jelly group (P = 0.021), whereas Colgate Sensitive Pro-Relief Enamel Repair Toothpaste, Himalaya herbals sensitivity toothpaste (P < 0.001) groups showed highly significant variances. All the three conducting media had a highly significant variance for the VAS scores. (P < 0.001).

Conclusion

The conducting material used and gender affect the pulpal sensory thresholds to electric impulses produced by EPT.

Bioelectricity in dental medicine: a narrative review

BACKGROUND

Bioelectric signals, whether exogenous or endogenous, play crucial roles in the life processes of organisms. Recently, the significance of bioelectricity in the field of dentistry is steadily gaining greater attention.

OBJECTIVE

This narrative review aims to comprehensively outline the theory, physiological effects, and practical applications of bioelectricity in dental medicine and to offer insights into its potential future direction. It attempts to provide dental clinicians and researchers with an electrophysiological perspective to enhance their clinical practice or fundamental research endeavors.

METHODS

An online computer search for relevant literature was performed in PubMed, Web of Science and Cochrane Library, with the keywords "bioelectricity, endogenous electric signal, electric stimulation, dental medicine."

RESULTS

Eventually, 288 documents were included for review. The variance in ion concentration between the interior and exterior of the cell membrane, referred to as transmembrane potential, forms the fundamental basis of bioelectricity. Transmembrane potential has been established as an essential regulator of intercellular communication, mechanotransduction, migration, proliferation, and immune responses. Thus, exogenous electric stimulation can significantly alter cellular action by affecting transmembrane potential. In the field of dental medicine, electric stimulation has proven useful for assessing pulp condition, locating root apices, improving the properties of dental biomaterials, expediting orthodontic tooth movement, facilitating implant osteointegration, addressing maxillofacial malignancies, and managing neuromuscular dysfunction. Furthermore, the reprogramming of bioelectric signals holds promise as a means to guide organism development and intervene in disease processes. Besides, the development of high-throughput electrophysiological tools will be imperative for identifying ion channel targets and precisely modulating bioelectricity in the future.

CONCLUSIONS

Bioelectricity has found application in various concepts of dental medicine but large-scale, standardized, randomized controlled clinical trials are still necessary in the future. In addition, the precise, repeatable and predictable measurement and modulation methods of bioelectric signal patterns are essential research direction.

A 3-year follow-up clinical study on the preservation for vitality of involved tooth in jaw cysts through an innovative method

Jaw cysts commonly affect the oral and maxillofacial region, involving adjacent tooth roots. The management of these teeth, particularly regarding root canal therapy and apicoectomy, lacks consensus. This study introduces a novel treatment concept and refined surgical approach to preserve pulp viability in teeth involved in jaw cysts. The objective was to investigate the effectiveness and potential benefits of this approach over a 36-month follow-up period. A conservative management approach prioritized vitality preservation, reserving root canal treatment and apicectomy for cases with post-operative discomfort. A comprehensive follow-up of 108 involved teeth from 36 jaw cyst cases treated with the modified method was conducted. Clinical observation, X-ray imaging, cone-beam computed tomography (CBCT), and pulp vitality testing assessed changes in cyst size, tooth color, pulp vitality, root structure, and surrounding alveolar bone. After 36 months, our modified surgical approach successfully preserved tooth vitality in 84 involved teeth. Adverse symptoms in 19 teeth, such as redness, swelling, fistula, and pain, resolved with postoperative root canal therapy. Follow-up was lost for five teeth in two cases. No cyst recurrences were observed, and in 34 cases, the bone cavity gradually disappeared, restoring normal bone density during long-term follow-up. Our modified surgical method effectively preserves tooth vitality in jaw cysts. This innovative approach has the potential to improve the management of teeth involved in jaw cysts.

Evaluation of the effect of different desensitizers on pulpal blood flow after full crown preparation using laser Doppler flowmetry: a randomized clinical trial

This study aims to evaluate the effect of Teethmate, Bifluoride 12, and Copal Varnish on the treatment of dentin hypersensitivity and the pulpal blood flow using laser Doppler flowmetry (LDF) after full crown preparations. Eighteen patients with 42 teeth with dentine hypersensitivity after full crown preparations were randomly treated with Teethmate, Bifluoride 12, and Copal Varnish. Dentine hypersensitivity was measured using a visual analog scale (VAS) and Schiff air index (SAI). LDF was used to assess the pulpal blood flow and results were recorded in perfusion units (PU). All measurements were performed at baseline, 5 min, 7 days, and 1 month after the application of desensitizers. Data were statistically analyzed by Wilcoxon and two-way ANOVA tests (p < 0.05). There was no significant difference between the tested desensitizers regarding VAS and PU values. VAS values decreased significantly at 7 days and 1 month after the application of desensitizers compared to baseline in all groups. The decrease in PU values significantly differed only in the Copal Varnish group at 5 min and 7 days after the application of the desensitizer (p < 0.05). A statistically significant difference was found between different times regarding SAI scores in all groups (p < 0.05). Teethmate, Bifluoride 12, and Copal Varnish showed similar effectiveness on dentine hypersensitivity and pulpal blood flow. Long-term clinical trials with larger sample sizes and histological studies are needed to evaluate their impacts on pulpal status.

Clinical, Radiographic, and Histologic Outcomes of Regenerative Endodontic Treatment in Human Immature Teeth Using Different Biological Scaffolds: A Systematic Review and Meta-analysis

BACKGROUND

Biological scaffolds such as blood clot (BC), platelet-rich plasma (PRP), platelet- rich fibrin (PRF), and platelet pellet (PP) are used in regenerative endodontic treatments (RETs).

OBJECTIVE

To systematically and quantitatively evaluate clinical, radiographic, and histologic outcomes of RET studies using different biological scaffolds.

METHODS

MEDLINE, Scopus, Cochrane library, and Embase were searched to identify studies on RET procedures with any scaffold type performed on immature non-vital human teeth, employing any type of biological scaffold. Clinical, radiographic, and histologic outcomes were extracted. Cochrane collaboration risk of bias tool and Newcastle-Ottawa scale were used for quality assessment. Random and fixed model meta-analysis was carried out with 95% confidence interval.

RESULTS

Thirty-two studies were included in the qualitative analysis from the primarily retrieved 1895 studies. Only one study had high risk of bias and 71.8% of the studies had high quality. None of the studies reported any histologic findings. Thirty studies were included in meta-analysis. Clinical success rate of RET using either BC, PRP, or PRF was >99%. Furthermore, 32%, 23%, and 27% of BC, PRP, and PRF cases regained vitality, respectively. Periapical healing was seen in 67%, 75%, and 100% of BC, PRP, and PRF cases, respectively. There was no statistical difference between BC, PRP, or PRF regarding clinical success or any radiographic outcomes.

CONCLUSION

There was no significant difference between BC, PRP, and PRF in terms of clinical and radiographic outcomes. When it is difficult or dangerous to induce bleeding in root canals, PRP and PRF may be employed instead.

A suggested universal protocol for dental examination in sports

The athletes of any sport and level submit their bodies to constant exercise. Any given pathology can increase the risk of injury, illness, or even reduced performance. The medical examination is valuable in diagnosing existing health problems and preventing medical issues that might compromise the athlete's overall health when exercising. The stomatognathic system is not an exemption, as oral pathologies, including dental caries and periodontal diseases, are found in high incidence in sports. The need for accurate and detailed dental examination in sports leaded dentists from the European Association for Sports Dentistry and the Academy for Sports Dentistry to elaborate a universal dental examination in sports protocol that can record the overall oral health of the athlete, including the teeth, periodontium, and musculoskeletal screening, for all athletes. The outcome of this stomatognathic examination allows sports physicians and professionals other than dentists to have a complete image of the individual oral health condition of any given athlete, and it allows the dentists to efficiently screen and prevent pathologies, as well as to advise on the eligibility to practice sports from the oral health perspective.

Genome-wide Association Study Identifies Novel Risk Loci for Apical Periodontitis

INTRODUCTION

Apical periodontitis (AP) is a common consequence of root canal infection leading to periapical bone resorption. Microbial and host genetic factors and their interactions have been shown to play a role in AP development and progression. Variations in a few genes have been reported in association with AP; however, the lack of genome-wide studies has hindered progress in understanding the molecular mechanisms involved. Here, we report the first genome-wide association study of AP in a large and well-characterized population.

METHODS

Male and female adults (n = 932) presenting with deep caries and AP (cases), or deep caries without AP (controls) were included. Genotyping was performed using the Illumina Expanded Multi-Ethnic Genotyping Array (MEGA). Single-variant association testing was performed adjusting for sex and 5 principal components. Subphenotype association testing, analyses of genetically regulated gene expression, polygenic risk score, and phenome-wide association (PheWAS) analyses were also conducted.

RESULTS

Eight loci reached near genome-wide significant association with AP (P < 5 × 10-6); gene-focused analyses replicated 3 previously reported associations (P < 8.9 × 10-5). Sex-specific and subphenotype-specific analyses revealed additional significant associations with variants genome-wide. Functionally oriented gene-based analyses revealed 8 genes significantly associated with AP (P < 5 × 10-5), and PheWAS analysis revealed 33 phecodes associated with AP risk score (P < 3.08 × 10-5).

CONCLUSIONS

This study identified novel genes/loci contributing to AP and specific contributions to AP risk in men and women. Importantly, we identified additional systemic conditions significantly associated with AP risk. Our findings provide strong evidence for host-mediated effects on AP susceptibility.

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).

Assessment of correlation between clinical, radiographic, microbiological, and histopathological examinations in identification of pulpal diseases - a single-centre study

Aim

This study aimed to analyse the presence of pulpitis using different techniques and compare the findings of the various examination methods.

Methods

A total of 108 patients were enrolled and randomly divided into two groups: 56 patients whose pulp samples were sent for histopathological analysis and 52 patients whose samples were sent for microbiological analysis. All participants underwent endodontic procedures, with clinical evaluation and assessment using periapical radiography. Bacteria were isolated and identified using agar culture and VITEK 2 identification cards.

Results

Histopathology confirmed chronic pulpitis in 33 samples (58.9%) and acute pulpitis in 23 samples (41.1 %). For chronic pulpitis, the histopathological diagnosis agreed with the clinical evaluation diagnosis in 65.2% of cases, and a similar percentage of agreement was observed for acute pulpitis. Chronic pulpitis was observed in 34.8% of patients on clinical examination; however, according to histopathology, these cases were acute. Dilated blood vessels were detected in 56.5% of patients with acute pulpitis and 15.2% of patients with chronic pulpitis. Neutrophilic leucocytes were observed in 43.5% of patients with acute pulpitis and 69.7% of patients with chronic pulpitis. Lymphocytes were observed in 17.4% of acute pulpitis samples but zero chronic pulpitis samples. Microbiological analysis identified gram-positive bacilli in 22 samples, gram-positive cocci in 51 samples, and fungi in 2 samples. Acute pulpitis was typically found to be associated with anaerobic Clostridium bifermentans, aerobic Streptococcus mitis, and Granulicatella elegans, whereas chronic pulpitis was more often associated with two facultative anaerobes, Streptococcus oralis and Streptococcus mitis.

Conclusion

Comparison of clinical, radiographic, and histological examination techniquesrevealed several notable discrepancies. Radiographic imaging only suggested the presence of pulpal pathologies; therefore, histopathological analysis of the pulp material was still ultimately required to verify the clinical diagnosis and exclude other pathologies. Although histopathology remains the gold standard for assessing pulpal disease, performing additional examinations may provide the most comprehensive, and perhaps the most effective, approach.

Pulp Changes Secondary to Orthodontic Forces: A Review of Literature

This review article encompasses the literature pertaining to changes in the dental pulp subsequent to forces exerted secondary to orthodontic treatment. The review was conducted at the College of Dentistry, Qassim University, Saudi Arabia, from October 2022 to February 2023. A literature search was conducted on PubMed, Embase, The Cochrane Library and Google Scholar for articles from 2000 to 2023. Keywords and MeSH terms used were 'orthodontic forces', 'pulp changes', 'dental pulpal changes', and 'pulp volume'. Two reviewers went through the titles. After removing irrelevant and duplicate articles, abstracts were assessed for relevant articles. Finally, the reviewers analyzed full-text articles, and a total of five articles including four randomized controlled trials and one retrospective study were selected. It was concluded that managing and minimizing injury to the pulp or supporting tissues is important when using orthodontic mechanics. In order to do so, clinicians must thoroughly understand any change in the pulpal tissue following the orthodontic treatment. Orthodontic tooth movements cause inflammatory changes in the tooth pulp and periodontal ligament which are directly related to the amount, direction, and time duration of force used. Long-term pulp blood flow analysis shows that even though there is a transient uptrend in the flow of blood after the removal of the orthodontic force, it reverts to normal levels three months later. However, pulp volume has been reported to decrease, more prominently in anterior teeth, as orthodontic forces stimulate the pulp to produce tertiary dentin.

Influence of the restoration after pulpotomy on the strength of electrical stimulus reaching the pulp space: An in vitro investigation

Introduction

The study evaluated the influence of coronal restoration after pulpotomy on the strength of electrical stimulus reaching the radicular pulp using an electric pulp test (EPT).

Materials and Methods

The pulp tissue from ten freshly extracted mandibular premolar teeth was removed and replaced with an electroconductive gel. The cathode probe of Powerlab was inserted into the pulp space and the anode probe was attached to the EPT handpiece. The EPT probe coated with electro-conducting material was positioned in the middle third of the buccal crown surface. The EPT stimulus reaching the pulp space of an intact tooth at 40 numerical readings was recorded. The tooth was removed from model and endodontic access was made. The 2-mm thick mineral trioxide aggregate was placed at the cementoenamel junction followed by composite resin restoration. The experimental setup was re-established and postpulpotomy EPT stimulus data were recorded. The data collected were compared using the Wilcoxon signed-rank test.

Results

There was a statistically significant difference (P = 0.038) between observed between the strength of EPT stimulus reaching the pulp space in prepulpotomy (mean 91.18 ± 101.02 V and median 25.79 V) and postpulpotomy (mean 58.49 ± 77.13 V and median 13.75 V) tooth samples.

Conclusion

The placement of the restoration and pulp capping agent after pulpotomy dampens the strength of EPT stimulus reaching the pulp canal space.

Prediction and validation of microbial community function from normal pulp to pulpitis caused by deep dentinal caries

INTRODUCTION

Microbial function changes may be responsible for dental pulp transformation from normal to diseased. However, studies on the prediction and verification of the function of the microbial community in the deep dentine and pulp of caries-induced pulpitis are lacking.

METHODS

This study included 171 cases of deep dentinal caries divided into normal pulp (NP), reversible pulpitis (RP), and irreversible pulpitis (IRP). In Experiment I, the microbial community composition was identified in 111 samples using 16S ribosomal DNA. Function prediction was performed through phylogenetic investigation of communities by Phylogenetic Investigation of Communities by Reconstruction of Unobserved States prediction and qPCR. In Experiment II, different microbiome functions were confirmed in 60 samples using liquid chromatography-tandem mass spectrometry.

RESULTS

In Experiment I, microbial abundance significantly differed in the IRP group compared to the other two groups. The RP and NP groups had the same microbiome composition, but the predicted functional difference between the RP and NP groups pertained to membrane transport (p < .010). The predicted functional difference between the IRP and NP groups pertained to amino-acid, co-factor, and vitamin metabolism (p < .010). In Experiment II, Kyoto Encyclopedia of Genes and Genomes functional annotation revealed that the differential metabolites between the RP and NP groups did not participate in membrane transport; however, the differential metabolites between the IRP and NP groups participated in amino-acid metabolism.

CONCLUSIONS

The near-pulp microbiome in RP and NP with deep dentinal caries had the same differential function. However, amino acid metabolism in near the pulp microbial community differed between IRP and NP with deep dentinal caries.

Tooth Complications after Orthodontic Miniscrews Insertion

Orthodontic miniscrews (OM) are widely used in modern orthodontic clinical practice to improve skeletal anchorage and have a high safety profile. A complication at the time of OM insertion is tooth root perforation or periodontal ligament trauma. Rarely, OM injury can cause permanent damage, such as ankylosis, osteosclerosis, and loss of tooth vitality. The aim of this work was to analyze potential risks and dental complications associated with the use of OMs. A search of the PubMed, Cochrane, Web of Science, and Scopus databases was conducted without a time limit using the keywords "orthodontic mini-screw" and "dental damage", resulting in 99 studies. After screening and eligibility, including articles obtained through a citation search, 13 articles were selected. Four studies revealed accidental injuries caused by OM. Most of the damage was localized at the root level and resolved spontaneously with restorative cement formation after prompt removal of the OM, while the pain disappeared. In some cases, irreversible nerve damage, extensive lesions to the dentin-pulp complex, and refractory periapical periodontitis occurred, requiring endodontic and/or surgical treatment. The choice of insertion site was the most important element to be evaluated during the application of OMs.

Effectiveness of precooling with ethyl chloride versus honey in alleviating intra-oral injection pain in adult patients: A randomized controlled trial

Objective:

The objective of the study was to assess and compare the effectiveness of precooling with ethyl chloride versus honey in alleviating the pain of dental injection.

Methods:

About 90 patients were recruited for this randomized controlled trial. In each of the following three groups, 30 patients were allocated: Group 1, precooling with ethyl chloride; Group 2, honey; and Group 3, control. The pain score of patients in each group was measured after injecting the dental local anesthesia using a visual analog scale. Paired t-test and multiple linear regression tests were used for statistical analysis. A p value of ⩽0.05 was considered to be as significant.

Results:

The mean pain scores of participants residing in different groups were as follows: Group 1: 2.83 ± 1.46, Group 2: 4.33 ± 1.62, and Group 3: 7.80. After administrating ethyl chloride, the majority of the 18 (60%) patients reported to suffer from “mild pain.” Furthermore, in patients who were given honey in Group 2, most of the 21 (70%) patients reported suffering from “moderate pain.” In Group 3 (control) where no anesthetic modality was used, the majority of the 25 (83.33%) patients experienced “severe pain.” A significant difference was noted among the pain scores of three groups ( p = 0.001).

Conclusion:

The administration of local anesthetic is part of almost all dental procedures. Precooling with ethyl chloride resulted in a greater reduction in pain scores than honey upon administration of local anesthesia injection.

An overview of assessment and management of acute dental pain

Dental care practitioners are often the first port of call for patients presenting with acute dental pain. Due to the increasing backlog of patients in the UK resulting from the COVID-19 pandemic, it is expected that an increasing number of patients will present to dental care practitioners with acute dental problems. This article aims to provide an overview of common presentations of acute dental pain, the importance of thorough assessment and accurate diagnosis, and the management of such conditions.

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

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

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.

Evaluation of the Response to Pulpal Sensibility Tests (Cold, EPT) in Anemic and Healthy Women

Introduction

The prevalence of anemia has been reported high in the female population in Iran. Anemia can be asymptomatic or can present in a variety of symptoms, especially when serum Hb values decrease. The present study would assess dental pulp response to cold and EPT sensibility tests in anemic and healthy women.

Materials and Methods

One hundred twenty maxillary central incisors belonging to participants aged 18–58 years were included in this survey. 60 patients had anemia (Hb ≤ 12.5) with/without medication (30 in each group) and 60 women as controls had no anemia (Hb > 12.5) with/without medication (30 in each group). Electric and cold pulpal sensibility tests were performed for all teeth. Statistical analysis was performed with t-student, Chi-square test, and two-way ANOVA. The significance level was set as p < 0.05.

Results

According to the results of this study, the mean value of hemoglobin in anemic and healthy women was 11.5 and 14.08 g/dl, respectively. The mean value of response to EPT in anemic women with and without medication was 3.21 and 3.14, respectively. The mean value of response to EPT in healthy women with and without medication was 3.81 and 3.58 g/dl, respectively. The mean value of time delay response to cold test was 3.03 and 2.82 s in anemic patients with/without medication. Also, the mean value of time delay response to cold test was 2.80 and 2.93 s in healthy women with/without medication. The pulpal responses to EPT tests had significant differences between anemic and healthy women (p=0.043). There were no significant differences between anemic and healthy women considering time delay response to the cold test (p=0.077).

Conclusion

Based on the results of the present study, tooth response to the EPT  sensibility test may alter in anemic patients despite medication. The evidence from this preliminary study suggests that peripheral neuropathy in anemic patients could affect pulpal sensibility tests.

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.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

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

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

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

Background

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

Objectives

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

Methods

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

Results

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

Discussion

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

Conclusion

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

Analgesic efficacy of corticosteroids and nonsteroidal anti-inflammatory drugs through oral route in the reduction of postendodontic pain: A systematic review

Analgesic medications in dentistry are indicated for the relief of acute pain, postoperative pain, chronic pain as well as controlling adjunctive intraoperative pain. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) has shown an effective reduction of postendodontic pain by action on the cyclooxygenase pathway. Another medication which is used recently is corticosteroid which enables the reduction of pain. They are hormones secreted from the adrenal gland and have strong anti-inflammatory actions. This review aims to compare the analgesic efficacy of NSAIDs and corticosteroids when administered through oral route for reducing postendodontic pain. The secondary objective was to assess the anesthetic effect of the nerve block when an oral premedication of NSAIDs or corticosteroids was administered. The databases of PubMed, ScienceDirect, LILACS, and Cochrane were searched for related topics from 1983 to April 2020. Bibliographies of clinical studies were identified in the electronic search. Clinical studies with postendodontic pain reduction using NSAIDs and corticosteroids were selected. Clinical studies that met all inclusion criteria were reviewed. Data extraction was performed independently by two reviewers. All individuals who administered single dose analgesic (NSAID or corticosteroid) before initiating root canal treatment were taken into inclusion criteria. All the relevant data were extracted from the selected studies were reviewed by two independent reviewers using a standardized data collection form, and in case of disagreement, a third reviewer was enquired to achieve a consensus. Risk of bias of the selected studies was done using Cochrane Risk of Bias Tool (version 1). Mean pain score levels at various time intervals showed an increased analgesic success rate for corticosteroids ( 32-1) in comparison to NSAIDs ( 32-21.4). Anesthetic effect of the nerve block administered was seen to be better when an oral premedication of corticosteroids (38.2%–80.8%) was given in comparison to NSAID (25.5%–73.1%). From the present study, it can be concluded that oral administration of corticosteroids provides a better analgesic efficacy when compared to NSAIDs as an oral premedication for postoperative pain reduction. It can also be concluded that corticosteroids when used as an oral premedication provide a better anesthetic effect of the nerve block administered when compared to NSAIDs given as an oral premedication. These findings could help the clinician determine which pretreatment analgesic would have a better effect in reduction of pain posttreatment as well as increasing the anesthetic efficacy of administered block. Systematic Review Registration Number: CRD42021235394.

Comparison of pulp sensibility test responses in normotensive and hypertensive individuals: A clinical study

Background

Pulp sensibility testing is an essential part of the diagnostic process in the assessment of pulpal health. Several lines of evidence suggest an interaction between control of blood pressure and pain regulatory mechanisms.

Aim

The aim of the study is to compare pulp sensibility test responses in normotensive and hypertensive individuals.

Materials and Methods

Ninety-eight patients participated in the study, with 49 individuals each in the hypertensive and normotensive groups. A minimum of 4 and maximum of 8 sound teeth were included in the study each from the anterior, premolar, and molar, i.e., 4 teeth from either arch. A total of 832 teeth were tested. The value and time when the responses evoked for electric pulp test (EPT) and cold test were recorded respectively.

Statistical Analysis

For intergroup and intragroup analyses, independent t-test and paired t-test were utilized.

Results

A statistically significant difference was noted in values for EPT as well as cold test responses when both the groups were compared (P < 0.01). Higher values were obtained with the hypertensive group.

Conclusion

Patients with established hypertension showed an increased threshold to electric pulp testing and cold stimulus as compared to normal healthy individuals.

Adhesive systems applied to dentin substrate under electric current: systematic review

Objectives

The purpose of this systematic review was to collect and discuss the technique of adhesive systems application on dentin substrate under electric current.

Materials and Methods

The first search strategy was based on data available at PubMed, LILACS, Scielo, Scopus, and Cochrane Library, using a combination of descriptors such as “dentin bond agents OR adhesive system AND electric current OR electrobond” or “dentin bonding agents OR dentin bonding agent application OR adhesive system AND electric current OR electrobond”, with no limit regarding the publication year. The second search strategy was based on the articles' references found previously. An additional search strategy was applied that concerned the proposed theme in the SBU-UNICAMP (Unicamp's Library System Institutional Repository).

Results

Twelve studies published between 2006 and 2020 were found. The analyses of the selected studies showed that the use of electric current during adhesive systems application on dentin, whether conventional or self-conditioning, increases resinous monomer infiltration in the dentin substrate, which improves the hybridization processes and the bond strength of the restorative material to dentin.

Conclusions

Despite the favorable results related to the use of this technique, there is still no specific protocol for the application of adhesive systems under electric current.

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.

Quantitative assessment of contrast-enhancement patterns of the healthy dental pulp by magnetic resonance imaging: A prospective in vivo study

AIM

This prospective in vivo study aimed to optimize the assessment of pulpal contrast-enhancement (PCE) on dental magnetic resonance imaging (dMRI) and investigate physiological PCE patterns.

METHODOLOGY

In 70 study participants, 1585 healthy teeth were examined using 3-Tesla dMRI before and after contrast agent administration. For all teeth, the quotient of post- and pre-contrast pulp signal intensity (Q-PSI) was calculated to quantify PCE. First, pulp chambers were analysed in 10 participants to compare the coefficient of variation of mean versus maximum Q-PSI values (Q-PSI_mean versus Q-PSI_max ). Second, dynamic PCE was evaluated in 10 subjects to optimize the time interval between contrast agent application and image acquisition. Finally, 50 participants (age groups: 20-29, 30-39, 40-49, 50-59 and 60-69 years) were examined to analyse age, gender, tooth types and maxilla versus mandible as independent factors of PCE. Statistical analysis was performed using Wilcoxon signed rank test and linear mixed models.

RESULTS

PCE assessment based on Q-PSI_max was associated with a significantly smaller coefficient of variation compared with Q-PSI_mean , with median values of 0.17 versus 0.21 (p = .002). Analysis of dynamic PCE revealed an optimal timing interval for image acquisition 4 min after contrast media application. No significant differences in PCE were observed by comparing age groups, female versus male participants and maxillary versus mandibular teeth (p > .05). Differences between tooth types were small (median Q-PSI_max values of 2.52/2.32/2.30/2.20 for molars/premolars/canines/incisors) but significant (p < .05), except for the comparison of canines versus premolars (p = .80).

CONCLUSIONS

PCE in dMRI was a stable intra-individual marker with only minor differences between different tooth types, thus forming an important basis for intra-individual controls when assessing teeth with suspected endodontic pathosis. Furthermore, it was demonstrated that PCE is independent of age, gender and jaw type. These findings indicate that dMRI-based PCE analysis could be a valuable diagnostic tool for the identification of various pulp diseases in future patient studies.

Vital Pulp Therapy in Permanent Teeth with Irreversible Pulpitis Caused by Caries: A Prospective Cohort Study

Background: When a tooth is diagnosed with irreversible pulpitis, root canal therapy (RCT) is generally performed to completely remove pulp tissue, which might lead to a higher risk of loss of vascularity, and teeth being more prone to fracture. Vital pulp therapy (VPT) is a personalized method of treating irreversible pulpitis, which conforms to the trend of minimally invasive endodontics. The remaining vital pulp could promote the physiological development of the roots of young permanent teeth with incomplete apical foramen. However, clear guidelines for VPT indication are still missing. Objective: This prospective cohort study evaluated the outcomes of vital pulp therapy (VPT) using iRoot BP Plus (Innovative Bioceramix Inc, Vancouver, BC, Canada) in permanent teeth of 6- to 20-year-old patients with irreversible pulpitis caused by caries and analyzed the preoperative factors affecting VPT prognosis. Methods: Fifty-nine permanent teeth in 59 patients with irreversible pulpitis caused by caries were treated with VPT using iRoot BP Plus. All patients received VPT under a standardized protocol. After informed consent, teeth were isolated with a dental dam, then operators performed VPT with iRoot BP Plus and restored the teeth with composite resin or stainless steel crown. Patients were postoperatively recalled after 3, 6 and 12 months and then recalled annually. Successful cases were defined as successful in both clinical and radiographic evaluations. A statistical analysis was performed using the Fisher exact test, and the level of significant difference was p < 0.05. Results: After 6–36 months of follow-up, a total of 57 teeth from 57 patients were accessible for evaluation. The mean age of subjects was 11.75 ± 3.81 years. The overall clinical and radiographic success rate of VPT was 91.2% (52/57). With an observation time of one year or more, the success rate was 90.5% (38/42). All the symptoms and physical examination findings showed no significant effect on VPT prognosis (p > 0.05) using a binary logistic regression model. Conclusions: Permanent teeth in 6- to 20-year-old patients diagnosed as irreversible pulpitis caused by caries can be successfully treated with VPT using iRoot BP Plus.

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

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

Prognosis of Regenerative Endodontic Procedures in Mature Teeth: A Systematic Review and Meta-Analysis of Clinical and Radiographic Parameters

This work aimed to investigate the use of Regenerative Endodontic Procedures (REP) on the treatment of pulp necrosis in mature teeth through systematic review and meta-analysis of evidence on clinical and radiographic parameters before and after REP. A search was performed in different databases on 9 September 2020, including seven clinical studies and randomized controlled trials (RCT). The methodological quality was assessed using Revised Cochrane risk-of-bias (RoB 2) and Before-and-After tools. Meta-analyses were performed to evaluate the success incidences regarding the reduction of periapical lesion and recovery of sensitivity. The certainty of the evidence was assessed using GRADE. Meta-analysis showed a high overall success of 0.95 (0.92, 0.98) I² = 6%, with high periapical lesion reduction at 12 months (0.93 (0.86, 0.96) I² = 37%) and by the end of follow-up (0.91 (0.83, 0.96) I² = 13%). Lower incidences of positive sensitivity response were identified for the electrical (0.58 (0.46, 0.70) I² = 51%) and cold tests (0.70 (0.54, 0.84) I² = 68%). The calculated levels of REP success were similar to those reported for immature teeth. With a very low certainty of evidence, the meta-analysis showed a high incidence of REP’s success for mature teeth with necrotic pulp evidenced by periapical lesion reduction and moderate positive responses to sensitivity tests.

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.

Clinical comparison of sensitivity and specificity between sensibility and vitality tests in determining the pulp vitality of mandibular premolars

This clinical study was designed to compare cold pulp testing (CPT), heat pulp testing (HPT) and electric pulp test (EPT) with pulse oximetry (PO), flowmetry (FM) and thermometry (TM) in terms of sensitivity and specificity. Twenty premolar teeth in need of root canal treatment were included in the study. Pulp sensibility tests (CPT, HPT and EPT) along with vitality tests (PO, FM and TM) were performed. As the gold standard, the teeth were endodontically treated and pulp vitality was determined by direct visual observation. Sensitivity, specificity and accuracy values for each test were as follows: HPT 1, 1, 100%; CPT 1, 0.818, 90%; EPT 1, 0.909, 95%; PO 1, 0.545, 75%; TM 0.111, 0.272, 20%; and FM 0.444, 0.272, 35%, respectively. The most accurate test among all was HPT. PO was the most accurate vitality test.

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.