The global prevalence of apical periodontitis: a systematic review and meta-analysis

Angiogenic and neurogenic potential of dental-derived stem cells for functional pulp regeneration: A narrative review

BACKGROUND

Dental pulp tissue engineering is expected to become an ideal treatment for irreversible pulpitis and apical periodontitis. However, angiogenesis and neurogenesis for functional pulp regeneration have not yet met the standard for large-scale clinical application, and need further research.

OBJECTIVE

This review focused on the potential mechanisms of angiogenesis and neurogenesis in pulp regeneration, including stem cell types, upstream and downstream regulatory molecules and cascade signalling pathways, thereby providing a theoretical basis and inspiring new ideas to improve the effectiveness of dental pulp tissue engineering.

METHODS

An electronic literature search was carried out using the keywords of 'pulp regeneration', 'stem cell transplantation', 'dental pulp stem cells', 'angiogenesis' and 'neurogenesis'. The resulting literature was screened and reviewed.

RESULTS

Stem cells used in dental pulp tissue engineering can be classified as dental-derived and non-dental-derived stem cells, amongst which dental pulp stem cells (DPSC) have achieved promising results in animal experiments and clinical trials. Multiple molecules and signalling pathways are involved in the process of DPSC-mediated angiogenic and neurogenetic regeneration. In order to promote angiogenesis and neurogenesis in pulp regeneration, feasible measures include the addition of growth factors, the modulation of transcription factors and signalling pathways, the use of extracellular vesicles and the modification of bioscaffold materials.

CONCLUSION

Dental pulp tissue engineering has had breakthroughs in preclinical and clinical studies in vivo. Overcoming difficulties in pulpal angiogenesis and neurogenesis, and achieving functional pulp regeneration will lead to a significant impact in endodontics.

Bimetallic nanozymes for effectively removing Enterococcus faecalis biofilms in pulp and periapical infection treatment

Pulpal and periapical infections, primarily caused by the biofilms of Enterococcus faecalis (E. faecalis), pose significant challenges due to their resistance to eradication, making them prevalent oral health concerns. Herein, we synthesized a bimetallic Zn-Fe nanozymes (ZFNs) with enhanced peroxidase-like (POD-like) activity, capable of activating hydrogen peroxide (H2O2) into highly reactive hydroxyl radicals to combat E. faecalis biofilms. The incorporation of Zn elements effectively optimizes the electronic structure of the reactive Fe sites, significantly improving the POD-like activity of ZFNs. Consequently, a trace amount of ZFNs (20 μg mL-1) combined with H2O2 (200 μM) achieved efficient E. faecalis inactivation (95 %) and disrupts biofilm formation. Notably, in a root canal infection model, ZFNs demonstrate a biofilm-clearing effect comparable to that of 3 % sodium hypochlorite NaOCl, a clinical drug) and exhibit satisfactory biosafety. In summary, ZFNs hold promise as a root canal irrigation solution for treating pulpal and periapical infections, offering new possibilities for addressing root canal infection challenges.

Confounders: A threat to the interpretation of research findings in endodontics

Confounding is a significant challenge in endodontic research, as it can blur the true effect and relationship between exposure and outcomes, potentially compromising the internal validity of research findings. Confounding variables can create apparent differences between study groups when no actual difference exists or fail to reveal true differences when they are present. Additionally, confounding can lead to either an underestimation or an overestimation of the effect of exposure on the outcome. This narrative review aims to (i) define confounder variables and explain how to identify them, (ii) elaborate methods for controlling confounders, and (iii) discuss how confounders can obscure any causal relationship. Confounding variables can be controlled through study design such as randomization, matching and restriction, or adjusted using statistical methods like stratification and multivariable models. However, inadequate control of confounding can result in residual confounding, which poses a significant threat to the interpretation of findings in endodontic research.

The heterogeneity of T cell infiltration in human periapical lesions

OBJECTIVES

T lymphocytes (T cells) are crucial important types of immune cells which are responsible for adaptive immune response during the progression of bacterial infectious diseases. Different subtypes of T cells can participate in regulating the progress of human periapical lesions. This study investigates the co-localization of different types of T cells by multiplex immunofluorescence staining (mIHC) from different types of human periapical lesions (PLs) which might elucidate the potential clinical relevance of T cell infiltration with PLs.

MATERIALS AND METHODS

20 PLs tissues and 6 healthy samples from healthy periodontal ligament tissues were collected for subsequent experiments. Histological examination and immunohistochemical analysis were performed using hematoxylin-eosin (H&E) staining, immunohistochemical staining (IHC) and mIHC. Data analysis involved quantifying the number of positive cells of CD3, CD4, GATA3, Tbet and Foxp3 using QuPath software. In addition, the co-localization of CD4, GATA3, Tbet and Foxp3 was also assessed.

RESULTS

Radicular cysts (RCs) (n = 10) and periapical granulomas (PGs) (n = 10) were identified by histological evaluation. The number of CD3+ cells in RCs was significantly higher compared to PGs and healthy controls. Additionally, the infiltration numbers of CD3, CD4, GATA3, T-bet and Foxp3 cells were greater in RCs than in PGs.

CONCLUSIONS

This study demonstrates the different expression levels of T cells in PLs and indicates the distinct inflammatory states between the two types of PLs.

Root canal therapy combined with endoscopic sinus surgery for odontogenic sinusitis: Efficacy comparison in a cohort study

BACKGROUND

Odontogenic maxillary sinusitis, often triggered by dental issues like periapical periodontitis, significantly contributes to chronic sinusitis, mainly affecting adults around 50 years old, emphasizing the need for a multidisciplinary diagnostic and treatment approach.

AIM

To investigate the therapeutic effect and clinical value of root canal therapy combined with nasal endoscopic surgery compared with simple root canal therapy in the treatment of severe odontogenic maxillary sinusitis caused by periapical periodontitis.

METHODS

The clinical data, diagnosis, and treatment of 200 patients with severe odontogenic maxillary sinusitis caused by periapical periodontitis from October 2020 to October 2021 were analyzed retrospectively. Among them, 63 patients were treated with simple root canal therapy as the control group, and 137 patients were treated with root canal therapy combined with nasal endoscopic surgery as the observation group. The therapeutic effect, Lund-Kennedy endoscopic score, paranasal sinus Lund-Mackay score, complication rate, recurrence rate, and patient satisfaction were compared between the two groups.

RESULTS

First, we compared the effective rates: 23 cases were cured, 22 were improved, and 8 were ineffective in the control group, yielding a total effective rate of 84.90%. Meanwhile, 97 cases were cured, 34 improved, and 6 were ineffective in the observation group, resulting in a total effective rate of 95.62%. The observation group had a higher total effective rate compared with the control group (P < 0.05). Second, we compared the Lund-Kennedy endoscopic score. Before treatment, no significant difference (P > 0.05) was observed in this score between the two groups. After treatment, the Lund-Kennedy endoscopic score decreased in both groups. The Lund-Kennedy endoscopic score of the observation group at 3 and 6 mo after treatment was lower compared to that of the control group (P < 0.05). Third, we compared the Lund-Mackay score of paranasal sinuses. Before treatment, there was no significant difference in this score between the two groups (P > 0.05). After treatment, the Lund-Mackay scores of paranasal sinuses decreased in both groups. The Lund-Mackay scores of paranasal sinuses in the observation group at 3 and 6 mo after treatment were lower compared to those of the control group (P < 0.05). Fourth, we compared the incidence and recurrence rate of complications. Three months after treatment, no significant difference was found in the incidence and recurrence rate of complications between the observation group (6.56%) and the control group (9.52%) (P > 0.05). However, 6 mo after treatment, the incidence and recurrence rate of complications in the observation group (2.91%) was significantly higher compared to that of the control group (12.69%) (P < 0.05). Fifth, we compared patient satisfaction. Six months after treatment, the patient satisfaction of the observation group (93.43%) was significantly better than that of the control group (84.12%) (P < 0.05).

CONCLUSION

Root canal therapy combined with nasal endoscopic surgery has a good therapeutic effect on severe odontogenic maxillary sinusitis caused by periapical periodontitis, and it can reduce the injury of maxillary sinus mucosa and bone, and significantly reduce the incidence of complications and recurrence rate. Meanwhile, it has high patient satisfaction and remarkable therapeutic effect, which is suggested to be popularized and applied in clinic.

Effect of the anatomical patterns of maxillary sinus floor on the endodontic microsurgery plan of maxillary sinusitis of endodontic origin

BACKGROUND

Due to the close relationship between maxillary posterior teeth and maxillary sinus floor (MSF), infection from teeth with endodontic disease may spread into maxillary sinus and cause the occurrence of maxillary sinusitis of endodontic origin (MSEO). Endodontic microsurgical intervention in infected teeth causing MSEO requires careful assessment and planning. This study evaluated the anatomical patterns of MSF using cone-beam computed tomography (CBCT), and further explored their influence on the endodontic microsurgery of MSEO.

METHODS

A total of 333 CBCT scans were collected between August and December 2023. The classification of MSEO, the degree of mucosal thickening, and the shortest distance from the root apex to MSF were recorded. An improved classification of the anatomical relationships between the teeth and MSF was proposed based on CBCT images. Additionally, the angle at the nadir of MSF, and the divergence angle between the roots and maxillary sinus septa were recorded. Analysis of variance was used to analyze the differences among different groups. A significance level of P < 0.05 was employed.

RESULTS

The anatomical relationship between the root apex and MSF affected the endodontic microsurgery plan of MSEO. Maxillary sinus elevation is needed when MSF is below the line between the buccal and palatal roots, when the root apices contact or protrude into MSF, or when apical lesion is directly connected to the maxillary sinus mucosa. In addition, maxillary sinus mucosal thickening may be more severe when the root apex or apical lesion is close to the maxillary sinus.

CONCLUSION

The anatomical relationship between maxillary posterior teeth and MSF is an important factor in evaluating and designing endodontic microsurgery for MSEO.

Navigating Endodontic Care: Perspectives Among Dentists Managing Older Adults-A Qualitative Study

Using a qualitative approach, this study explored the perspectives and practices among New Zealand general dental practitioners (GDPs) providing endodontic care to older adults. Semi-structured questions guided focus group discussions with 18 GDPs who had varied practice experience and characteristics. Transcribed data were analysed and using reflexivity, six primary themes emerged to provide context: philosophies towards managing older adults; confidence; pulpal diagnosis; treatment planning; informed consent; and referral to an endodontist. GDPs were philosophically positive towards older people with endodontic problems although pulp diagnosis could be difficult. Age-related changes in the pulp-dentine complex, medical conditions, mobility difficulties, and finances frequently complicated treatment decisions. Confidence, consent processes, and specialist referral were mostly managed on an individual basis. Ongoing professional development to update practice is essential for GDPs to holistically manage a growing and heterogeneous older population when they present with signs and symptoms of pulp and periapical disease.

Impact of p. Gingivalis-induced chronic apical periodontitis on systemic iron homeostasis via the hepatic IL-6/STAT3/Hepcidin signaling pathway

BACKGROUND AND AIMS

Chronic apical periodontitis (CAP), an inflammatory disease of the oral cavity caused by bacterial infections with Porphyromonas gingivalis (P. gingivalis) as a key pathogen, has been associated with systemic effects, potentially influencing distant organs including liver. The liver plays a key role in iron metabolism and immunity by hepcidin. This study aims to investigate the impact of P. gingivalis-induced CAP on liver and systemic iron metabolism, focusing on the role of the IL-6/STAT3 signaling pathway in hepatic hepcidin synthesis.

METHODS

A murine model of CAP was established by pulp chamber infection with P. gingivalis. Serum levels of IL-6, ferritin, and hepcidin were measured via ELISA. High-throughput sequencing was used to analyze hepatic gene expression, and immunohistochemistry with fluorescent staining was performed to validate protein expression in liver tissues.

RESULTS

CAP led to significant changes in serum iron, ferritin, and IL-6. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses revealed enrichment in pathways like JAK/STAT signaling and acute-phase responses, and gene set enrichment analysis (GSEA) also indicated activation of IL-6/JAK/STAT3 signaling pathway. Iimmunofluorescence confirmed increased IL-6, p-STAT3, and hepcidin expression. These levels were alleviated by stattic treatment, mitigating CAP-induced inflammatory and iron-regulatory effects.

CONCLUSION

P. gingivalis-induced CAP triggered systemic inflammation and disrupts iron metabolism via the IL-6/STAT3 signaling pathway, potentially affecting liver function. Targeting this pathway may offer therapeutic strategies for managing iron dysregulation in chronic inflammatory diseases like CAP.

Association between Apical Periodontitis and Autoimmune Diseases: A Systematic Review with Meta-analysis

OBJECTIVES

The aim of this study was to perform a qualitative and quantitative synthesis of the available studies evaluating the possible relationship between apical periodontitis and autoimmune diseases.

METHODS

The literature search was conducted across 6 electronic databases (PubMed/MEDLINE, Embase, SciELO, Web of Science, Cochrane Library, and Scopus). The search covered articles published up to September 2023. There was no disagreement between the 2 reviewers. The RevMan software (V5.3) (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) was used for the meta-analysis. A dichotomized analysis was performed using the Mantel-Haenszel statistical method with a fixed-effect model and the risk ratio as the effect measure. A 95% confidence interval was adopted, and the significance level was set at P < .05. The presence of apical periodontitis was predefined as the event, with the experimental group consisting of patients with autoimmune disease and the control group consisting of patients without autoimmune disease (healthy individuals). The data used included the number of individuals presenting the event vs the total number of study participants.

RESULTS

Nine studies were included and considered eligible. The methodological quality of the studies was classified as moderate in 5 of the 9 included studies, while 2 were rated as low, and 2 were rated as high-quality. The relative risk was 1.24 with a 95% confidence interval (1.08-1.62), in which the prevalence of apical periodontitis in comparing patients with autoimmune diseases and healthy patients yielded statistically significant results (P < .0001). Thus, patients with autoimmune diseases had a 24% higher relative risk of developing apical periodontitis compared to the healthy/control group.

CONCLUSIONS

The analysis of the studies included in this review suggests a potential association between apical periodontitis and autoimmune diseases. However, it is important to consider that the selected studies have limitations, primarily because they are observational studies.

Who requires dental treatment under general anesthesia due to pain and severe dental anxiety? Findings from panoramic X-ray images and anamnesis

OBJECTIVE

The aims were to describe the dental status and mental and somatic health profile of patients with severe dental anxiety requiring dental treatment under general anesthesia (GA) in Rogaland County, Norway (2018-2021), and to compare patients with and without reported abuse history.

MATERIAL AND METHODS

Dental status was assessed by panoramic X-rays. General health variables were collected from patient records. Statistical comparisons of patients with and without abuse experience by tests of association (significance level p < 0.05).  Results: 38 women and 18 men (mean ± standard deviation [SD]: 37.9 ± 9.2 years) were included; 27 reported abuse experience. Dental assessment showed 4.6 ± 3.8 missing teeth, 4.8 ± 3.0 root remnants, 5.8 ± 3.7 teeth with caries and 2.6 ± 1.9 teeth with apical periodontitis, among patients with ≥1 of the respective findings. 57.1% used analgesics due to dental pain. 55.4% had comorbid psychiatric conditions; 35.7% used psychopharmaceuticals. There were no statistical differences in dental variables but the abuse experience group had higher frequencies of comorbid psychiatric disorders (p = 0.01) and mixed somatic conditions (p = 0.03).

CONCLUSIONS

Patients with severe dental anxiety requiring dental treatment under GA have complex health problems. They need access to treatment under GA, as treatment of serious odontogenic conditions is otherwise unmanageable.

Radicular Cysts and Periapical Granulomas: Data Documentation for 696 Cases and Findings on Fibrosis, and Porphyromonas gingivalis and Fusobacterium nucleatum in These Lesions

OBJECTIVE

The objective of our study was to re-evaluate periapical lesions, including radicular cysts (RCs) and periapical granulomas (PGs) for locations, histopathological features, and degree of fibrosis in relation to the inflammatory response. In addition, we examined the presence of Porphyromonas gingivalis (Pg) and Fusobacterium nucleatum (Fn) since both are widely recognized pathogens in periodontal infections.

METHODS

We re-evaluated samples of RCs and PGs (n = 728) and collected data for analyses by IBM's SPSS Statistics. Among these samples, we stained 93 samples to determine the immunoexpression of Pg and Fn. For immunostaining, we used Gingipain R1 antibody for Pg and Rabbit anti-Fn antibody for Fn.

RESULTS

Fibrosis is associated with mild inflammation. We found a significant positive correlation between Pg and Fn. Thus, these pathogens are likely to occur together in periapical inflammatory lesions. We additionally noted that these periodontopathic pathogens are more likely to be present in RCs than in PGs.

CONCLUSIONS

Asymptomatic radiologically diagnosed periapical lesions may not necessarily need root canal retreatment in healthy patients since these lesions may represent scar tissue rather than active apical periodontitis. Clinical and radiological follow-up is still needed. Yet, periapical lesions, especially cysts, may contain dystopic periodontopathic pathogens, and Pg and Fn often occur together in periapical lesions.

A novel AI model for detecting periapical lesion on CBCT: CBCT-SAM

OBJECTIVES

Periapical lesions are not always evident on radiographic scans. Sometimes, asymptomatic or initial periapical lesions on cone-beam computed tomography (CBCT) could be missed by inexperienced dentists, especially when the scan has a large field of view and is not for endodontic treatment purposes. Previously, numerous algorithms have been introduced to assist radiographic assessment and diagnosis in the field of endodontics. This study aims to investigate the efficacy of CBCT-SAM, a new artificial intelligence (AI) model, in identifying periapical lesions on CBCT.

METHODS

Model training and validation in this study was performed using 185 CBCT scans with confirmed periapical lesions. Manual segmentation labels were prepared by a trained operator and validated by a maxillofacial radiologist. The diagnostic and segmentation performances of four AI models were evaluated and compared: CBCT-SAM, CBCT-SAM without progressive Prediction Refinement Module (PPR), and two previously developed models: Modified U-Net and PAL-Net. Accuracy was used to evaluated the diagnostic performance of the models, and accuracy, sensitivity, specificity, precision and Dice Similarity Coefficient (DSC) were used to evaluate the models' segmentation performance.

RESULTS

CBCT-SAM achieved an average diagnostic accuracy of 98.92% ± 010.37% and an average segmentation accuracy of 99.65% ± 0.66%. The average sensitivity, specificity, precision and DSC were 72.36 ± 21.61%, 99.87% ± 0.11%, 0.73 ± 0.21 and 0.70 ± 0.19. CBCT-SAM and PAL-Net performed significantly better than Modified U-Net in segmentation accuracy (p = 0.023, p = 0.041), sensitivity (p = 0.000, p = 0.002), and DSC (p= 0.001, p= 0.004). There is no significant difference between CBCT-SAM, CBCT-SAM without PPR and PAL-Net. However, with PPR incorporated into the model, CBCT-SAM slightly surpassed PAL-Net in the diagnostic and segmentation tasks.

CONCLUSIONS

CBCT-SAM is capable of providing expert-level assistance in the identification of periapical lesions on CBCT.

CLINICAL SIGNIFICANCE

The application of artificial intelligence could increase dentists' chairside diagnostic accuracy and efficiency. By assisting radiographic assessment, such as periapical lesions on CBCT, it helps reduce the chance of missed diagnosis by human errors and facilitates early detection and treatment of dental pathologies at the early stage.

Antimicrobial efficacy of alternative root canal disinfection strategies: An evaluation on multiple working models

Researching disinfection strategies is pivotal because effectively eliminating bacteria and their byproducts during root canal treatment (RCT) remains a challenge. This study investigated the antimicrobial efficacy of natural antimicrobial compounds, propolis (PRO) and copaiba oil-resin (COR), compared to conventional agents in Endodontics. Antimicrobials were tested against endodontic pathogens via macrodilution with standardized inoculums to determine the minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC). Biofilm killing efficacy were performed using two dual-species biofilms: Enterococcus faecalis (ATCC 29212) and Streptococcus mutans (ATCC 20523) and Streptococcus oralis (J22) and Actinomyces naeslundii (T14V-J1) grown on dentine discs. At the intratubular level (dentine cylinders), dentine tubule contamination was performed with E. faecalis and S. mutans. The specimens were exposed to antimicrobials to simulate their use at different sets of RCT and bacterial viability was quantified using Live/Dead staining via confocal laser scanning microscopy (CLSM). Biofilm characteristics and immediate removal of S. oralis and A. naeslundii biofilm model were evaluated employing optical coherence tomography (OCT) and CFU/mL counting. Statistical tests were applied according to data distribution for each analysis (α=0.05). Macrodilutions showed different effects against endodontic pathogens. Direct contact and intratubular analysis showed that PRO and COR promoted disinfection like conventional agents (p > 0.05). According to OCT analysis, PRO and COR showed similar biofilm reduction after immediate contact (p < 0.05). CFU/mL counting showed decontamination (p < 0.05) after using natural and conventional agents. PRO and COR showed antimicrobial effects, indicating their suitability as complementary approaches in RCT to eliminate as much microbial load as possible.

Lifestyle, caries, and apical periodontitis: Results from a university-based cross-sectional study

AIM

Lifestyle factors significantly influence the development of inflammatory diseases, and emerging evidence suggests they may also impact oral health. However, no studies have explored their role in apical periodontitis (AP) amongst adults. This study aimed to assess the association between adherence to the Mediterranean diet (MD), physical activity, perceived stress, and sleep quality with the periapical and caries status in a university-based cohort.

METHODOLOGY

A total of 149 periodontally healthy patients were included in the study. Clinical assessments and radiographic examinations [Orthopantomography (opt) and periapical radiographs] were conducted to evaluate the periapical status. Data on their periapical index (PAI) score and the decayed, missing and filled teeth (DMFT) index were recorded. Validated questionnaires were used to investigate patient's lifestyles. A final logistic regression model was performed for the multivariable analysis to evaluate the predictive ability of adherence to Mediterranean lifestyle on the presence of AP; other local, systemic and environmental factors were included as independent factors in the model.

RESULTS

Significant associations were observed between AP and high/low adherence to the MD (p = .00), high/low-moderate physical activity (p = .00), high/low sleep quality (p = .00) and high/low perceived stress (p = .00). The final multivariable regression model showed that low adherence to MD (OR = 3.68; 95% confidence interval [CI]: 1.24-10.83; p = . 01) and reduced sleep quality (OR = 3.04; 95% CI: 1.42-6.50; p = .00) were identified as potential risk factors for AP development. On the other hand, the DMFT index showed no significant association with lifestyle factors (OR = 1.0; CI: 1.01-1.14; p = .02) but was correlated with the development of AP (OR = 1.07; CI: 1.01-1.14; p = .02).

CONCLUSION

Results from the present study suggest a potential association between low adherence to MD and reduced sleep quality with the development of AP. Individuals with low adherence to MD and inadequate sleep quality faced respectively 4-fold and 3-fold increased odds of developing periapical lesions. Further research is essential to elucidate the causal mechanisms underlying these associations and to determine whether lifestyle adjustments could improve endodontic success rate.

Orifice barrier preferences for coronal restoration of root filled teeth by endodontists and other dental practitioners in Australia: A questionnaire survey

OBJECTIVES

To compare the use of orifice barriers (OB) in root-filled teeth (RFT) between specialist endodontic practitioners (SEP) and general and other specialist practitioners (GDP+), and identify common materials, reasons for selection, and techniques.

METHODS

An online survey was distributed to SEP and GDP+ practising in Australia. Demographic and multiple-choice questions relating to material selection and technique choices were asked to evaluate and relate usage patterns to practising and training backgrounds. Fisher's exact tests were undertaken to compare categorical variables across practitioner groups. Significance level was set at p<.05.

RESULTS

There were 457 eligible responses: 393(86%) GDP+ and 64(14%) SEP. Of 429 reporting endodontically treating or restoring teeth, 317(73.9%) placed OB; preferred depth of root filling removal by most (91.8%) was ≤ 2 mm, with more SEP preferring 2 mm than GDP+(p=.02). Preferred materials for OB were conventional and resin-modified GIC (GIC), resin composite materials (RC), Cavit™ and zinc polycarboxylate cement (ZPC). 'Ease of use' was a common reason among all practitioners for GIC and RC. Significantly more SEP(p<.001) chose ZPC in all teeth and more commonly because of 'Ease of use' for both posterior (p<.001) and anterior (p=.002) teeth. All ZPC-using SEP preferred using a paste-filler/lentulo spiral, significantly more than GDP+ for posterior (p<.001) and anterior (p=.002) teeth. Cavit™ was often chosen for 'Sealing ability'.

CONCLUSIONS

OB were widely placed by dental practitioners in Australia, with a small group of materials selected, most commonly for ease of use or sealing ability. The findings of this study suggest that further research should be undertaken to investigate the relative performance of these materials as OB and to inform the clinician's choices when restoring RFT.

The influence of microorganisms on bone homeostasis in apical periodontitis

OBJECTIVE

This review aims to provide an overview of the role of microorganisms in the onset and progression of periapical diseases, particularly regarding their effects on bone homeostasis.

DESIGN

The search for this narrative review was conducted in PubMed, Web of Science and Google Scholar using relevant keywords, including checking reference lists of journal articles by hand searching.

RESULTS

Microorganisms directly promote osteoclasts through pathways such as nuclear factor-κB (NF-κB) and extracellular regulated protein kinases (ERK), while inhibiting osteoblasts function by interfering with the wingless-related integration site (Wnt)/β-catenin pathway in the periapical area. Moreover, microorganisms indirectly regulate periapical bone homeostasis by inducing programmed cell death and modulating the immune microenvironment through the activation of innate immunity via pattern-recognition receptors (PRRs) and subsequent cascades of responses. Among these microorganisms, Enterococcus faecalis, Porphyromonas gingivalis and Fusobacterium nucleatum play significant roles.

CONCLUSION

Microorganisms regulate pathways such as NF-ĸB and Wnt/β-catenin, as well as programmed cell death and the immune microenvironment in the periapical area, thereby disrupting bone homeostasis.

Association between endodontic, patient-related factors and severe odontogenic infections; a South Australian retrospective audit

AIM

Endodontic conditions are associated with severe odontogenic infections. However, no studies have explicitly explored their role in the infectious process. This study aimed to assess associations between tooth-related and patient-related factors resulting in severe odontogenic infections and clinical care needs.

METHODOLOGY

A retrospective audit was conducted of all records of patients who presented with severe odontogenic infections requiring admission between 2018 and 2023, at the largest public hospital in South Australia. Pericoronitis, postoperative, and non-odontogenic infections were excluded. Associations between tooth-related factors (type, location, presence/absence of caries, restorations, root canal filling, apical periodontitis, and space of infection), patients-related factors (diabetes and smoking statuses), clinical management (length of admission, intensive care unit admission number of days, and need for general anaesthesia) were explored. χ2, Mann-Whitney's test and Fisher's exact test were used for statistical analysis, and the level of statistical significance was set at 5%.

RESULTS

Of 382 records identified, 189 met the inclusion criteria. Mandibular (95.8%) molars (92.1%) were the most commonly offending teeth. Eight (4.2%) were root canal filled, 27 (14.3%) restored, 166 carious (87.8%), and 181 (95.8%) were associated with an apical radiolucency. Over half the sample were smokers (56.9%) and 16.4% were diabetics. The most common infection involved the submandibular space (56.1%). Intensive care unit admission was required for 157 patients (83.1%), and stay depended on the space of infection, with buccal space having the shortest duration (median 1 day) compared with submandibular (median 4 days) (p < .001). Need for general anaesthesia was associated with Ludwig's angina (n = 3, 100%) (p = .04) and submandibular space infection (n = 104, 98.1%) (p < .001), plus intensive care unit admission (p < .001). Conversely, for buccal space infection, the need for general anaesthesia was lower (n = 5, 23.8%). No further significant differences were found.

CONCLUSION

Untreated mandibular molars with apical periodontitis were the most frequent tooth-related findings. Results from the present study suggest associations between the most severe clinical presentations (Ludwig's angina and submandibular infection) and complexity in clinical care. Buccal space infections required the least complex management.

Apical periodontitis and its effects on renal tissue in rats

BACKGROUND

Motivation for the study. Apical periodontitis (AP) can trigger immune responses that affect other organs. Main findings. This animal study examined the effects of AP on renal tissue, finding significant changes in parameters such as renal corpuscle area and Bowman's space, which may have implications for chronic kidney disease. Implications. Future research will provide insight into how dental conditions may affect renal health. If confirmed, regular dental checkups would not only be critical to improve the overall health of patients with kidney disease, but could also serve as a preventive measure.

OBJECTIVES.

To evaluate the effect of apical periodontitis (AP) induced in Wistar rats on histologically examined renal tissue.

MATERIALS AND METHODS.

Fourteen 12-week-old male Wistar rats weighing an average of 250 grams were used. AP was induced with pulp exposure of the upper and lower first molars using a #1011 HL spherical bur in high rotation. The lesions were left exposed to the oral environment for a period of 7 weeks. Blood pressure was measured by the tail-cuff plethysmography method from the fourth week. The kidney was dissected for histological analysis (H&E). Mann-Whitney and Student's t-test were used for non-parametric and parametric data, respectively, with a significance level of 5%.

RESULTS.

A statistically significant increase in both Bowman's space area and renal corpuscle area was found in the AP group (p<0.05). The AP group had a higher percentage of renal tissue with inflammatory infiltrate, but without significant difference. Blood pressure did change during the experimental period and no difference was identified between the groups.

CONCLUSIONS.

Induction of AP in Wistar rats resulted in significant changes of certain renal histological parameters, suggesting a possible interaction between AP and renal tissue that requires further research.

Effectiveness of Root Canal Irrigation and Dressing for the Treatment of Asymptomatic Apical Periodontitis: A Systematic Review Assessing Complementary Timeframes

Sodium hypochlorite (NaOCl), ethylenediaminetetraacetic acid (EDTA), and calcium hydroxide (Ca(OH)2) are used in root canal treatment. However, further research is needed to assess their effectiveness at time points not considered in previous guidelines. This review complements the systematic review by Rossi-Fedele and Rödig (2023) by considering time points excluded by the latter. A search was conducted in PubMed-MEDLINE, Scopus, EMBASE, Google Scholar, and repositories between March and May 2024. Four studies met the inclusion criteria, providing data from 212 teeth for irrigation and 108 for dressings. No significant differences in pain reduction within 7 days or radiographic reduction of apical lesion size were found between 2% chlorhexidine, 5.25% NaOCl, EDTA, and various NaOCl concentrations. Single and multiple visit protocols also showed no significant differences in postoperative pain. Two studies had a 'low risk' of bias and two 'some concerns'. Evidence suggests that Ca(OH)2 dressings may not offer additional benefits.

Are ultrasonic tips associated with final irrigation protocols effective in removing biofilms in long oval canals and dentinal tubules?

OBJECTIVE

This study investigated the associations among endodontic instruments, ultrasonic tips and various final irrigation protocols for removing intracanal and intratubular biofilms in long oval canals.

METHODOLOGY

One hundred mandibular premolars inoculated with Enterococcus faecalis were divided into two groups: the control group (CG: n = 10), which received no treatment; and the test groups (n = 30), which included saline (SS), sodium hypochlorite (2.5% NaOCl) and chlorhexidine (2% CHX). The samples were prepared with Reciproc® Blue 25/0.08, Flatsonic, Clearsonic and Reciproc Blue 40/0.06. Each test group was divided into three subgroups (n = 10): conventional irrigation (CI) with syringes and needles, passive ultrasonic irrigation (PUI) and continuous ultrasonic irrigation (CUI) with an Irrisonic tip. The root canals were examined using confocal laser scanning microscopy. Mann‒Whitney and Kruskal‒Wallis tests followed by Dunn post hoc tests (p < 0.05) were used for statistical analysis.

RESULTS

NaOCl and CHX were effective for intracanal and intratubular decontamination. Saline showed significant decontamination in the intratubular areas when CUI was used. The CI method was the least effective for intracanal decontamination.

CONCLUSION

The use of Flatsonic and Clearsonic ultrasonic tips is promising for root canal disinfection.

CLINICAL RELEVANCE

The disinfection techniques in endodontic treatment focus on the removal of biofilms from long oval canals, which is crucial for effective cleaning during root canal procedures.

Clinical and imaging aspects associated with persistent apical periodontitis: subsides for the treatment decision-making process

OBJECTIVES

To evaluate cases of persistent apical periodontitis (PAP) and what are the imaging and clinical aspects that could be considered in the PAP diagnosis and in their treatment decision-making process.

METHODOLOGY

423 patients with apical periodontitis at the time of non-surgical root canal treatment (NSRCT) were followed-up for at least 1 year. Periapical radiographic images were used to compare and determine periapical status at each time using the PAI scoring system. Cases scored as PAI 5 at the follow-up appointment were evaluated by CBCT, using the CBCTPAI scoring system. Associated, the data from imaging exams and from clinical evaluation were considered to make a decision for PAP treatment.

RESULTS

Regarding sample composition, it was observed an association with ethnicity and PAP (p = 0.045). After follow-up, cases classified as PAI Score 1 and 2 and absence of symptoms/complaint were classified as successful. Cases classified as PAI Score 3 and absence of symptoms/complaint were referred for new follow-up visits until complete resolution of PAP. Cases scored as PAI 4 with clinical symptoms were indicated for non-surgical root canal retreatment. Cases scored as PAI 5 were assessed by CBCT, and in the presence of symptoms/complaint and a CBCTPAI score 3 were related to non-surgical root canal retreatment, while CBCTPAI scores 4 and 5 were refereed for endodontic surgery.

CONCLUSIONS

Clinical data, PAI and CBCTPAI scoring systems from image exams can be useful for PAP diagnosis and their treatment.

CLINICAL RELEVANCE

In the decision-making process, clinical and imaging data are fundamental for the choose of an ideal protocol for treating PAP.

Extracellular vesicles of Candida albicans show dual effects on Enterococcus faecalis growth and virulence: A laboratory-based investigation

AIM

Previous studies have shown the important relationships between Enterococcus faecalis and Candida albicans in post-treatment endodontic disease (PTED). However, the fungal-bacterial interactions and their possible functional routes are less understood. In this study, we investigated the effect of extracellular vesicles (EVs) derived from C. albicans on E. faecalis growth and pathogenicity.

METHODOLOGY

Candida albicans EVs were isolated from a yeast nitrogen base (YNB) medium, and their morphology, size distribution, and protein concentration were observed and identified. The effects of EVs on planktonic E. faecalis were evaluated using growth curves and colony-forming unit counts, whereas the effects on E. faecalis biofilms were determined using scanning electron and confocal laser scanning microscopes. The ability of E. faecalis to resist a detrimental environment, infect dentinal tubules, and biofilm formation on gutta percha was examined. Additionally, the effect of EVs on cell invasion and cytotoxicity of E. faecalis were assessed. Statistical analysis was performed using one-way analysis of variance, and p-values of <.05 were considered significantly different.

RESULTS

Candida albicans EVs were nanoparticles with bilayer membranes and with peak sizes of 111.9 and 230 nm. EVs exhibited a complex effect on E. faecalis and its biofilms; 5 μg/mL of EVs showed inhibitory effects whereas 0.156 μg/mL of EVs facilitated their growth. The EVs showed consistent effects on E. faecalis virulence. Notably, 5 μg/mL of EVs reduced the damage to RAW264.7 cells caused by E. faecalis, as well as the invasion ability of E. faecalis to macrophages and the intracellular survival ability of E. faecalis after macrophage phagocytosis, whereas 0.156 μg/mL of EVs had completely opposite effects.

CONCLUSION

Candida albicans EVs showed dual effects on E. faecalis growth and virulence in vitro, suggesting C. albicans EVs are involved in fungal-bacterial communication. Moreover, the inhibitory effects exhibited by 5 μg/mL of EVs in vitro may suggest a new agent for the control of E. faecalis.

Association of serum calcium level with periodontitis: a cross-sectional study from NHANES 2009-2014

Purpose

This study aimed to investigate the association between serum calcium levels and periodontitis in a U.S. adult population, using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2014.

Method

Data were analyzed from 8,601 participants aged over 30 years, who were categorized based on the presence or absence of periodontitis. Serum calcium levels were measured using standardized NHANES protocols, and periodontitis status was determined through clinical oral examinations. To assess the relationship between calcium levels and periodontitis, multivariate logistic regression models were applied across three levels of adjustment. Additionally, trend tests and subgroup analyses were conducted to explore associations across different demographic and clinical subgroups. A smoothing curve fitting and threshold effect analysis were also performed to examine potential nonlinear relationships.

Results

After adjusting multiple covariates, participants in the highest quartile of serum calcium showed an 18% reduced risk of periodontitis compared to those in the lowest quartile (OR = 0.82, 95% CI: 0.71-0.95, p = 0.0083; p for trend = 0.0057). The association remained stable across various subgroups. Smoothing curve fitting indicated a nonlinear negative correlation between calcium levels and periodontitis, though without a significant inflection point at 2.48 mmol/L (p = 0.094).

Conclusion

Elevated serum calcium levels appear to be associated with a lower risk of periodontitis in adults. These findings suggest that adequate calcium intake may play a role in periodontitis prevention, providing valuable insight for clinical guidance on nutritional and preventive strategies in periodontal health.

Interaction between polymorphisms in TNF-⍺ and RANKL genes is associated with the development of persistent apical periodontitis, in Brazilian subjects

OBJECTIVES

To investigate the association between genetic polymorphisms in suppressor of cytokine signaling-1 (SOCS-1), tumor necrosis factor-⍺ (TNF-α) and its receptors 1 and 2 (TNFRSF1A and TNFRSF1B), receptor activator of nuclear factor kappa-b (RANK), receptor activator of nuclear factor-kappa B ligand (RANKL) and osteoprotegerin (OPG), and persistent apical periodontitis (PAP).

METHODS

Patients with pulp necrosis and apical periodontitis at the time of non-surgical root canal treatment were followed up for at least one year. A total of 423 subjects were included, 172 with signs/symptoms of PAP and 251 with apical periodontitis healed. DNA was extracted from saliva and used for genotyping polymorphisms in SOCS1 (rs243327 and rs33977706), TNF-α (rs1800629), TNFRSF1A (rs1800693), TNFRSF1B (rs1061622), RANK (rs1805034), RANKL (rs1054016) and OPG (rs1032128) by real-time PCR. The frequency of genotypes and alleles was assessed using chi-squared test or Fisher's exact test and odds ratio. Interactions were also tested using multifactor dimensionality reduction (α = 5 %).

RESULTS

In the polymorphism rs1800629 in TNF-α, carrying at least one A risk allele significantly decreased the risk to develop PAP (OR=0.47; 95 %CI: 0.28-0.79; p=0.004). For the polymorphism rs1054016 in RANKL carrying both T risk alleles significantly decreased the risk to develop PAP (OR=0.47; 95 %CI: 0.24-0.92; p=0.027). None of the other polymorphisms evaluated were associated with PAP (p>0.05). A strong interaction was observed among rs1800629, rs1061622 and rs1054016.

CONCLUSIONS

Genetic polymorphisms rs1800629 (TNF-α) and rs1054016 (RANKL) had a strong interaction and were associated with a lower risk to develop PAP.

From anatomy to surgery: Effectiveness of virtual simulation adjuvant to traditional methods in the preclinical training of apicoectomy

Anatomy forms the foundation for the training and execution of routine surgical procedures. However, a gap persists in effectively bridging anatomical knowledge with the confident performance of procedures. Virtual simulation (VS) techniques, based on experiential and situated learning theory, hold promise in addressing this challenge. Apicoectomy, a procedure involving root apex resection to preserve a tooth, requires a blend of regional and dental anatomy knowledge, making it an ideal model for assessing the effectiveness of VS. This prospective cohort study evaluated primarily the enhancement of incorporating VS training in the preclinical skill training of apicoectomy for undergraduate dental students, compared to relying solely on traditional methods. VS training includes the simulated dissection process, patient examination, and apicoectomy based on graphically synthesized virtual models. Secondly, the study investigated the influence of exposure to VS training on students' confidence and satisfaction. The training was divided into three progressive levels aligned with students' cognitive processes, employing Miller's competence learning framework. Participants were categorized into the control group (CG) (n = 214) and VS training group (VSTG) (n = 220) based on their classes. The results demonstrated that VSTG showed significantly greater training enhancement (VSTG: 7.14 ± 1.74; CG: 6.57 ± 2.02, p = 0.002) and higher confidence levels (VSTG: 2.94 ± 0.13; CG: 2.69 ± 0.13, p < 0.001), along with greater satisfaction with the training compared to the CG (VSTG: 3.70 ± 0.18; CG: 3.20 ± 0.17, p < 0.001). In conclusion, VS proves to be a valuable adjunct for enhancing procedural skill training in surgical procedures.

B Cells at the Core: Immune Mechanisms and Therapeutic Potentials in Periapical Lesions

INTRODUCTION

Periapical lesions (PLs) are common inflammatory diseases primarily caused by microbial infections within root canals. These infections trigger complex immune responses in periapical tissues, with B lymphocytes playing dual roles: defending against pathogens while also contributing to tissue damage. This highlights the crucial role of B cells in the immunological processes of PLs.

METHODS

A comprehensive review of the literature on B cells in PLs was conducted using PubMed, Web of Science, Scopus, and ScienceDirect databases.

RESULTS

The review included 120 studies that examined the distribution and subtypes of B cells, their dual functions in PLs, and the potential applications of B-cell-related therapies in treating apical periodontitis.

CONCLUSIONS

This review enhances our understanding of the complex immune mechanisms in PLs and aids in the development of new therapeutic approaches from a B-cell perspective.

Chemokine receptor-2 deficiency induced mild experimental periapical lesion in mice

Background/purpose

Macrophages are considered to play an important role in the development of chronic apical periodontitis (CAP). However the function of tissue resident macrophages in CAP is unclear. This study aims to investigate the potential role of macrophages of different origins in CAP.

Materials and methods

Chemokine receptor-2 deficiency (CCR2-/-) mice and C57BL/6N mice (control group, WT mice) were used to induce apical periodontitis. The pulp of mandibular first molars of both sides were exposed to the oral environment. After 0, 7, 21, 28 days of pulp explosion, animals were sacrificed, the mandibular bones were collected and scanned with micro-CT, further processed for HE & IHC Staining to analyze the development of CAP, as well as the expression of surface markers of macrophages.

Results

Both CCR2-/- and WT mice exhibited CCR2 negative macrophages in normal periapical area, which indicated the presence of tissue resident macrophages. CCR2 deficiency decreased the number of macrophages in periapical lesions, the M1 type macrophages' number as well as osteoclasts around the edge of the lesion decreased compared to wild type. Meanwhile CCR2 deficiency decreased the volume of periapical lesion significantly compared to wild type, but did not inhibite and disappeare the lesion thoroughly.

Conclusion

Monocyte-macrophage system derived macrophages promote the progression of periapical lesions, while tissue resident macrophages in periodontal ligament might also be involved in the progression of periapical lesion.

Endodontic Treatment in Patients Undergoing Hematopoietic Stem Cell Transplantation: A Retrospective Cohort Study

INTRODUCTION

This study investigated the implications of root canal treatment (RCT) of infected teeth with apical periodontitis (AP) in patients undergoing hematopoietic stem cell transplantation (HSCT).

METHODS

One hundred patients were selected. Clinical data, oncologic and endodontic diagnosis and treatment, and type of HSCT were recorded. Data on the exacerbation of AP were investigated. Leukocyte/neutrophil and C-reactive protein levels were evaluated before and after RCT.

RESULTS

One hundred patients underwent HSCT (55% autologous). The need for RCT was identified in 41% of the participants. AP was diagnosed in 75.6% of these patients and large lesions (≥5 mm) occurred in 45.2%. A higher prevalence of AP was observed in males (P = .012). RCT was performed in 54.8% of the individuals and no AP exacerbation, pain, swelling, bacteremia, and need for additional medications was observed. Blood cultures were negative for bacteria and fungi. C-reactive protein levels were ≥1 mg/dL in 54.9% of the individuals 1 month before RCT and <1 mg/dL in 64.6% 6 months after treatment (P > .05).

CONCLUSIONS

RCT was effective in controlling infection with no complications in patients undergoing HSCT. Given the potential for exacerbation of endodontic infections, RCT and patient monitoring are essential and highly recommended.

Apical Periodontitis and Systemic Health: A Bibliometric Analysis of the Top 100 Most-cited Publications

INTRODUCTION

Bibliometric analysis quantitatively measures the impact of scientific articles within their respective fields, with citation counts being a key indicator of influence. This study aimed to identify the top 100 most-cited articles related to apical periodontitis and systemic health, analyzing their main characteristics.

METHODS

The top 100 most-cited articles were identified using Web of Science. Data on publication year, citations, title, authors, institutions, countries, journal impact factor, study design, keywords, and open access status were extracted. VOSviewer software analyzed author and keyword networks, while Power BI evaluated international collaborations, study design, and citations. Poisson regression was performed in R software (P < .05).

RESULTS

We reviewed 1,141 studies and selected the top 100 most-cited articles, totaling 4,744 citations (4,005 excluding self-citations), with an average of 47.44 citations per article. The most-cited article, a 2015 review by Segura-Egea JJ, had 187 citations. The highest publication activity was in 2017 and 2019 (n = 13). Leading institutions were the University of Sevilla and São Paulo State University. Europe accounted for 41% of publications and 2,251 citations, followed by Latin America and the United States. Cross-sectional studies were the most common (18%), with systemic diseases, particularly coronary heart disease and diabetes mellitus, as dominant topics. Most articles (69%) were published in journals with an impact factor above 3, with the Journal of Endodontics leading in number of articles.

CONCLUSIONS

This bibliometric review highlights the increasing research interest in the relationship between apical periodontitis and systemic health, with most contributions coming from Europe and Latin America.

Endodontic emergency patients' profile and treatment outcome - a prospective cohort study

BACKGROUND

Toothache is a debilitating condition, often with mild to excruciating pain, swelling, eating difficulties and insomnia. This study aims to delineate the profiles of patients seeking emergency dental care, focusing on the diagnosis, treatment, and outcomes following non-surgical root canal treatment.

METHODS

This prospective cohort study was conducted from 2012 to 2021 at the Section for Endodontics, Department of Clinical Dentistry, University of Bergen, Norway. A total of 281 emergency patient forms were analyzed. Data registered included patient demographics, dental history, chief complaints, medications used, diagnostic results, treatments provided and outcome.

RESULTS

A total of 272 patients (272 teeth) were included in the study. Pain was the predominant complaint (98.5%), where only 57.4% of the patients managed to localize pain to a specific tooth. The mean age of patients was 51.2 years with no significant gender differences. The maxillary right first molar (15.4%) was the most frequent tooth needing treatment. The majority of the patients had experienced pain for three days before they attended the emergency appointment. The most frequently used drug for pain management was paracetamol which was stated to have little effect. Teeth that needed endodontic treatment often had restorations rather than caries. The most frequent diagnoses were pulpitis (26.8%) followed by necrotic pulp (25.4%) and previously root filled teeth (22.8%). Root canal treatment was performed on 60% of the teeth and a success rate of 95% was registered at one-year recall.

CONCLUSIONS

There was no singular diagnostic cause leading patients to seek an emergency appointment, highlighting the necessity of a thorough diagnostic procedure. Over the counter pain medications have little effect on alleviating dental pain, often resulting in desperate measures of self-medication. 60% of the teeth needing emergency treatment had previous coronal restorations such as fillings or crowns, indicating that conservative treatment does not appear to fully protect against future pulpal disease. The good prognosis of root canal treatment for teeth with acute symptoms supports recommending dentists to attempt root canal treatment rather than opting for tooth extraction.

Development of Periapical Index Score Classification System in Periapical Radiographs Using Deep Learning

Periapical index (PAI) scoring system is the most popular index for evaluating apical periodontitis (AP) on radiographs. It provides an ordinal scale of 1 to 5, ranging from healthy to severe AP. Scoring PAI is a time-consuming process and requires experienced dentists; thus, deep learning has been applied to hasten the process. However, most models failed to score the early stage of AP or the score 2 accurately since it shares very similar characteristics with its adjacent scores. In this study, we developed and compared binary classification methods for PAI scores which were normality classification method and health-disease classification method. The normality classification method classified PAI score 1 as Normal and Abnormal for the rest of the scores while the health-disease method classified PAI scores 1 and 2 as Healthy and Diseased for the rest of the scores. A total of 2266 periapical root areas (PRAs) from 520 periapical radiographs (Pas) were selected and scored by experts. GoogLeNet, AlexNet, and ResNet convolutional neural networks (CNNs) were used in this study. Trained models' performances were evaluated and then compared. The models in the normality classification method achieved the highest accuracy of 75.00%, while the health-disease method models performed better with the highest accuracy of 83.33%. In conclusion, CNN models performed better in classification when grouping PAI scores 1 and 2 together in the same class, supporting the health-disease PAI scoring usage in clinical practice.

Post-COVID-19 Trends in Dental Emergencies: A Two-Year Retrospective Study from Romania

Background/Objectives: Dental emergencies significantly impact public oral health, particularly in the post-COVID-19 context. This study aimed to analyze the patterns of dental emergencies presenting to the Emergency Dental Service in Bihor, Romania, during the years 2022 and 2023, focusing on demographic characteristics and the frequency of diagnoses. Methods: A retrospective analysis of medical records from the Emergency Dental Service at Oradea County Emergency Clinical Hospital was conducted. Inclusion criteria encompassed patients presenting with dental emergencies during the specified period. Data regarding demographics, diagnoses, and living environments were collected and statistically analyzed. Results: A total of 4769 patients were analyzed, with acute pulpitis (39.2%, n = 1869) and acute apical periodontitis (37.5%, n = 1788) identified as the most common diagnoses. The study population included 52.3% males and 47.7% females, with a larger proportion residing in urban areas (58.0%) compared with rural areas (42.0%). Significant age-related patterns were evident: pulpitis was more common among patients aged 10-39 years, trauma was associated with patients aged 0-9 years, and gingival infections were prevalent in the 70-79 age group. Diagnoses also varied by dentition type, with abscesses, caries, trauma, and rhizolysis occurring more frequently in deciduous teeth, while pulpitis and post-extraction alveolitis were predominant in permanent teeth. However, no statistically significant differences were found in diagnosis frequency between genders or between rural and urban patients, indicating equitable access to emergency services across environments. Conclusions: The findings underscore the need for targeted interventions in pediatric populations to address early childhood caries, which remains a significant burden. Enhanced public health strategies and preventive education are essential to mitigate the prevalence of dental emergencies, particularly in the aftermath of the COVID-19 pandemic.

Dental Pathophysiology of Odontogenic Sinusitis: Endodontic Infections

Bacterial odontogenic sinusitis (ODS) arises from maxillary dental issues or oral procedures, and affects at least the maxillary sinuses, with or without other paranasal sinus involvement. It has been historically underreported, in contrast to more recent findings attributing 25-40% of chronic maxillary sinusitis to dental causes. Endodontic infections represent one of the most common causes of ODS. Endodontic factors like root canal infection and microbial proximity to sinus cavities play pivotal roles. Host immunological responses further shape disease severity and progression. This article aims to explore the complexity of endodontic infections that cause ODS, elucidating anatomical, microbial, and immunological aspects.

Unilateral Sinus Disease: What Is, and Is Not Odontogenic Sinusitis?

The differential diagnosis of unilateral sinus disease (USD) is broad, and while concerning etiologies like sinonasal neoplasia, invasive fungal sinusitis, and cerebrospinal fluid rhinorrhea should always be considered, most cases are due to noninvasive inflammatory or infectious conditions. To diagnose USD appropriately, clinicians must integrate the clinical history and examination, nasal endoscopy, computed tomography (CT), and possibly MRI. Odontogenic sinusitis (ODS) is the most common cause of unilateral maxillary sinus opacification on CT, with 45% to 75% of such cases being odontogenic in nature. This study provides USD diagnostic considerations and reinforces the diagnostic approach to ODS.

Outcomes of apexification in immature traumatised necrotic teeth and risk factors for premature tooth loss: A 20-year longitudinal study

BACKGROUND/AIM

To evaluate the long-term survival of immature traumatized incisors with pulp necrosis and apical periodontitis after endodontic treatment with two apexification techniques (calcium hydroxide apexification and MTA-apical plug) and to identify major factors affecting the survival of these teeth.

MATERIALS AND METHODS

Records of 2400 children and adolescents were screened for presence of traumatic dental injuries to immature incisors where endodontic treatment with the two apexification techniques was performed during January 2003 and December 2022, compared to a control group of mature teeth treated with conventional endodontic techniques. The studied variables were age; sex; apexification technique, presence of luxation and hard tissue injuries; preoperative root development stage (RDS), preoperative and postoperative periapical index (PAI), the time-point for tooth loss, and overall survival time in years. Kaplan-Meier estimates were used to graphically present the survival functions and Cox proportional hazard model to calculate hazard ratios (HR, 95% CI).

RESULTS

The median survival time was 10 years for calcium hydroxide apexification, 16.1 for MTA-apexification, for luxation injuries other than intrusions and avulsions 15.5 years, for intrusions 12.5 years and for avulsions 6.8 years. The variables with significant negative impact on tooth survival were calcium hydroxide apexification, avulsion and postoperative PAI 3-5. No significant relationships were found for the variables MTA apexification, concussion; subluxation; lateral luxation; extrusion, intrusion, hard tissue injuries, preoperative RDS and PAI scores and postoperative PAI 1-2. After adjustment, the risk for premature tooth loss was 13.5 times higher in calcium hydroxide apexification, approximately 2 to 4 times higher in PAI 3-5, and 5.6 times higher in avulsions.

CONCLUSIONS

Calcium hydroxide apexification, avulsion, and postoperative PAI 3-5 were identified as prognostic variables with significant negative impact on the risk for premature tooth loss.

Single-cell RNA sequencing combined with proteomics of infected macrophages reveals prothymosin-α as a target for treatment of apical periodontitis

INTRODUCTION

Chronic apical periodontitis (CAP) is a common infectious disease of the oral cavity. Immune responses and osteoclastogenesis of monocytes/macrophages play a crucial role in CAP progression, and this study want to clarify role of monocytes/macrophages in CAP, which will contribute to treatment of CAP.

OBJECTIVES

We aim to explore the heterogeneity of monocyte populations in periapical lesion of CAP tissues and healthy control (HC) periodontal tissues by single-cell RNA sequencing (scRNA-seq), search novel targets for alleviating CAP, and further validate it by proteomics and in vitro and in vivo evaluations.

METHODS

ScRNA-seq was used to analyze the heterogeneity of monocyte populations in CAP, and proteomics of THP-1-derived macrophages with porphyromonas gingivalis infection were intersected with the differentially expressed genes (DEGs) of macrophages between CAP and HC tissues. The upregulated PTMA (prothymosin-α) were validated by immunofluorescence staining and quantitative real time polymerase chain reaction. We evaluated the effect of thymosin α1 (an amino-terminal proteolytic cleavage product of PTMA protein) on inflammatory factors and osteoclast differentiation of macrophages infected by P. gingivalis. Furthermore, we constructed mouse and rat mandibular bone lesions caused by apical periodontitis, and estimated treatment of systemic and topical administration of PTMA for CAP. Statistical analyses were performed using GraphPad Prism software (v9.2) RESULTS: Monocytes were divided into seven sub-clusters comprising monocyte-macrophage-osteoclast (MMO) differentiation in CAP. 14 up-regulated and 21 down-regulated genes and proteins were intersected between the DEGs of scRNA-seq data and proteomics, including the high expression of PTMA. Thymosin α1 may decrease several inflammatory cytokine expressions and osteoclastogenesis of THP-1-derived macrophages. Both systemic administration in mice and topical administration in the pulp chamber of rats alleviated periapical lesions.

CONCLUSIONS

PTMA upregulation in CAP moderates the inflammatory response and prevents the osteoclastogenesis of macrophages, which provides a basis for targeted therapeutic strategies for CAP.

High-intensity ethanol binge drinking accentuates bone damage in induced apical periodontitis in rats

This study aimed to evaluate the effects of excessive and episodic consumption of ethanol (EtOH, a high-intensity drinking manner) on induced apical periodontitis in rats. Thirty-two animals were divided into the following four groups: control, EtOH, apical periodontitis, and EtOH + apical periodontitis. Ethanol exposure (3 g/kg 20 % w/v EtOH) was performed by orogastric gavage for 3 consecutive days, followed by 4 days of withdrawal for 4 weeks. Lesions were induced by exposing the dental pulp of the lower first molar and by the absence of any treatment/curative for 28 days. Finally, the animals were euthanized, and mandibles were collected. The mandible was divided medially, with one hemimandible being used for micro-computed tomography analysis of the volume of the periapical lesion and bone quality parameters, such as bone volume and trabecular bone assessments; the other hemimandible was used for histological analysis, with a descriptive histopathological analysis of the tissue and the pattern of bone loss presented, as well as an assessment of the collagen content present. The data were subjected to statistical analysis (one-way analysis of variance with Tukey's post-hoc test). Our results showed that the EtOH + apical periodontitis group had a larger volume of periapical lesions than animals that were not exposed to ethanol. Additionally, bone quality parameters showed a reduction in bone volume and thickening of the trabeculae, associated with increased tissue destruction and reduced collagen content in the remnant region of the alveolar bone. These results suggest that exposure to EtOH in a pattern of excessive alcohol consumption is an aggravating factor in apical periodontitis and, consequently, in its progression, the quality and quantity of the alveolar bone remaining in the region of the periapical lesion are the modulating aspects.

Diagnostic accuracy of periapical radiography and panoramic radiography in the detection of apical periodontitis: a systematic review and meta-analysis

OBJECTIVE

Apical periodontitis (AP) is one of the most common pathologies of the oral cavity. An early and accurate diagnosis of AP lesions is crucial for proper management and planning of endodontic treatments. This study investigated the diagnostic accuracy of periapical radiography (PR) and panoramic radiography (PAN) in the detection of clinically/surgically/histopathologically confirmed AP lesions.

METHOD

A systematic literature review was conducted in accordance with the PRISMA guidelines. The search strategy was limited to English language articles via PubMed, Embase and Web of Science databases up to June 30, 2023. Such articles provided diagnostic accuracy values of PR and/or PAN in the detection of AP lesions or alternatively data needed to calculate them.

RESULTS

Twelve studies met inclusion criteria and were considered for the analysis. The average value of diagnostic accuracy in assessing AP lesions was 71% for PR and 66% for PAN. According to different accuracy for specific anatomical areas, it is recommended to use PR in the analysis of AP lesions located in the upper arch and lower incisor area, whereas lower premolar and molar areas may be investigated with the same accuracy with PR or PAN.

CONCLUSIONS

Two-dimensional imaging must be considered the first-level examination for the diagnosis of AP lesions. PR had an overall slightly higher diagnostic accuracy than PAN. Evidence from this review provided a useful tool to support radiologists and dentists in their decision-making when inflammatory periapical bone lesions are suspected to achieve the best clinical outcome for patients, improving the quality of clinical practice.

Exploring the Influence of Genetic Single-Nucleotide Polymorphism (SNPs) on Endodontic Pathologies: A Comprehensive Review

A considerable portion of the global population is affected by pulpitis and periapical lesions. While the impact of infections caused by various microbes and host effector molecules in pulpal and periapical diseases is widely recognized, disease susceptibility and progression are also influenced by the dynamic interaction between host genetic factors and environmental influences. Apical periodontitis occurs as an inflammatory response to microorganisms present in the root canals of infected teeth. Initially functioning as the body's defense mechanism, this response often progresses to chronic inflammation. Several studies have established associations between genetic polymorphisms and various dental conditions, including temporomandibular joint (TMJ) disorders, dental caries, orthognathic surgeries, open bite malocclusion, periapical periodontitis, pulp stones, pulpitis, periapical abscesses, local anesthesia complications, and endodontic treatment outcomes. Key findings from this review highlight the role of specific single-nucleotide polymorphisms (SNPs) in genes such as matrix metalloproteinase (MMP)1, MMP2, MMP3, interleukin (IL)-1β, IL-6, IL-17, and tumor necrosis factor-alpha (TNF-α), which influence inflammatory pathways and tissue remodeling. For example, SNPs in interleukin genes, such as IL-1β (-511 C/T), have been linked to an increased risk of apical periodontitis, while MMP gene polymorphisms contribute to tissue degradation in periapical lesions. This review underscores the importance of identifying genetic markers that drive disease progression and inflammatory processes in pulpal and periapical pathologies. A better understanding of these mechanisms can inform strategies for disease prevention, personalized treatment approaches, and improved endodontic outcomes.

The immune landscape in apical periodontitis: From mechanism to therapy

Apical periodontitis (AP) is featured by a persistent inflammatory response and alveolar bone resorption initiated by microorganisms, posing risks to both dental and systemic health. Nonsurgical endodontic treatment is the recommended treatment plan for AP with a high success rate, but in some cases, periapical lesions may persist despite standard endodontic treatment. Better comprehension of the AP inflammatory microenvironment can help develop adjunct therapies to improve the outcome of endodontic treatment. This review presents an overview of the immune landscape in AP, elucidating how microbial invasion triggers host immune activation and shapes the inflammatory microenvironment, ultimately impacting bone homeostasis. The destructive effect of excessive immune activation on periapical tissues is emphasized. This review aimed to systematically discuss the immunological basis of AP, the inflammatory bone resorption and the immune cell network in AP, thereby providing insights into potential immunotherapeutic strategies such as targeted therapy, antioxidant therapy, adoptive cell therapy and cytokine therapy to mitigate AP-associated tissue destruction.

Gut microbiota dysbiosis links chronic apical periodontitis to liver fibrosis in nonalcoholic fatty liver disease: Insights from a mouse model

AIM

In this study, we investigated the systemic implications of chronic apical periodontitis (CAP). CAP may contribute to the nonalcoholic fatty liver disease (NAFLD) progression through the gut microbiota and its metabolites, which are related to the degree of fibrosis.

METHODOLOGY

Sixteen 7-week-old male apolipoprotein E knockout (apoE-/-) mice were randomly divided into two groups: the CAP and Con groups. A CAP model was established by sealing the first- and second-maxillary molars with bacterium-containing cotton balls. Apical lesions were evaluated by micro-CT. Histological evaluations of NAFLD were performed using second harmonic generation/two-photon excitation fluorescence (SHG/TPEF) assays. Additionally, we comprehensively analyzed the gut microbiota using 16S rRNA gene sequencing and explored metabolic profiles by liquid chromatography-mass spectrometry (LC-MS). Immunofluorescence analysis was used to examine the impact of CAP on tight junction proteins and mucin expression. Transcriptome assays have elucidated gene expression alterations in liver tissues.

RESULTS

Micro-CT scans revealed an evident periapical bone loss in the CAP group, and the total collagen percentage was increased (Con, 0.0361 ± 0.00510%, CAP, 0.0589 ± 0.00731%, p < .05). 16S rRNA sequencing revealed reduced diversity and distinct taxonomic enrichment in the CAP group. Metabolomic assessments revealed that differentially enriched metabolites, including D-galactosamine, were enriched and that 16-hydroxyhexadecanoic acid and 3-methylindole were depleted in the CAP group. Immunofluorescence analyses revealed disruptions in tight junction proteins and mucin production, indicating intestinal barrier integrity disruption. Liver transcriptome analysis revealed upregulation of Lpin-1 expression in the CAP group.

CONCLUSION

This study provides comprehensive evidence of the systemic effects of CAP on liver fibrosis in NAFLD patients by elucidating alterations in the gut microbiota composition and metabolism.

Radiographical diagnostic competences of dental students using various feedback methods and integrating an artificial intelligence application-A randomized clinical trial

INTRODUCTION

Radiographic diagnostic competences are a primary focus of dental education. This study assessed two feedback methods to enhance learning outcomes and explored the feasibility of artificial intelligence (AI) to support education.

MATERIALS AND METHODS

Fourth-year dental students had access to 16 virtual radiological example cases for 8 weeks. They were randomly assigned to either elaborated feedback (eF) or knowledge of results feedback (KOR) based on expert consensus. Students´ diagnostic competences were tested on bitewing/periapical radiographs for detection of caries, apical periodontitis, accuracy for all radiological findings and image quality. We additionally assessed the accuracy of an AI system (dentalXrai Pro 3.0), where applicable. Data were analysed descriptively and using ROC analysis (accuracy, sensitivity, specificity, AUC). Groups were compared with Welch's t-test.

RESULTS

Among 55 students, the eF group by large performed significantly better than the KOR group in detecting enamel caries (accuracy 0.840 ± 0.041, p = .196; sensitivity 0.638 ± 0.204, p = .037; specificity 0.859 ± 0.050, p = .410; ROC AUC 0.748 ± 0.094, p = .020), apical periodontitis (accuracy 0.813 ± 0.095, p = .011; sensitivity 0.476 ± 0.230, p = .003; specificity 0.914 ± 0.108, p = .292; ROC AUC 0.695 ± 0.123, p = .001) and in assessing the image quality of periapical images (p = .031). No significant differences were observed for the other outcomes. The AI showed almost perfect diagnostic performance (enamel caries: accuracy 0.964, sensitivity 0.857, specificity 0.074; dentin caries: accuracy 0.988, sensitivity 0.941, specificity 1.0; overall: accuracy 0.976, sensitivity 0.958, specificity 0.983).

CONCLUSION

Elaborated feedback can improve student's radiographic diagnostic competences, particularly in detecting enamel caries and apical periodontitis. Using an AI may constitute an alternative to expert labelling of radiographs.

Segmentation of periapical lesions with automatic deep learning on panoramic radiographs: an artificial intelligence study

Periapical periodontitis may manifest as a radiographic lesion radiographically. Periapical lesions are amongst the most common dental pathologies that present as periapical radiolucencies on panoramic radiographs. The objective of this research is to assess the diagnostic accuracy of an artificial intelligence (AI) model based on U²-Net architecture in the detection of periapical lesions on dental panoramic radiographs and to determine whether they can be useful in aiding clinicians with diagnosis of periapical lesions and improving their clinical workflow. 400 panoramic radiographs that included at least one periapical radiolucency were selected retrospectively. 780 periapical radiolucencies in these anonymized radiographs were manually labeled by two independent examiners. These radiographs were later used to train the AI model based on U²-Net architecture trained using a deep supervision algorithm. An AI model based on the U²-Net architecture was implemented. The model achieved a dice score of 0.8 on the validation set and precision, recall, and F1-score of 0.82, 0.77, and 0.8 respectively on the test set. This study has shown that an AI model based on U²-Net architecture can accurately diagnose periapical lesions on panoramic radiographs. The research provides evidence that AI-based models have promising applications as adjunct tools for dentists in diagnosing periapical radiolucencies and procedure planning. Further studies with larger data sets would be required to improve the diagnostic accuracy of AI-based detection models.

CD34 and Ki-67 Immunoexpression in Periapical Granulomas: Implications for Angiogenesis and Cellular Proliferation

BACKGROUND/OBJECTIVES

The main mechanism of the formation of granulation tissue is the progression of an infection from the tooth to the periapical bone. At this level, the immune system tries to localize and annihilate the microorganism's injury. Ki-67 is a protein directly associated with the cell proliferation rate, while CD34 is a biomarker involved in angiogenesis, and studies suggest that they both have a positive correlation with the intensity of the local inflammatory infiltrate. This study will determine the immunoexpression of CD34 and Ki-67 in periapical granulomas and assess their impact on the growth and development of this tissue, as well as consider their roles in the proliferative process and aggressiveness of evolution.

METHODS

In the present study, 35 periapical granulomas obtained after a tooth extraction were included. The specimens were analyzed via histopathology and immunohistochemistry.

RESULTS

A positive reaction for the Ki-67 antibody was observed in 32 (86.5%) of the 35 periapical granuloma cases included in our study. We identified the overexpression of Ki-67 and CD34 and further calculated the Ki-67 index to evaluate and correlate the proliferation potential and angiogenesis with regard to the presence of an inflammatory infiltrate.

CONCLUSIONS

These findings suggest that the persistence of an inflammatory environment directly influences Ki-67 and CD34 expression, sustaining the proliferative capacity of cells and abnormal angiogenesis. This study is the first to evaluate the presence of the CD34+ and Ki-67+ proliferating vessels in periapical granulomas.

A multi-national survey-based evaluation of undergraduate/predoctoral endodontic education

AIM

To evaluate the current status of endodontic education and assessment at an undergraduate/predoctoral level in dental schools worldwide.

METHODOLOGY

The current survey comprised a 50-item online questionnaire related to undergraduate endodontic education. The project leaders emailed the survey's details to faculty members responsible for endodontic teaching at one dental school in every country to seek their willingness to participate in the survey. After the faculty members accepted, the survey details were sent to participants along with the survey link. Simple descriptive statistics were used to represent the data.

RESULTS

Amongst the 44 faculty members from different countries who agreed to participate, 36 completed the survey. Endodontic training starts in 50% of dental schools from the third year of the curriculum. Each dental school employs a diverse range of educational methods. During pre-clinical training, 19.4% of the participating dental schools used only natural teeth. Stainless-steel hand instruments, syringe irrigation with a needle, resin-based sealer and the cold lateral compaction technique are the most frequently used in pre-clinical and clinical training. A significant percentage of dental institutions necessitate that students treat a predetermined quantity of canals or teeth throughout their pre-clinical and clinical education. Dental institutions conduct formative, summative or a combination of the formative and summative throughout the clinical and pre-clinical phases of endodontic training.

CONCLUSIONS

According to the data collected from this survey, there are considerable variations in the curriculum for undergraduate/predoctoral endodontic programmes amongst the surveyed dental schools. Pre-clinical and clinical education should integrate a larger array of modern tools and procedures.

The role of Lactobacillus plantarum in oral health: a review of current studies

Background

Oral non-communicable diseases, particularly dental caries and periodontal disease, impose a significant global health burden. The underlying microbial dysbiosis is a prominent factor, driving interest in strategies that promote a balanced oral microbiome. Lactobacillus plantarum, a gram-positive lactic acid bacterium known for its adaptability, has gained attention for its potential to enhance oral health. Recent studies have explored the use of probiotic L. plantarum in managing dental caries, periodontal disease, and apical periodontitis. However, a comprehensive review on its effects in this context is still lacking.

Aims

This narrative review evaluates current literature on L. plantarum's role in promoting oral health and highlights areas for future research.

Content

In general, the utilization of L. plantarum in managing non-communicable biofilm-dependent oral diseases is promising, but additional investigations are warranted. Key areas for future study include: exploring its mechanisms of action, identifying optimal strains or strain combinations of L. plantarum, determining effective delivery methods and dosages, developing commercial antibacterial agents from L. plantarum, and addressing safety considerations related to its use in oral care.

Distinct role of Klotho in long bone and craniofacial bone: skeletal development, repair and regeneration

Bone defects are highly prevalent diseases caused by trauma, tumors, inflammation, congenital malformations and endocrine abnormalities. Ideally effective and side effect free approach to dealing with bone defects remains a clinical conundrum. Klotho is an important protein, which plays an essential role in regulating aging and mineral ion homeostasis. More recently, research revealed the function of Klotho in regulating skeleton development and regeneration. Klotho has been identified in mesenchymal stem cells, osteoblasts, osteocytes and osteoclasts in different skeleton regions. The specific function and regulatory mechanisms of Klotho in long bone and craniofacial bone vary due to their different embryonic development, ossification and cell types, which remain unclear and without conclusion. Moreover, studies have confirmed that Klotho is a multifunctional protein that can inhibit inflammation, resist cancer and regulate the endocrine system, which may further accentuate the potential of Klotho to be the ideal molecule in inducing bone restoration clinically. Besides, as an endogenous protein, Klotho has a promising potential for clinical therapy without side effects. In the current review, we summarized the specific function of Klotho in long bone and craniofacial skeleton from phenotype to cellular alternation and signaling pathway. Moreover, we illustrated the possible future clinical application for Klotho. Further research on Klotho might help to solve the existing clinical difficulties in bone healing and increase the life quality of patients with bone injury and the elderly.

Machine learning and deep learning models for the diagnosis of apical periodontitis: a scoping review

OBJECTIVES

To assess the existing literature on the use of machine learning (ML) and deep learning (DL) models for diagnosing apical periodontitis (AP) in humans.

MATERIALS AND METHODS

A scoping review was conducted following the Arksey and O'Malley framework. The PubMed, SCOPUS, and Web of Science databases were searched, focusing on articles using ML/DL approaches for AP diagnosis. No restrictions were applied. Two independent reviewers screened publications and charted data in predefined Excel tables for analysis.

RESULTS

Nineteen publications focused on diagnosing AP by identifying periapical radiolucent lesions (PRLs) in dental radiographs were included. The average sensitivity and specificity for reviewed models were 83% and 90%, respectively. Only three studies explored the direct impact of artificial intelligence (AI) assistance on clinicians' diagnostic performance. Both consistently showed improved sensitivity without compromising specificity. Significant variability in dataset sizes, labeling techniques, and algorithm configurations was noticed.

CONCLUSIONS

Findings affirm AI models' effectiveness and transformative potential in diagnosing AP by improving the accurate detection of periapical radiolucencies using dental radiographs. However, the lack of standardized reporting on crucial aspects of methodology and performance metrics prevents establishing a definitive diagnostic approach using AI. Further studies are needed to expand AI applications in AP diagnosis beyond radiographic analysis.

CLINICAL RELEVANCE

AI can potentially improve diagnostic accuracy in AP diagnosis by enhancing the sensitivity of PRL detection in dental radiographs without compromising specificity.

Association between oral health conditions and the risk of major noncommunicable diseases: A protocol for systematic review and meta-analysis

Objective

Although epidemiological studies suggest that oral health conditions may be associated with an increased risk of noncommunicable diseases, the findings have yet to be comprehensively synthesized, particularly for a major noncommunicable diseases-related health and economic burden. Therefore, we will perform a systematic review and meta-analysis of all available observational studies investigating the association between oral health conditions and subsequent risk of major noncommunicable diseases.

Methods

With limited English publications, we will search electronic databases, including MEDLINE, Embase, PubMed, Cochrane Library, Scopus, and CINAHL. Based on the temporal properties and natural course of disease progression, we will seek cohort or case-control studies that investigate the association between oral disease conditions and the risk of noncommunicable diseases. Regarding the World Health Organization agenda, oral health conditions will include dental caries, periodontal disease, oral cancer, edentulism, other oral conditions (i.e., oro-dental trauma, cleft lip and palate, and noma), and endodontic lesions. Based on the global disease burden, primary outcomes of interest will include the four major systemic noncommunicable diseases: cardiovascular diseases, cancers, chronic respiratory diseases, and type 2 diabetes mellitus. Random-effects meta-analysis will be used to estimate pooled effects estimate and 95% confidence intervals. Statistical heterogeneity will be investigated using the I 2 index and τ 2 statistics. Preplanned subgroup and sensitivity analyses and random-effects meta-regression analyses will be performed to address possible heterogeneity and establish the robustness of the meta-analytic estimates. The prediction intervals, expected (E)-value, and evidence certainty will be appraised to synthesize the findings and draw evidence-based conclusions.

Conclusion

This systematic review will summarize all available evidence regarding the association between oral health conditions and the risk of major noncommunicable diseases. The findings will encourage collaboration between oral health and primary care professionals for early detection and management of noncommunicable diseases and promote oral health well-being.

Systematic review registration

PROSPERO: CRD42021274184.

Clinical Investigation of Bacteriome in Primary Endodontic Infections With Apical Periodontitis Using High-Throughput Sequencing Analysis

INTRODUCTION

This study characterized the bacteriome in primary endodontic infection (PEI) with apical periodontitis (AP), identified core and rare bacteriome species and community diversity metrics, and analyzed the relationship between the bacteriome composition, diversity and features, and patient variables.

METHODS

Twenty-seven patients with PEI and AP were sampled. The DNA was extracted and quantified using quantitative polymerase chain reaction. Raw V3-V4 amplicon sequencing data were processed with the DADA2 pipeline to generate amplicon sequence variants, and taxonomic assignment of the amplicon sequence variants up to the species level was done against the Human Oral Microbiome Database. Core bacteriome and differential abundance analyses were performed using ANCOM. Alpha diversity was determined using Chao1, Shannon, and Simpson indexes. LeFse analysis was used to identify abundant taxa. Sparse Estimation of Correlations among Microbiomes analysis estimated linear and nonlinear relationships among bacteria.

RESULTS

Of 27, 24 root canal samples were analyzed, and 3 root canal sampling were filtered out with a low read count. The bacterial phyla with top mean relative abundance were Bacteroidetes, Firmicutes, Synergistetes, Fusobacteria, and Actinobacteria. A total of 113 genera and 215 species were identified. The samples were gathered into 3 clusters. LefSe analysis identified differences in abundant taxa between distinct age, gender, symptomatology, and lesion size groups. Sparse Estimation of Correlations among Microbiomes distance analysis indicated Slackia exigua as the node with the highest degree.

CONCLUSIONS

The bacteriome in PEI with AP among the patients in this study was complex and displayed high microbial heterogeneity. Moreover, age, gender, symptomatology, and lesion size were associated with differences in bacteriome features in PEI with AP.