Endodontic management of traumatized permanent teeth: a comprehensive review

Endodontic and restorative management of an adult with avulsion of multiple teeth: A case report with 5 years and 9 months of follow-up

Simultaneous avulsion of four or more teeth is a rare event. This case report examines the dental care given to an adult who, during a bicycle accident, experienced the avulsion of a mandibular incisor as well as all of his maxillary incisors. In the immediate aftermath of the accident, four out of the five incisors were located, promptly collected, and stored in a tooth rescue box, all within a 20-min window. Replantation and splinting were performed on the day of the accident. Endodontic treatment involved sequential intracanal dressing with an antibiotic-corticosteroid paste followed by calcium hydroxide prior to root canal obturation. 3 months post-accident, signs of external replacement resorption (ERR) began to appear in all the replanted teeth. The gap created by the missing maxillary central incisor was managed with a three-unit fixed dental prosthesis, despite the onset of ERR in the incisors used as abutment teeth. Regular follow-ups showed a relatively slow ERR progression rate over a span of nearly 6 years. The patient expressed satisfaction with both the esthetic and functional outcomes. This case, marked by multiple avulsions, underscores the importance of immediate and appropriate intervention alongside the imperative for carefully considered long-term management strategies. Given the decelerated bone remodeling rate in adults, ERR generally progresses at a slower pace than in children. Accordingly, this case demonstrates the viability of retaining replanted teeth over the long term, even when these teeth have been subjected to nonphysiological storage for extended durations, a factor known to impede periodontal healing.

Management of rarely seen internal tunnelling root resorption associated with a maxillary permanent incisor

This case presents clinical techniques and materials that may be applied in the management of internal tunnelling root resorption, a rare condition which has little published literature.A 25-year-old woman was referred to a specialist centre by her general dental practitioner following an incidental finding of a radiographic radiolucency, suggestive of root resorption associated with tooth 21. A provisional diagnosis of external cervical resorption was made, and following cone beam computed tomography (CBCT), a definitive diagnosis of internal tunnelling root resorption given. Non-surgical endodontic treatment was completed using continuous wave compaction with a calcium-silicate based sealer. No further intervention has been required.A summary of the histology, aetiology, prevalence, diagnosis, management and prognosis of internal tunnelling root resorption is provided. The benefits of CBCT for diagnosing and managing internal tunnelling resorption defects and using continuous wave compaction with a calcium-silicate based sealer, compared to cold obturation techniques, are discussed.

Risk of pulp necrosis and related complications in the permanent anterior teeth with lateral luxation: A systematic review and meta-analysis

This systematic review aimed to evaluate the evidence related to the occurrence of pulp necrosis and related complications in permanent anterior teeth with lateral luxation. It was envisaged to address the ambiguity related to the recommendation for pulp extirpation in teeth with mature root apex. An a priori protocol was formulated as per the best practices of evidence-based medicine and registered in PROSPERO. A comprehensive search was performed electronically in PubMed, LILACS, Web of Science, EMBASE, Scopus, and Cochrane on July 10,2023 without any restriction of language or year of publication. The screening of titles and abstracts and later the full-text articles were performed. Later, the data extraction was performed by using a self-designed sheet, risk of bias (ROB) assessment was done, meta-analysis was performed, and the GRADE approach was used to assess the quality of evidence. The qualitative synthesis was performed on 13 studies done from 1985 to 2020 in hospital settings. There was variability in the minimum and total observation periods, sample sizes, and characteristics of the sample population. The overall pooled prevalence of pulp necrosis was found to be 57% (95% CI: 42, 72%). It was 12% (95% CI: 8%, 18%, I2 = 0%) in immature teeth, and 58% (95% CI: 42, 73%, I2 = 86%) in mature teeth. The pooled prevalence of EIRR was found to be 11% (95% CI: 4, 27%, I2 = 95%) with greater risk in teeth with mature root apex (RR: 1.26, 95% CI: 1.12, 1.42, I2 = 0%). The ROB was moderate or high in nine studies and the GRADE of evidence was very low in 14 of 15 outcomes. There are greater chances of pulp necrosis in teeth with lateral luxation, especially with mature apex. However, it can still be less than 60% in most cases with the prevalence of EIRR less than 20%. Hence, an absolute recommendation for endodontic intervention in mature teeth with lateral luxation must be interpreted with slight caution.

What is new in the 2023 European Society of Endodontology S3-level clinical practice guidelines?

BACKGROUND

The European Society of Endodontology published in 2023, the S3-level clinical practice guidelines, which supersede the Quality Guidelines for Endodontic Treatment published in 2006.

OBJECTIVES

This review aims to summarize and compare the above guidelines to support their dissemination.

METHOD

A narrative synthesis of the main differences alongside tabulation according to the main themes.

RESULTS

Three tables were prepared according to the following themes: diagnosis of pulpal and apical condition; treatment of pulpitis; and treatment of nonvital pulp and apical periodontitis.

CONCLUSIONS

A compared and simplified message regarding the most recent clinical practice guidelines has been prepared.

REGISTRATION

Not applicable as a narrative review.

Ortho-Endo Management of Traumatically Intruded Immature Incisors: A Case Report of Novel Interventional Approach With 20 Months Follow-Up

The case report describes the successful interdisciplinary management of a nine-year-old girl who suffered from traumatic intrusion and rotation of her immature teeth with 12 mm apical displacement of teeth 11 and 21 and 10 mm of teeth 12 and 22. It emphasizes the importance of a comprehensive and contemporary approach, which includes orthodontic intervention and regenerative endodontic procedures (REP). The report follows the CARE (case report) guidelines. The patient was initially observed for four weeks to see if there was potential for spontaneous re-eruption. After eight weeks of orthodontic intervention, the rotation was corrected. However, negative pulp sensitivity and external inflammatory (infection-related) resorption (EIR) occurred, which led to REP using injectable platelet-rich fibrin (i-PRF). Follow-ups over 20 months showed the favorable outcomes of the treatment. A long-term perspective is essential in understanding the outcomes and potential complications associated with traumatic dental injuries (TDI) in children. The case report highlights the importance of collaboration between orthodontists and pediatric dentists, among other specialists. It provides valuable insights into the complexities of managing TDI in children and highlights contemporary regenerative strategies as viable solutions.

The consequences of Dental trauma

Traumatic dental injuries pose a variety of complex ongoing issues to the dental practitioner. As dental injuries are commonly experienced at a young age, the treatment often takes place during adolescence or early in adulthood years at crucial development stages and very early in the life of the permanent successor. Therefore, the ability to correctly diagnose the injury, and follow an appropriate management plan should increase practitioners' ability to improve both the outcomes of dental trauma and long-term prognosis of the tooth.The consequences of dental trauma can be explored by taking into consideration the type of injury, which enables an assessment of the degree of insult to the pulpal tissues, neurovascular bundle, periodontal ligament and cemental cells. This has a direct influence on post-trauma complications. Early intervention, where indicated, and appropriate follow-up utilising international guidelines is imperative to identify changing diagnoses and act accordingly. This review paper will discuss the classification of traumatic injuries and their associated outcomes with management strategies for emerging disease including potential endodontic and restorative complexities and when to refer to secondary care.

Guided endodontics versus conventional access cavity preparation: an ex vivo comparative study of substance loss

BACKGROUND

To compare the outcomes of conventional access cavity preparation (CONV) versus guided endodontics (GE) for access cavity preparation in anterior teeth with pulp canal calcification (PCC) regarding root canal detection, substance loss, procedural time, and need for additional radiographs.

METHODS

Extracted, sound human teeth with PCC (n = 108) were matched in pairs, divided into two groups and used to produce 18 models. An independent endodontist and a general dentist performed access cavity preparation under simulated clinical conditions on nine models each (54 teeth). The endodontist used the conventional technique and the general dentist GE. Time needed to access the root canals and the number of additional radiographs were recorded. Pre- and postoperative cone-beam computed tomography scans were obtained to measure substance loss. Statistical significance was tested by examining the overlap of 95% confidence intervals (CIs) between the groups.

RESULTS

All root canals were successfully accessed by both methods. There were no significant differences in substance loss (CI: CONV 15.9-29.6 mm3 vs. GE 17.6-27.5mm3) or procedural time (CI: CONV 163.3-248.5 s vs. GE 231.9-326.8 s). However, 31 additional radiographs were required for GE compared to none for CONV.

CONCLUSIONS

For access cavity preparation in teeth with PCC, both CONV by a specialist and GE by a general dentist produce good results in terms of substance loss and time requirements.

A Partial Pulpotomy in Traumatized Permanent Incisors With Pulp Exposure

A complicated crown fracture in a permanent incisor is one of the most difficult traumatic dental injuries to deal with. Treatment involves multiple visits and invasive intraoperative interventions and this is a very costly procedure. However, progress in vital pulp therapy and adhesive dentistry may allow practitioners to treat these injuries with a conservative method. Correct diagnosis of the pulp is important as it forms the basis for the establishment of an appropriate management strategy. A partial pulpotomy is indicated if the patient has significant pulp exposure or if it is reported after a considerable delay. It has been reported that partial pulpotomies after complicated crown fractures have a 96% success rate. Other studies have reported that partial pulpotomy is a treatment of choice after a complicated traumatic crown fracture, with a very high success record. Traditionally, calcium hydroxide has been applied as a dressing agent. However, research has recently focused on other calcium silicate cements (CSC), such as Biodentine (BD). This study aimed to illustrate the successful management of a vital permanent incisor with complicated crown fractures, which were treated by partial pulpotomy using Biodentine material and evaluated for healing clinically and radiographically. No radiographic signs of failure or clinical symptoms were detected over a one-year period.

Beyond Tradition: Non-surgical Endodontics and Vital Pulp Therapy as a Dynamic Combination

Symptomatic irreversible pulpitis and apical periodontitis in mature permanent teeth present challenges in their management. Traditional treatment approaches, such as root canal therapy or tooth extraction, may compromise tooth structure and oral function. This review article explores the combination of non-surgical endodontic treatment and vital pulp therapy as an alternative approach for these conditions. The purpose is to examine this combined approach's effectiveness, benefits, challenges, and limitations. The objectives include reviewing the literature, evaluating clinical outcomes, discussing potential benefits, and providing recommendations for clinical practice. The combination approach aims to preserve tooth structure, promote healing, and reduce postoperative complications. The article discusses the rationale for combining the two techniques, presents evidence supporting their efficacy, and outlines the techniques and protocols involved. Clinical outcomes, case studies, potential challenges, and comparative analysis with traditional approaches are also explored. Future directions and research recommendations highlight areas for further investigation, innovations, and the development of clinical guidelines. In conclusion, the combination of non-surgical endodontic treatment and vital pulp therapy offers a valuable strategy for managing mature permanent mandibular molars with symptomatic irreversible pulpitis and apical periodontitis. Further research and advancements are needed to refine the treatment protocol and expand the evidence base, and clinicians should stay updated to provide optimal care and improve patient outcomes.

Outcome of Regenerative Endodontic Procedures in Non-Vital Immature Permanent Teeth Using Two Intracanal Medications: A Prospective Randomized Clinical Study

INTRODUCTION

This randomized clinical trial aimed to assess and compare the long-term clinical and radiographic outcomes of Regenerative Endodontic Procedures (REP) in treating non-vital immature permanent teeth using two intra-canal medicaments.

METHODS

Forty-five patients yielding a total of 50 anterior and posterior non-vital immature teeth were randomly divided into 2 groups. REP utilizing either non-setting calcium hydroxide (Ca(OH)₂) (n=25) or modified triple antibiotic paste (TAP) (n=25), as intra-canal medicaments were performed. NeoMTA Plus (Avalon Biomed Inc™, Houston, Texas, USA) was applied for coronal sealing. Cases were followed up clinically and radiographically for 36 months. Survival rate, success rate, and clinical outcome measures were analyzed. Preoperative and recall radiographs were evaluated for dimensional changes in root length, dentin thickness, apical diameter, and periapical radiolucency.

RESULTS

At 36 months follow up, success and survival rates were 81.6%, and 100% respectively, in which 79.4% of cases showed complete resolution of periapical radiolucency, with no significant difference between non-setting Ca(OH)2 and modified TAP groups (P>0.050). The cumulative changes in root length, root dentin thickness and apical diameter, throughout the study period, were observed in 47.9%, 77.1%, and 89.6 %, of cases respectively, with no significant differences between both groups (P≥ 0.39). Intra-canal calcifications were detected in 60% of cases with no significant difference between both groups (P=0.77).

CONCLUSIONS

REP, using either non-setting Ca(OH)₂ or modified TAP as intra-canal medicament, exhibited high success and survival rates, over a follow up period of 36 months, with equally favorable clinical and radiographic outcome data.

In vitro Dental Discoloration Provoked by Intracanal Calcium Silicate-based Dressing Used for Regenerative Endodontic Procedures: One-Year Spectrometric Analysis

INTRODUCTION

Regenerative endodontic procedures (REP) provide conditions for the continuity of apical formation and increase of the dentin walls thickness, being a useful technique to resume root development of necrotic teeth with incomplete apex. This study aimed to evaluate the coronal discoloration promoted by a new intracanal calcium silicate-based dressing and compare it with other intracanal dressings used in REP.

METHODS

Sixty bovine incisors were prepared to simulate teeth with incomplete apexes, and divided according to the intracanal dressing used: triple antibiotic paste - TAP, double antibiotic paste - DAP, calcium hydroxide associated with 2% chlorhexidine gel, calcium hydroxide associated with saline solution, and Bio-C Temp. As control, no dressing was performed. The intracanal dressings remained in the simulated root canal for 21 days. Luminosity (ΔL) and color difference (ΔE_ab and ΔE₀₀) were evaluated using long-term (1 year) spectrophotometric analysis. The results were analyzed using the ANOVA test with Tukey's post hoc with a significance of 5%.

RESULTS

TAP showed the highest values of ΔE_ab and ΔE₀₀ and lowest values of ΔL (p < .05). Bio-C Temp showed higher ΔE_ab than the other groups from 6 months (p < .05), higher ΔE₀₀ and lower ΔL after one year (p < .05).

CONCLUSIONS

Bio-C Temp induced noticeable coronary discoloration after the one-year analysis.

Prevalence of traumatic dental injuries in emergency dental services: A systematic review and meta-analysis

OBJECTIVES

This study aimed to perform a systematic review and meta-analysis regarding the prevalence of traumatic dental injuries (TDI) in emergency dental services.

METHODS

Seven electronic and two grey literature databases were searched, up to December 2021, for studies that reported the TDI prevalence among dental emergencies. The Joanna Briggs Institute critical appraisal checklist for prevalence studies, and The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach were used to assess the risk of bias and quality of evidence respectively. The R software was used to perform a proportion meta-analysis on a random-effects model to estimate the pooled prevalence and respective 95% CI.

RESULTS

From a total of 1476 studies identified after excluding duplicates, 38 met the inclusion criteria, and another five were identified through hand searching, summing 43 included observational studies with a total sample of 209099 individuals searching for emergency dental care. The overall pooled prevalence of TDI was 15.4% (95% CI: 11%-21%, I² = 100%). Paediatric dental emergency services and age group from 0 to 21 years presented the highest prevalence, 29% (95% CI: 22%-38%, I² = 99.5%) and 24% (95% CI: 15%-35%, I² = 98%) respectively.

CONCLUSIONS

The overall pooled prevalence of TDI in emergency dental services was 15.4%, and 24% in the age group under 21 years. Considering the impact of prompt and correct emergency care in the long-term prognosis of TDI, such knowledge is relevant to organize emergency healthcare and support public policies in this area.

Root Maturation of an Immature Dens Invaginatus Despite Unsuccessful Revitalization Procedure: A Case Report and Recommendations for Educational Purposes

BACKGROUND

The clinical management of teeth with complex dens invaginatus (DI) malformations and apical periodontitis may be challenging due to the lack of routine. The aim of this case report is to describe the endodontic treatment of an immature tooth with DI and to discuss strategies for preclinical training for teeth with such malformations.

CASE REPORT

A 9-year-old male presented with an immature maxillary incisor with DI (Oehlers Type II) and apical periodontitis which was diagnosed by cone beam computed tomography (CBCT). Revitalization was initially attempted but then abandoned after failure to generate a stable blood clot. Nevertheless, considerable increase in both root length and thickness could be detected after medication with calcium hydroxide followed by root canal filling with MTA as an apical plug.

CONCLUSIONS

The endodontic management of teeth with DI requires thorough treatment planning. In immature teeth, under certain conditions, root maturation may occur even with conventional apexification procedures. From an educational perspective, different strategies including CBCT and 3D-printed transparent tooth models for visualization of the complex internal morphology and redesigned 3D-printed replica with various degrees of difficulty for endodontic training, can be used to overcome the challenges associated with endodontic treatment of such teeth.

Head and dental injuries among farriers and hoof care practitioners: A nationwide survey in Switzerland

BACKGROUND/AIM

There is a paucity of evidence on injuries sustained by farriers and hoof care practitioners, two professions exposed to unique occupational hazards. The aim of this study was to collect and examine data on occupational head/face and dental injuries among farriers and hoof care practitioners in a nationwide survey in Switzerland.

MATERIALS AND METHODS

Data on occupational head/face and dental injuries were gathered in a questionnaire-based, voluntary survey, which was mailed to all farriers and hoof care practitioners in Switzerland. The statistical analysis comprised multiple regressions with a nested design (α = 0.05).

RESULTS

The survey included 278 respondents (response rate of 78.1%). Head/face injuries were more frequently reported by farriers than hoof care practitioners (60.6% and 20.7%, respectively). Among full-time workers, farriers had a higher chance of an occupational head/face injury compared with hoof care practitioners (p = .007). The rate of dental injuries, mainly related to a horse kick, was 11.1% and 1.9% among farriers and hoof care practitioners, respectively. Negligence in wearing mandatory eye protection was reported by 37.5% of respondents.

CONCLUSIONS

Farriery and hoof care management entail a significant risk of occupational head/face and dental injuries. Preventive safety measures-eye protection in particular-and knowledge in dental first aid should be promoted among farriers and hoof care practitioners to decrease the frequency and severity of work-related injuries.

Successful Orthograde Treatment of Teeth with External Inflammatory Root Resorption and Perforation Using a Tricalcium Silicate-Based Material

One possible consequence of dentoalveolar trauma is the development of external inflammatory root resorption (EIRR), which represents an anatomic and microbiologic challenge for clinicians. This case report describes different strategies implemented for successful endodontic management of teeth with multiple EIRR lesions, highlighting the orthograde root canal filling using a tricalcium silicate-based material (Biodentine, Septodont, Saint-Maur-des-Fossés, France). A 17-year-old female patient presented with severe pain in the anterior maxillary teeth and a history of trauma. Two- and three-dimensional radiographic exams confirmed EIRR in three teeth, with a total of 11 EIRR lesions, three exhibiting communication with the root canal. Therefore, chemo-mechanical preparation complemented by ultrasonic activation of irrigants and some changes of intra-canal dressing with calcium hydroxide were performed to reduce the microbiologic load of the affected teeth as much as possible. Then, the canals were entirely filled with Biodentine to interrupt the root resorption process and strengthen the remaining root structure. A 60-month follow-up showed the disappearance of bone rarefactions and the complete repair of the 11 EIRR lesions. The favorable long-term response indicates the feasibility of using tricalcium silicate-based putty as part of orthograde endodontic treatment of teeth with EIRR and root perforations.

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

BACKGROUND

Revitalization is a type of regenerative endodontic treatment (RET) that offers the exciting prospect of revitalizing damaged tissue, therefore improving outcomes for non-vital immature teeth. To evaluate its potential, there needs to be consistency in outcome reporting of clinical studies investigating revitalization to allow for evidence synthesis and inform clinical decision making.

OBJECTIVES

The aim of this scoping review was to identify outcomes that are reported in systematic reviews on revitalization including how and when these outcomes are measured. Additionally, evidence of selective reporting bias in the reviews was assessed.

METHODS

A comprehensive electronic search of healthcare databases and grey literature was conducted to identify systematic reviews published in the English language reporting outcomes of revitalization in permanent immature teeth. There was no restriction on the date of publication. Outcome data was extracted by four reviewers independently and mapped with a healthcare taxonomy into five core areas: survival, clinical/physiological changes, life impact, resource use and adverse events. Selective reporting bias and how it was measured was assessed independently by two reviewers.

RESULTS

Twenty-six systematic reviews were included in this scoping review. There was lack of standardization in reporting and significant heterogeneity across reviews in outcome endpoints. The outcomes reported could be aligned within the five core areas of the taxonomy including tooth survival which was reported in nine reviews. Patient-reported outcomes were generally limited and no review reported on Oral Health Related Quality of Life. Many of the reviews reporting on randomized control trials were at low risk of selective reporting bias whilst other study designs were at higher risk.

DISCUSSION

Consistency in outcome reporting is necessary to realize the benefits of old but particularly novel therapies. Data from this review confirmed heterogeneity in reporting outcomes of revitalization and the need for development of a core outcome set (COS).

CONCLUSIONS

Several important outcomes including survival, root development, tooth discolouration and periapical healing have been identified in this review which could inform the development of a COS in this area.

REGISTRATION

Core Outcome Measures in Effectiveness Trials (COMET) database (registration no. 1879).

Retrospective analysis of the outcomes of pulpotomies in traumatised permanent anterior teeth

BACKGROUND/AIM

Complicated crown fractures are frequently encountered in the paediatric population and pulpotomy procedures (either partial or coronal) are recommended to maintain the pulp. The aim of this study was to determine the pulp outcomes of permanent teeth with complicated crown fractures treated with pulpotomy in a hospital-setting and to identify potential factors which may influence the outcomes.

MATERIAL AND METHODS

Data for this retrospective study were extracted from dental records of patients with complicated crown fractures and treated with pulpotomies at a single centre between 1 January 2015 and 30 August 2019. Pulp outcomes were determined, and the associations between the outcome and independent variables were assessed using the Chi-Square test of independence and the Point-Biserial Correlation Test. Predictors of outcome were identified using the binary logistic regression model.

RESULTS

The overall success of pulpotomy in managing traumatised permanent teeth was 61%, which was lower than those previously reported. Pulp healing was seen in 54.1% and 73.7% of teeth treated with partial pulpotomies and coronal pulpotomies, respectively. The presence of a radiographically detectable dentine bridge (p < .01) and longer clinical experience of the clinician (p < .04) was significantly associated with successful outcomes. The history of pain and the stage of root development were identified as significant predictors of the outcome.

CONCLUSION

Pulpotomy is a viable treatment modality for complicated crown fractures in the paediatric population. However, appropriate case selection and further training may be required to ensure improved pulp healing outcomes. A longer follow-up period should be considered to identify late-stage complications.

Evaluation of the outcome of apexogenesis in traumatised anterior and carious posterior teeth using mineral trioxide aggregate: a 5-year retrospective study

The purpose of this study was to evaluate the outcome of apexogenesis with mineral trioxide aggregate (MTA) in traumatised anterior and carious posterior teeth over 5 years. A comprehensive chart review was performed to obtain a retrospective of sequential previously completed cases with recalls. Clinical and radiographic data were collected for 97 vital immature teeth (40 traumatised anterior and 57 carious posterior teeth) pulpotomised (partial or full pulpotomy) using MTA with an average follow-up time of 5 years. Chi-squared test and Fisher's exact test were implemented to analyse data. The success rate in anterior teeth and posterior teeth was 82.5% and 96.4% respectively. Crown discolouration was observed in 25 (62.5%) anterior teeth. There was a significant difference between the number of successful and unsuccessful cases (P < 0.05) and there was no correlation between type of treatment and success/failure (P > 0.05). The success rate of apexogenesis using MTA in immature teeth was relatively high.

Present status and future directions: The restoration of root filled teeth

This narrative review will focus on a number of contemporary considerations relating to the restoration of root filled teeth and future directions for research. Clinicians are now more than ever, aware of the interdependence of the endodontic and restorative aspects of managing root filled teeth, and how these aspects of treatment are fundamental to obtaining the best long-term survival. To obtain the optimal outcomes for patients, clinicians carrying out endodontic treatment should have a vested interest in the restorative phase of the treatment process, as well as an appreciation for the structural and biomechanical effects of endodontic-restorative procedures on restoration and tooth longevity. Furthermore, the currently available research, largely lacks appreciation of occlusal factors in the longevity of root filled teeth, despite surrogate outcomes demonstrating the considerable influence this variable has. Controversies regarding the clinical relevance of minimally invasive endodontic and restorative concepts are largely unanswered with respect to clinical data, and it is therefore, all too easy to dismiss these ideas due to the lack of scientific evidence. However, conceptually, minimally invasive endodontic-restorative philosophies appear to be valid, and therefore, in the pursuit of improved clinical outcomes, it is important that the efficacies of these treatment protocols are determined. Alongside an increased awareness of the preservation of tooth structure, developments in adhesive bonding, ceramic materials and the inevitable integration of digital dentistry, there is also a need to evaluate the efficacy of new treatment philosophies and techniques with well-designed prospective clinical studies.

Present status and future directions: Root resorption

Root resorption is the loss of dental hard tissue because of odontoclastic action. In permanent teeth, it is undesirable and pathological in nature. Root resorption may occur on the inner aspect of the root canal (internal root resorption) or on the outer aspect of the root (external root resorption). Regardless of its location, root resorption is irreversible, and may result in discomfort for the patient, requires management and/or, in some cases, results in the premature loss of the affected tooth. Root resorption is often challenging to accurately diagnose and manage. The aim of this narrative review is to present the relevant literature on the aetiology, pathogenesis, diagnosis and management, as well as discuss the future directions of diagnosis and management of root resorption.

Present status and future directions - Guided endodontics

Luxation injuries and other stimuli may lead to a pulp canal obliteration (PCO). Even though the apposition of tertiary dentine is a sign of a vital pulp, in some cases root canal treatment is indicated in the long term due to apical periodontitis or pulpitis. Depending on the extent of PCO, root canal treatment may be challenging even for experienced and well-equipped endodontic specialists. The 'guided endodontics' (GE) technique was introduced 6 years ago as an alternative to conventional access cavity preparation for teeth with PCO and apical pathosis or irreversible pulpitis. Using three-dimensional radiological imaging such as cone-beam computed tomography and a digital surface scan, an optimal access to the orifice of the calcified root canal can be planned virtually with appropriate software. GE is implemented either with the help of templates analogous to guided implantology (= static navigation) or by means of dynamic navigation based on a camera-marker system. GE has emerged as a field of research in the last 6 years with very promising laboratory-based results regarding the accuracy of guided endodontic access cavities for both static and dynamic navigation. Clinical implementation seems to provide favourable results, but the evidence is mainly based on numerous case reports and a few case series. This narrative review aims to provide an update on the present status of GE and to identify relevant research areas that could contribute to further improvements of this technique.

Complicated Crown Fracture of Permanent Incisors: A Conservative Treatment Case Report and a Narrative Review

Dental trauma may have a severe impact on the social and psychological wellbeing of a patient. Most cases of dental injuries involve anterior teeth, especially the maxillary upper incisors. Crown fractures, with or without pulp exposure, are the most common trauma in permanent dentition. There are many methods of management, in which the initial state of the pulp, the time since the injury, and the presence of an accompanying injury play a key role. This case report aimed at showing a possible conservative treatment after complicated tooth fracture that consisted of partial pulpotomy followed by adhesive reattachment of the tooth fragment using a technique based on heated resin composite. Such a specific procedure represents a conservative approach to traumatic coronal lesions, providing a suitable opportunity to maintain the tooth vitality, aesthetics, and function. Indeed, reattachment of tooth fragment using a composite/adhesive is a simple technique to achieve excellent results in terms of aesthetic and function.

An amelogenin-based peptide hydrogel promoted the odontogenic differentiation of human dental pulp cells

Amelogenin can induce odontogenic differentiation of human dental pulp cells (HDPCs), which has great potential and advantages in dentine-pulp complex regeneration. However, the unstability of amelogenin limits its further application. This study constructed amelogenin self-assembling peptide hydrogels (L-gel or D-gel) by heating-cooling technique, investigated the effects of these hydrogels on the odontogenic differentiation of HDPCs and explored the underneath mechanism. The critical aggregation concentration, conformation, morphology, mechanical property and biological stability of the hydrogels were characterized, respectively. The effects of the hydrogels on the odontogenic differentiation of HDPCs were evaluated via alkaline phosphatase activity measurement, quantitative reverse transcription polymerase chain reaction, western blot, Alizarin red staining and scanning electron microscope. The mechanism was explored via signaling pathway experiments. Results showed that both the L-gel and D-gel stimulated the odontogenic differentiation of HDPCs on both Day 7 and Day 14, while the D-gel showed the highest enhancement effects. Meanwhile, the D-gel promoted calcium accumulation and mineralized matrix deposition on Day 21. The D-gel activated MAPK-ERK1/2 pathways in HDPCs and induced the odontogenic differentiation via ERK1/2 and transforming growth factor/smad pathways. Overall, our study demonstrated that the amelogenin peptide hydrogel stimulated the odontogenic differentiation and enhanced mineralization, which held big potential in the dentine-pulp complex regeneration.

A Diagnostic Insight of Dental Pulp Testing Methods in Pediatric Dentistry

The accurate diagnosis of pulpal pathology in pediatric dentistry is essential for the success of vital pulp therapy. Pulp testing is often a challenging task due to understanding and cooperation issues of pediatric patients, as well as the particularities of pulpal physiology encountered in primary and immature permanent teeth. Sensibility tests, although still widely used by dental practitioners, are no longer recommended by pediatric specialists mainly due to their subjective nature. Vitality pulp tests have gained popularity in the last decade in light of some encouraging results of clinical studies. However, their use is not a routine practice yet. This paper is a literature review aimed to guide dental practitioners towards selecting the appropriate pulp testing method for their pediatric cases. It provides an overview on a multitude of pulp testing methods and an update in recommendations for primary and immature permanent teeth.

A critical analysis of clinical research methods to study regenerative endodontics

Regenerative endodontic treatment such as revitalization provides a treatment option for immature teeth with pulp necrosis. The main difference to the alternative procedure, the apical plug, is the induction of a blood clot inside the canal as a scaffold for healing and new tissue formation. Due to the biology-based and minimally-invasive nature of the treatment, revitalization has raised considerable interest in recent years. Whereas the procedure is fairly new and recommendations from endodontic societies have been in place only for a few years, the treatment protocol has evolved over the past two decades. Evidence has been created, not only from laboratory and animal work, but also from clinical studies including case reports, cohort studies and eventually prospective randomized controlled clinical trials, systematic reviews and meta-analyses. However, the research methods and clinical studies with subsequent reports oftentimes present with methodical limitations, which makes it difficult to objectively assess the value of this treatment modality. Several open questions remain, including the need for a more differentiated indication of revitalization after different traumatic injuries, the long-term prognosis of treated teeth and the true benefits for the patient. Therefore, this review aims to identify and reflect on such limitations, scrutinizing study design, diagnostic tools, procedural details and outcome parameters. A core outcome set is also proposed in this context, which can be considered in future clinical investigations. These considerations may lead to a more detailed and stringent planning and execution of future studies in order to create high-quality evidence for the treatment modality of revitalization and thus provide more robust data, create a larger body of knowledge for clinicians and further specify current recommendations.

Short-Term Pain Evolution and Treatment Success of Pulpotomy as Irreversible Pulpitis Permanent Treatment: A Non-Randomized Clinical Study

The objective of this work was to evaluate (1) the short-term evolution of pain and (2) the treatment success of full pulpotomy as permanent treatment of irreversible pulpitis in mature molars. The study consisted of a non-randomized comparison between a test group (n = 44)—full pulpotomy performed by non-specialist junior practitioners, and a control group (n = 40)—root canal treatments performed by specialized endodontists. Short-term pain score (Heft–Parker scale) was recorded pre-operatively, then at 24 h and 7 days post-operatively. Three outcomes were considered for treatment success: radiographic, clinical and global success. For short-term evolution of pain, a non-parametric Wilcoxon test was performed (significance level = 0.05). For treatment success, a Pearson Chi square or Fisher test were performed (significance level = 0.017–Bonferroni correction). There was no significant difference between test and control groups neither regarding short term evolution of pain at each time point, nor regarding clinical (80% and 90%, respectively) or global success (77% and 67%, respectively). However, a significant difference in radiographic success was observed (94% and 69%, respectively). The present work adds to the existing literature to support that pulpotomy as permanent treatment could be considered as an acceptable and conservative treatment option, potentially applied by a larger population of dentists.

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

Background

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

Objectives

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

Methods

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

Results

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

Discussion

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

Conclusion

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

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

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

Orthodontic Forced Eruption of Permanent Anterior Teeth with Subgingival Fractures: A Systematic Review

(1) Background: To assess orthodontic forced eruption (OFE) as a pre-restorative procedure for non-restorable permanent teeth with subgingival dental hard tissue defects after dental trauma. (2) Methods: A systematic electronic search of three databases, namely, MEDLINE, Cochrane Library, and EMBASE, revealed a total of 2757 eligible publications. Randomized controlled clinical trials (RCT), retro- and prospective clinical studies, or case series (with a minimum of three patients) were reviewed. (3) Results: Thirteen full-text papers were included: one RCT, one prospective clinical trial, two retrospective cohort studies, and nine case series. Within case series, statistical significance between age and cause of fracture (p < 0.03) was determined. The mean extrusion rate of OFE was 1.5 mm a week within a four to six weeks treatment period followed by retention. Three OFE protocols for maxillary single teeth are available: 1. OFE without migration of gingiva and alveolar bone, 2. OFE with gingival migration and slight alveolar bone migration, and 3. OFE with migration of both gingiva and alveolar bone. (4) Conclusions: The current state of the evidence suggests that OFE is a feasible pre-treatment option for non-restorable permanent teeth. OFE can promote the migration of tooth surrounding hard and soft tissues in the esthetic zone. Root resorption does not seem to be a relevant side effect of OFE.

Management of Pulp Canal Obliteration-Systematic Review of Case Reports

Background and Objectives: This systematic review aimed to assess the literature focusing on the clinical management of traumatized teeth with Pulp Canal Obliteration (PCO) and propose an updated clinical decision-making algorithm. The present review follows the PRISMA guidelines and was registered on PROSPERO database (CRD42020200656). Materials and Methods: An electronic search strategy was performed in Pubmed, EBSCOhost and LILACS from inception to March 2021. Only anterior permanent teeth with PCO due to dental trauma were included. Regarding clinical approaches, only teeth managed with a “watchful waiting” approach, tooth bleaching or root canal treatment (RCT) were included. Quality assessment was performed using the JBI Critical Appraisal Tool for Case Reports. Results: Twenty case reports were selected, resulting in a total of 27 patients. The number of traumatized teeth diagnosed with PCO was 33. The “watchful waiting” approach was the most implemented clinical strategy. Discolored non-symptomatic PCO teeth were mostly managed with external bleaching. The prevalence of pulp necrosis (PN) was 36.4%. For teeth diagnosed with PN, non-surgical RCT was performed in 10 teeth and surgical RCT in one tooth. Guided endodontic technique was performed in six of those teeth. Conclusions: For discolored non-symptomatic PCO teeth, external bleaching is advocated and the RCT approach should not be implemented as a preventive intervention strategy. Symptomatic PCO teeth should follow regular endodontic treatment pathways. Clinical approach of teeth with PCO should follow a decision-making algorithm incorporating clinical and radiographic signs and patient-reported symptoms.

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

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

External Root Resorption Management of an Avulsed and Reimplanted Central Incisor: A Case Report

Background: Avulsion and reimplantation of permanent teeth represent a major challenge in terms of treatment and long-term prognosis. The present study reported clinical management of external root resorption of an avulsed and reimplanted maxillary central incisor. Case report: A 9-year-old boy reported an uncomplicated crown fracture and avulsion of tooth 11 and complicated crown fracture of tooth 21 due to trauma. Reimplantation of element 11 was obtained within 30 min post-trauma and 3 days after both elements were diagnosed with necrotic pulp. In addition, tooth 11 showed early external root resorption. Both elements underwent endodontic treatment and root closure with apical plug using calcium-silicate-based cement. At 6-month follow-up root resorption appeared to be arrested. Twenty-four months after trauma the clinical results were stable, although signs and symptoms of ankylosis were observed. Conclusions: An immediate endodontic approach and use of calcium-silicate-based cement seemed to contrast the progression of root resorption of an avulsed and reimplanted central incisor after 24 months of follow-up.