Treatment of pulpal and apical disease: The European Society of Endodontology (ESE) S3-level clinical practice guideline

Chemical and in vivo analyses of calcium silicate-based materials in bone and connective tissues

AIM

Calcium silicate-based cements have been widely used in dentistry mainly due to their physicochemical and biological properties. Commercially available materials use radiopacifiers containing metals (bismuth, tantalum, tungsten and/or zirconium). To investigate volumetric changes, in vivo biocompatibility and systemic migration from eight commercially available materials, including powder/liquid and 'ready-to-use' presentations.

METHODOLOGY

After characterization, tubes were implanted in healthy Wistar rats' alveolar bone and subcutaneous tissues. Micro-CT was used to evaluate volumetric change before/after 30 days of implantation. Histological and immunohistochemistry analysis were used to evaluate materials' biocompatibility. After euthanasia, kidney samples were retrieved, acidic digested and evaluated by inductively coupled plasma mass spectrometry (ICP-MS) for bismuth, tantalum, tungsten and zirconium mass fractions. Statistical analysis compared the results for normality and comparisons adopted a level of significance of 0.05.

RESULTS

Characterization photomicrographs and spectroscopy analysis revealed calcium, silicon and radiopacifiers for tested cements. Volumetric changes after implantation showed higher alteration in subcutaneous tissues than alveolar bone indicating that Biodentine, EndoSequence BC RRM Putty and ProRoot MTA were the most stable materials. Histological analysis found intense inflammation for NeoPUTTY and moderate for the other materials; osteocalcin and osteopontin were positively marked for all materials. Despite its volumetric stability, ProRoot MTA showed a 1000-fold higher mass fraction of bismuth accumulation and MTA Repair HP a 37-fold higher tungsten accumulation in kidney samples when compared with the nonexposed controls. All tantalum-analysed samples indicated a similar mass fraction with the nonexposed controls. Biodentine exhibited a significant lower kidney mass fraction of zirconium accumulation when compared with this control.

CONCLUSIONS

Volumetric analysis revealed that Bio-C Repair, NeoPUTTY and MTA Repair HP presented greater volumetric loss when implanted in the subcutaneous tissue. NeoPUTTY presented more intense inflammatory infiltrate. Systemic migration analysis highlighted the predominance of bismuth in the ProRoot MTA group. These results suggest that endodontic repair cements are affected by their chemical composition, the type of implant tissue and different clinical settings.

An 'Index of Oro-dental Disease': A holistic method for understanding the impacts of different risk factors on oral health in archaeological populations

OBJECTIVE

To gain a more holistic understanding of oral health in the past by producing an 'Index of Oro-dental Disease' (IOD), incorporating multiple oro-dental diseases and accounting for differences in antemortem/postmortem alveolar bone and tooth loss.

MATERIALS

UK Adult Dental Health Survey, 2009 anonymised dataset (N = 6206). Archaeological dental data from skeletal individuals from medieval and post-medieval Barton-upon-Humber, North Lincolnshire (N = 214, 1150-1855) and St James's Gardens Burial Ground, London (N = 281, 1789-1853).

METHODS

Creation of a formula for the production of index values. Application of the formula to clinical, 'mock archaeological', and archaeological datasets.

RESULTS

Patterns in mean IOD values within different groups were identifiable regardless of preservation. It was possible to identify potential differences between IOD scores related to aging, tobacco consumption, geographical location, and time period.

CONCLUSIONS

Innovative use of modern clinical data and the production of 'mock archaeological' datasets provides validation of the IOD method. The approach may be useful for understanding the impact of different risk factors on oral health in the past, whilst also accounting for missing data and increasing comparability between groups.

SIGNIFICANCE

Allows for the investigation of risk factors that affect overall oral health but manifest in different ways in different individuals, whilst also producing larger sample sizes.

LIMITATIONS

Impacts of age and posterior/anterior site positioning within the mouth suggest a careful consideration of age distribution and preservation of samples is required.

FUTURE RESEARCH

Future adaption and testing of the method on a greater range of population groups and different variables/risk factors for oro-dental disease.

Physicochemical and functional properties of a novel clodronate-containing chelating gel: A comparative in vitro study

AIM

All commercial chelating gels contain EDTA which reacts chemically with sodium hypochlorite (NaOCl). This research aimed to develop a non-EDTA clodronate gel and to measure physicochemical and functional gel properties of the novel and commercial gels.

METHODOLOGY

A 1.37 M clodronate gel was made by combining polyethylene glycol (PEG) 400 and tetrasodium clodronate. File-Eze™, Glyde™, Odontoprep®, RC-Prep®, SlickGel™ ES and the clodronate gel were tested in pH, density and viscosity experiments. pH: A pH meter was used at 23°C. Viscosity: A rheometer recorded viscosity at a shear rate of 10/s at 35°C. Free available chlorine (FAC): NaOCl reactivity with the clodronate gel was compared to a 4% NaOCl control by measuring FAC with iodometric titration. Tissue Dissolution: File-Eze, Glyde, RC-Prep and clodronate gel mixtures with 4% NaOCl, PBS (phosphate buffered saline) (negative control) and 4% NaOCl (positive control) were tested. Percentage weight losses of porcine palatal mucosa were recorded over 5 min at 35°C. Smear Layer Removal (SLR): Scanning electron micrography and ImageJ software assessed the SLR ability of File-Eze, Glyde, RC-Prep, clodronate gel, PBS (negative control) and 15% EDTA (positive control) by calculating the area fraction percentage of the image occupied by open dentinal tubules (AF%).

RESULTS

pH: Values ranged from 5.78 ± 0.09 (RC-Prep) to 11.34 ± 0.05 (clodronate gel). Viscosity: Ranges were 6390 ± 290 (File-Eze) to 714 ± 50 mPa.s (Odontoprep). FAC: The clodronate gel differed significantly from 4% NaOCl (p < 0.0001, two-way anova, Šídák's tests), albeit with small absolute differences. Tissue Dissolution: All gel-NaOCl mixtures, except for clodronate gel-NaOCl, differed significantly to 4% NaOCl (p < 0.0001, one-way AVOVA, Tukey's multiple comparisons test). Weight losses were: 4% NaOCl, 30.0 ± 3.7%; clodronate gel-4% NaOCl, 29.2 ± 3.5%; whilst other gel-4% NaOCl mixtures ranged from 2.8 ± 2.0% to -0.6 ± 4.5% and PBS was -0.13 ± 3.3%. SLR Ability: Median AF%s were: 15% EDTA-9.7%; File-Eze-8.7%; clodronate gel-5.8%; Glyde-2.5%; RC-Prep-2.2%; PBS-0.22%. All gels differed to 15% EDTA (p < 0.0001, Kruskal-Wallis, Dunn's tests) except File-Eze.

CONCLUSIONS

The gels varied in physical properties, but none of them both dissolved organic tissue in NaOCl mixtures and removed smear layer well. Thus, none of the gels tested possessed all functional properties required of a chelating gel for glide path creation.

Cuproptosis Aggravates Pulpitis by Inhibiting the Pentose Phosphate Pathway

Excessive copper becomes toxic, driving inflammation, and, when copper exceeds a certain threshold, it even leads to a novel programmed cell death termed cuproptosis. However, disordered copper metabolism and its mechanism in pulpitis remain unclear. In this work, we found that lipoteichoic acid (LTA) or lipopolysaccharides (LPS) triggered copper deposition in pulpitis and consequently intensified cuproptosis by impeding the pentose phosphate pathway (PPP). We initially assessed the copper content in pulpitis tissues via inductively coupled plasma mass spectrometry and observed significantly greater concentrations than in healthy pulp tissues. We found that a relatively high copper content was triggered by LTA or LPS, leading cells to cuproptosis. Stimulation of LTA or LPS induced copper deposition and cuproptosis, worsening the progression of pulpitis in vivo. Mechanistically, we found that copper detoxification is dependent on the PPP. We used a 13C-glucose stable isotope-tracing experiment to assess the effect of glucose utilization on cuproptosis. Excessive copper hindered the PPP, resulting in an inadequate generation of nicotinamide adenine dinucleotide phosphate to replenish glutathione and counteract copper toxicity. The PPP regulates the phenotype, function, and survival of preodontoblast-like cells in cuproptosis. Our findings revealed the intricate interplay among bacteria, copper homeostasis, and metabolic reprogramming, providing potential strategies for host-targeted therapy in pulpitis.

The biocompatibility, penetrability, sealing ability, and antibacterial properties of iRoot SP compared to AH plus: An In Vitro evaluation

OBJECTIVES

This study aimed to evaluate the biocompatibility, penetrability, sealing ability, and antibacterial properties of iRoot SP compared to AH Plus in root canal filling.

DESIGN

Two types of iRoot SP and AH Plus were used for in vivo evaluation. The solubility of sealers was tested according to the International Organization for Standardization (ISO). Cell Counting kit-8 was performed for biocompatibility analysis. To evaluate the sealing efficacy, 27 extracted human single-rooted teeth were treated with the single-cone obturation technique. The penetrability was analyzed using confocal laser scanning microscope and the sealing ability was assessed through micro-computed tomography. The biofilm of Enterococcus faecalis was formed on the coagulated root canal sealers to determine the antibacterial properties by colony-forming units and scanning electronic microscopy.

RESULTS

All sealers exhibited standard solubility (<3 %). The biocompatibility of the three root canal sealers was excellent with no statistically significant differences compared to the control group (P > 0.05). The penetrability of both iRoot SP variants was greater than that of AH Plus, especially in the apical third of teeth (P < 0.001). No significant differences in sealing efficacy among the sealers were observed (P > 0.05). IRoot SP also reduced Enterococcus faecalis counts and inhibited the biofilm formation compared to AH Plus (P < 0.01).

CONCLUSIONS

IRoot SP exhibited good biocompatibility. It has superior penetrability and enhanced antibacterial properties compared to AH Plus, but shown no difference in sealing ability, warranting further in vivo studies and long-term assessments. The research underscores the strong potential of bioceramic sealers for clinical applications.

Endodontic treatment modifies circulatory inflammatory mediator levels: A systematic review with meta-analysis

BACKGROUND

There is limited and conflicting data on the reduction of circulatory inflammatory mediators in patients with apical periodontitis (AP) following endodontic treatment.

OBJECTIVE

To answer the following research question: in adult healthy patients with AP [Population (P)], is there a difference before [Comparator (C)] and after various endodontic treatments (nonsurgical, surgical or retreatment) [Intervention (I)] on systemic levels of inflammatory biomarkers [Outcome (O)] in the follow-up period [Time (T)]?

METHODS

An electronic literature search was conducted in the databases Scopus, PubMed, Clarivate Analytics' Web of Science, Cochrane Database of Systematic Reviews and Grey literature from inception to July 2024 with no language restrictions. Observational studies examining changes in serum levels of inflammatory mediators were included. Two independent reviewers selected studies, extracted data and critically appraised the included studies. Qualitative and quantitative (meta-analysis) data synthesis methods were employed. The Newcastle-Ottawa Scale was used to assess the quality of the included studies.

RESULTS

Sixteen studies met the inclusion criteria, of which six were included in the meta-analysis. These studies were published between 1992 and 2024, involving a total of 596 patients (54% females) aged between 16 and 75 years. The meta-analysis of pooled data showed a significant decrease in high-sensitive C-reactive protein (hs-CRP) levels in the serum of patients with AP 6 months after treatment [2.26 ± 1.76 versus 1.28 ± 1.06 mg/L, (Z = 2.03, p = .04)] and a decrease in interleukin-1β (IL-1β) levels 12 months after treatment [13.01 ± 5.95 versus 10.86 ± 3.52 pg/mL, (Z = 3.72, p < .01)]. One study was assessed as poor quality, while all others were considered high quality.

DISCUSSION

Despite the differences in methodologies across the included studies, it has been established that effective endodontic treatment leads to a reduction in systemic inflammatory biomarkers in the body.

CONCLUSION

Following effective endodontic treatment in patients with AP, the systemic levels of hs-CRP and IL-1β exhibit a significant reduction at 6 and 12 months, respectively. Further clinical studies should investigate whether effective endodontic treatment and reduced levels of investigated biomarkers may change the clinical presentation of systemic diseases.

REGISTRATION

PROSPERO database (CRD42024559271).

Comprehensiveness of Large Language Models in Patient Queries on Gingival and Endodontic Health

AIM

Given the increasing interest in using large language models (LLMs) for self-diagnosis, this study aimed to evaluate the comprehensiveness of two prominent LLMs, ChatGPT-3.5 and ChatGPT-4, in addressing common queries related to gingival and endodontic health across different language contexts and query types.

METHODS

We assembled a set of 33 common real-life questions related to gingival and endodontic healthcare, including 17 common-sense questions and 16 expert questions. Each question was presented to the LLMs in both English and Chinese. Three specialists were invited to evaluate the comprehensiveness of the responses on a five-point Likert scale, where a higher score indicated greater quality responses.

RESULTS

LLMs performed significantly better in English, with an average score of 4.53, compared to 3.95 in Chinese (Mann-Whitney U test, P < .05). Responses to common sense questions received higher scores than those to expert questions, with averages of 4.46 and 4.02 (Mann-Whitney U test, P < .05). Among the LLMs, ChatGPT-4 consistently outperformed ChatGPT-3.5, achieving average scores of 4.45 and 4.03 (Mann-Whitney U test, P < .05).

CONCLUSIONS

ChatGPT-4 provides more comprehensive responses than ChatGPT-3.5 for queries related to gingival and endodontic health. Both LLMs perform better in English and on common sense questions. However, the performance discrepancies across different language contexts and the presence of inaccurate responses suggest that further evaluation and understanding of their limitations are crucial to avoid potential misunderstandings.

CLINICAL RELEVANCE

This study revealed the performance differences of ChatGPT-3.5 and ChatGPT-4 in handling gingival and endodontic health issues across different language contexts, providing insights into the comprehensiveness and limitations of LLMs in addressing common oral healthcare queries.

Current Trends in Endodontic Clinical Practice in Croatia: A Report From a Croatian National Survey

OBJECTIVE

To assess the state of endodontic practices and identify factors influencing the use of modern endodontic techniques among dental practitioners in Croatia.

MATERIALS AND METHODS

A questionnaire was distributed to all dental offices in Croatia, yielding 819 responses (27% response rate). Data were descriptively analyzed and statistically modeled.

RESULTS

Nearly 74% of endodontic treatments in Croatia are performed by general practitioners (17 teeth per month per practitioner), while endodontic specialists handle the highest number of treatments per specialist (67 teeth per month, representing 15% of total treatments). 56% of respondents use radiography before the procedure "always" or "almost always" with intra-oral periapical radiography being the most commonly used technique. Rubber dams are used "never" to "rarely" by 74% of respondents. Apex-locators are highly prevalent, used "almost always" to "always" by 83% of practitioners. Magnifiers are rarely used, with 63% of respondents reporting they "never" use them. Lasers are never used by 92% of respondents, whereas 59% frequently use engine-driven instrumentation. 76% of respondents "always" or "almost always" determine the working length of the root canal. Sodium hypochlorite is the most common irrigant (88%), and EDTA for smear layer removal is used by 36% of respondents. The cold lateral condensation is the most popular obturation technique (64%). CBCT is unused by 59% of responders, most probably because it is not accessible.

CONCLUSIONS

Croatian endodontic practices are comparable to those in countries with similar economic status, but there is substantial potential, particularly among general practitioners, to enhance knowledge and awareness of modern technologies through continuous education. Underused techniques in Croatia include rubber dams, magnifiers, lasers, and CBCT.

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.

Why do dentists refrain from intervention in cases of persistent asymptomatic apical periodontitis in root canal filled teeth? An interview study among general dental practitioners

AIM

To explore the context in which general dental practitioners (GDPs) decide to refrain from further treatment, that is, ortho- or retrograde retreatment or extraction of a root canal filled tooth with persistent asymptomatic apical periodontitis (PAAP).

METHODOLOGY

Fifteen GDPs were strategically selected for in-depth interviews. The informants were encouraged to describe in their own words and in as much detail as possible, the three most recent patient cases of PAAP of a root canal filled tooth, in which they decided to refrain from further treatment. The interviews were recorded digitally and transcribed verbatim. The collected material was analysed according to Qualitative Content Analysis with an inductive approach.

RESULTS

A pattern of varying degrees of uncertainty associated with the decision process was identified. The motives to refrain intervention had great diversity. The result from analysis of the qualitative data was formulated in an overall theme 'Between doubt and certainty in a complex clinical context' covering the latent content. The first main category covering the manifest content was 'The continuum of confidence' with three subcategories 'Experienced uncertainty', 'Reluctant approval' and 'At ease with refraining' illustrating the feelings and attitudes experienced by the informants. The second category was 'In support of acceptance' with three subcategories 'Patient's autonomy, risks and cost-benefits', 'Emotional aspects' and 'Relieving measures' representing the reasons for refraining from intervention.

CONCLUSIONS

The decision to refrain from further treatment, that is, ortho- or retrograde retreatment or extraction of a root canal filled tooth with PAAP was made with some measure of confidence, combined with compensatory strategies to support the decision, taking into account not only values beneficial to the patient and awareness of limited external resources, but also factors related to the informants' personal preferences, convenience, concerns, ambition and emotions.

Non-Surgical Endodontic Management of Large Periapical Lesions After Traumatic Dental Injuries

Traumatic dental injuries of permanent teeth result in multiple immediate and long-term consequences depending upon the severity of trauma, age of the patient, the status of root maturity, and the emergency care provided. The healing responses may get disturbed due to severe damage, loss of vascularity of the supporting structures, and infections. As a result, the prohealing mediators and pathways are overpowered by the destructive stimuli often manifested by an increased osteoclastic activity. Among the various late complications, the apical periodontitis or the periapical lesions are most worrisome for the patients and create clinical dilemma for the dentists. In the past, many such lesions were classified as cysts and subjected to surgical management. However, better understanding of lesion pathophysiology, three-dimensional imaging, and molecular pathways have established their inflammatory nature. The advancements in materials such as calcium silicates, and regenerative techniques have propelled the research related to non-surgical endodontic management as its clinical acceptability. The treatment largely follows the recommendations of regenerative medicine and is based on four principles: (a) establishing the drainage or an endodontic access to the area, (b) removal of most of the triggering agents such as necrosed pulp, toxins, and inflammatory mediators, (c) disinfection of the area, controlling inflammation and reversal of the acidic pH, and (d) maintenance of this infection/inflammation-free state for a long time through adequate sealing. This review aims to highlight the rationale of the approach, case selection, pathophysiology of the causation and healing, clinical protocols, and the limitations of non-surgical endodontic management of large periapical lesions secondary to traumatic dental injuries.

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.

Physicochemical properties and biological interaction of calcium silicate-based sealers - in vivo model

OBJECTIVES

To investigate volumetric changes, in vivo biocompatibility, and systemic migration from eight commercial endodontic sealer materials in paste/paste, powder/liquid, and pre-mixed forms.

MATERIALS AND METHODS

The sealers AH Plus Bioceramic, AH Plus Jet, BioRoot RCS, MTApex, Bio-C Sealer, Bio-C Sealer Ion+, EndoSequence BC Sealer and NeoSEALER Flo were studied. After characterisation by scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDS), Raman spectroscopy and X-ray diffractometry (XRD), tubes were implanted in Wistar rats' alveolar bone and subcutaneous tissues. Micro-CT evaluated volumetric changes pre/post 30 days of implantation. Histological and immunohistochemistry analyses assessed biocompatibility. Kidney samples underwent spectrometry (ICP-MS) for tantalum, tungsten and zirconium. Statistical analysis determined normality and significance (udp < 0.05).

RESULTS

Characterisation revealed calcium, silicon, and radiopacifiers in the materials. Volumetric changes showed greater alteration in subcutaneous tissues than alveolar bone; BioRoot RCS and MTApex (powder/liquid) were most stable. Histological analysis indicated intense inflammation for AH Plus Jet, moderate for others; IL-10 was marked positively for all materials. AH Plus Jet had an 18-fold higher tungsten and a 37-fold higher zirconium mass fraction in kidneys versus controls, while tantalum showed lower accumulation patterns.

CONCLUSION

Root canal filling materials' responses varied by implantation site and form, demonstrating acceptable biocompatibility. Tantalum and zirconium oxide radiopacifiers appear systemically safe; tungsten-based radiopacifiers are unsuitable due to metal accumulation risks.

CLINICAL RELEVANCE

This study highlights the need for further in vivo studies on endodontic sealers' chemical, biological, and physical behaviors and their systemic migration.

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.

Postoperative Pain Following Vital Pulp Therapy in Carious Permanent Teeth of Children and Adolescents: A Prospective Cohort Study

BACKGROUND

Vital pulp therapy (VPT) is one of the treatments recommended for vital deep carious permanent molars. However, postoperative pain remains underexplored in children and adolescents who have undergone VPT.

AIM

This study investigated the incidence, intensity, duration, temporal pattern, and analgesic intake of postoperative pain following VPT in children and adolescents. Additionally, factors associated with postoperative pain incidence were explored.

DESIGN

A prospective cohort study was conducted in 159 patients aged 6-18 years, involving 174 VPT-treated teeth. Pain intensity, measured with the Wong-Baker FACES Pain Scale (WBFPS), and analgesic intake were recorded daily for 7 days post treatment.

RESULTS

Over the 7-day period, 40.23% of patients experienced postoperative pain. Mean pain intensity decreased from 3.43 ± 1.96 on Day 1 to 1.26 ± 1.71 on Day 2. About 52.86% of patients were pain-free between Days 1 and 2, and over 97% were pain-free by Day 7. Analgesics were taken by 25.86% of patients. Compared with the protective liners group, the more invasive types of VPT were associated with higher odds of pain.

CONCLUSION

Postoperative pain following VPT was common; however, it was mild, controllable with analgesics, and resolved in most patients. The more invasive VPT types were linked to an increased incidence of pain.

The employment of recommended root canal treatment procedures by dentists in Croatia and the Czech Republic

AIM

This study aimed to evaluate the compliance of dentists in Croatia and the Czech Republic with endodontic recommendations and identify the subjective and objective factors influencing their adherence to them.

METHODOLOGY

A total of 1386 dentists from Croatia and the Czech Republic participated in an online survey through a self-administered, author-designed questionnaire. After excluding those who did not perform root canal treatments (RCT), 1376 responses (394 from Croatia and 982 from the Czech Republic) were statistically analysed.

RESULTS

The median age of respondents was 40 years, with a higher proportion of females in both countries. Croatian dentists treated fewer patients weekly but performed more RCTs and placed more composite fillings than their Czech counterparts. Czech dentists more frequently employed magnification devices, rubber dam (RD), pre-endodontic build-ups, nickel-titanium (NiTi) instruments, irrigant activation, bioceramic sealers, indirect post-endodontic restoration of lateral teeth, and single-visit treatments. These practices were also more common among endodontists than general dental practitioners and other specialists in both countries. Croatian dentists adhered more consistently to the recommended irrigation protocol. In the Czech group, adherence to recommended procedures, such as magnification, RD usage, and irrigation protocol correlated with younger age, smaller weekly number of patients, and preference for treating patients in the supine position. No such correlations were observed among the Croatian dentists.

CONCLUSIONS

Despite notable improvements in recent years, dentists still do not fully comply with the recommended RCT working procedures in Croatia and the Czech Republic.

Novel pain assessment tool specific for pulp symptoms to aid diagnosis

AIM

Although many pain assessment tools exist, none are specific to the relatively unique presentation of pulpal pain. The aim of this study was to develop and validate a novel pain assessment tool based on pulp symptoms.

METHODOLOGY

A preliminary list of items best-describing pulpitis was developed based on deductive and inductive approaches and the preliminary tool was piloted (n = 80). A final 11-item pain assessment tool was developed comprising 5 closed-ended items evaluating pain intensity to diverse stimuli (thermal and sweet) and 6 closed-ended items assessing various aspects of pulp pain (such as spontaneity, duration, referral, postural pain, pain upon biting and requirement for analgesics). The tool was tested on 300 adult patients (age range = 18-54 years) who presented with symptoms indicating some form of pulpitis. The 11 items were each scored from 1 to 4, yielding a total score between 11 and 44. These scores were subsequently compared to a set of diagnoses made utilizing established clinical reference standards, these include patient history, clinical examination, periapical radiographs, and pulp testing.

RESULTS

All items in the tool reached an excellent content validity index score (≥0.83) for relevance. Following the pilot, six items were rephrased and five were removed. After final testing the constructed tool had a reliability coefficient of .8641, indicating a high level of internal consistency. Factor analysis extracted two factors that accounted for 59.61% of variance. The sensitivity and specificity was 95.36% and 86.58%, respectively. Likelihood ratio was 7.104 (LR+) and 0.05 (LR-) at cut-off point. The area under the ROC curve was 0.9714 with a SE of 0.0076. The cut off score by Youden index was 25 between reversible and irreversible pulpitis.

CONCLUSIONS

The developed tool proved to be both valid and reliable. It is the first comprehensive multidimensional tool designed to standardize the pulp pain assessment protocol, covering various attributes of pulp pain and effectively distinguishing between reversible and irreversible pulpitis with a defined cut-off score. Furthermore, its use is anticipated to provide support in diagnosing ambiguous cases of inflamed pulp, which is especially helpful for less experienced dentists.

Minimally Invasive Endodontic Treatment through the Labial/Buccal Cervical Approach - Protocol and Case Series

INTRODUCTION

Traditional access cavity preparation involves removing the roof of the pulp chamber and smoothing the dentin bulges at the root canal orifice, thereby creating straight-line access. However, this may damage more healthy dental tissue and reduce the tooth's fracture resistance. This case series presents a novel minimally invasive endodontic protocol for 1 maxillary canine and 4 mandibular premolars, which required root canal therapy, due to labial/buccal cervical decay that caused pulpitis or periapical periodontitis.

METHODS

Our treatment protocol includes the following steps: preoperative assessment, removing decay in the labial/buccal cervical region, preparing an endodontic access cavity utilizing the affected region, establishing a working-length reference line using resin, cleansing the pulp horn with ultrasonic retro-preparation tip, root canal preparation, disinfection, obturation through the labial/buccal cervical access, and final resin restoration.

RESULTS

Ideal root canal obturation outcomes were achieved in all cases, while avoiding the abrasion of tooth tissue at the pulp chamber roof, caused by traditional endodontic access cavity methods.

CONCLUSIONS

Minimally invasive endodontic treatment through the labial/buccal cervical approach offers clinicians new insights and options for endodontic access design.

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.

The short-term postoperative pain and impact upon quality of life of pulpotomy and root canal treatment, in teeth with symptoms of irreversible pulpitis: A randomized controlled clinical trial

BACKGROUND

Few studies focus upon patient-reported outcomes in endodontics.

AIM

To determine whether full pulpotomy offers a less painful, improved health-related quality of life (HRQoL) compared with root canal treatment (RCT) in cases of irreversible pulpitis (IP) in the 7 days after the treatment.

METHODOLOGY

One hundred sixty-eight participants presenting with symptoms of IP were randomized to either pulpotomy (n = 86) or RCT (n = 82). Two participants were excluded, 61 participants underwent full pulpotomy with Biodentine (35.7%), 80 had RCT (46.8%), and 25 were randomized to have pulpotomy which progressed to RCT (PRCT) due to uncontrollable bleeding (14.6%). Clinical and radiographic assessments, using CBCT and periapical radiographs, were carried out preoperatively, for the evaluation of the results only CBCT images were used. Pain (VAS) and HRQoL (EQ 5D) assessments were carried out at baseline and Days 1, 3, 5 and 7 post-baseline. Analysis included descriptive and continuous variables, chi-squared, Fisher's exact, and two-sample t-tests.

RESULTS

In pulpotomy and RCT groups, VAS pain decreased significantly over the first week (p < .001). The magnitude of reduction was similar in RCT and pulpotomy (p = .804), RCT and PRCT (p = .179), pulpotomy vs. PRCT (p = .144) and in the comparison of combined RCT /PRCT groups (ORCT) with Pulpotomy (0.729). However, the overall level of VAS pain was significantly higher in the PRCT group than in the Pulpotomy (p = .045) and RCT group (p = .049). Using CBCT, significantly more radiolucencies were found in the PRCT group than in the pulpotomy group and overall teeth presenting with CBCT radiolucencies had significantly higher pain scores (p = .015), particularly at Days 1, 3 and 5. There were significant differences in many OHRQoL domains (Questions 1, 6, 11 and 12) between RCT and PRCT groups with higher frequencies of the impact of oral health problems at Day 0 and Day 7 in the PRCT group.

CONCLUSION

In the treatment of IP, pulpotomy is as effective as RCT in reducing post-operative pain, and improving QoL and HRQoL, teeth displaying uncontrollable bleeding and periapical radiolucencies detected using CBCT are associated with more intense postoperative pain and lower QoL.

The effectiveness of partial pulpotomy compared with full pulpotomy in managing deep caries in vital permanent teeth with a diagnosis of non-traumatic pulpitis

BACKGROUND

Pulpitis may be pain free or alternatively characterized by mild to severe pain and associated symptoms. Evidence has recently emerged that patients presenting with carious pulp exposure range of symptoms can be treated effectively with pulpotomy.

OBJECTIVE

The current systematic review aimed to answer the following research question: "In patients with deep caries lesions in permanent teeth associated with no symptoms, reversible pulpitis or signs and symptoms indicative of irreversible pulpitis (P), is partial pulpotomy (I) as effective as full pulpotomy (C), in terms of a combination of patient and clinical reported outcomes (O), with "tooth survival" as the most critical outcome?

METHODS

The systematic literature search was conducted in the following electronic databases: OVID, Scopus, PubMed (Including MEDLINE), and Cochrane Central Register of Controlled Trials (CENTRAL) supplemented with Grey literature and hand searching of relevant journals. The English language clinical trials comparing the patient and clinical reported outcomes between partial and full/complete were included. After a structured literature search, two authors independently performed study selection, extracted data and performed a risk of bias assessment; a third reviewer resolved disagreements. As there were only two studies with different exclusion criteria, no meta-analysis was performed and the quality of evidence was assessed by the GRADE approach.

RESULTS

After study selection a total of two randomised clinical trials with a total of 156 teeth were included both for the management of teeth with irreversible pulpitis. There were no studies for asymptomatic teeth or teeth with reversible pulpitis. A "Low" risk of bias was noted for both studies with a high level of overall evidence. A meta-analysis was not carried out due to differences in inclusion criteria between the studies related principally to caries depth. Both studies reported a high rate of clinical success for pulpotomy with a pooled unadjusted success rate for full pulpotomy of 90% and 83% partial pulpotomy of at 1-year; however, no significant difference between the treatments was noted in either study. There was significantly reduced postoperative pain reported in the full pulpotomy group over 1-week compared with the partial pulpotomy in one but not in the other study.

DISCUSSION

Pulpotomy as a definitive treatment modality is as effective in managing teeth exhibiting signs and symptoms indicative of irreversible pulpitis and challenges the established protocols to manage this condition. Although based on only two RCTs with a limited number of patients, no difference was shown in terms of clinical or radiographic outcome or postoperative pain between groups. Further well designed randomised clinical trials of longer duration are required in this area to improve the evidence available.

CONCLUSION

There is no consistent difference in patient-reported pain between partial and full pulpotomy at day 7 postoperatively and the clinical success rate was similar after 1 year for both treatment modalities.

Microbial Dynamics in Endodontic Pathology-From Bacterial Infection to Therapeutic Interventions-A Narrative Review

Endodontic infection is a penetration of microorganisms into the dental pulp. Bacteria are the most common entities that induce an infection. This state is associated with significant pain and discomfort. Therapeutic intervention involves removal of infected pulp from the tooth and roots, which eliminates viable tissue, thus creating a tooth less resistant to mechanical pressure. Studies suggest that there are several types of bacteria most commonly associated with endodontic infections. Furthermore, it is considered that different types of pathogens could play a major role in primary and secondary endodontic infections. The aim of this review is to summarize major bacteria involved in the process of endodontic infection. Furthermore, we discuss the bacterial properties that allow them to penetrate dental pulp and hypothesize about possible future treatment strategies.

Comparative Effectiveness of Regenerative Endodontic Treatment Versus Apexification for Necrotic Immature Permanent Teeth With or Without Apical Periodontitis: An Umbrella Review

BACKGROUND/AIM

The evidence related to the superiority of the recommended treatment protocols for necrotic immature permanent teeth is unclear. We aimed to compare the clinical, radiographic, and overall success rates of apexification and regenerative endodontic treatment (RET), assess the methodological quality, and assess the strength of evidence for outcomes.

METHODS

A search was performed in PubMed, Scopus, LILACS, EMBASE, Web of Science, and the Cochrane Library. The titles, abstracts and full texts of systematic reviews (SRs) comparing RET and apexification were screened. The quality and strength of evidence were analyzed via AMSTAR-2, ROBIS, and modified Kohler's criteria.

RESULTS

Twelve SRs were included, with nine having meta-analytic outcomes. The quality of only one study was high, and the risk of bias was low in two studies. Comparable success and survival rates for RET and apexification, with no superiority of any treatment, were reported. RET was superior in stimulating root thickness and lengthening. Weak evidence was noted for a higher clinical and radiographic success rate of the apical plug technique and for root lengthening and an increase in root thickness in RET.

CONCLUSION

RET and apexification exhibited comparable success rates of > 85% across all domains. Most comparisons did not reveal significant differences in clinical, radiographic, or overall success. However, the quality of evidence was weak (class IV) for both outcomes, and the majority of systematic reviews exhibited low or critically low quality and high risk of bias.

Vital Pulp Therapy Outcomes in Children's First Permanent Molars Under General Anesthesia: A Retrospective Study

INTRODUCTION

Pulpotomy is a proven treatment option for permanent teeth with pulp involvement, showing high success rates similar to root canal treatment. General anesthesia (GA) is used when traditional dental procedures are not feasible, especially in pediatric cases. Despite its effectiveness, limited data on endodontic treatments under GA is available, with many guidelines favoring extractions. This study aimed to evaluate the success rate of pulpotomies performed under GA on children's first permanent molars and to identify factors influencing treatment outcomes.

METHODS

The study involved 171 pediatric patients, aged 8 to 12, who underwent pulpotomy procedures on 197 teeth at a public dentistry clinic between January 2018 and July 2022. Clinical and radiographic follow-ups were conducted at different intervals to assess the effectiveness of the treatments, achieving a recall rate of 83%.

RESULTS

The overall success rate of pulpotomies performed under GA was 93.36%. Success rates varied according to the follow-up period: 100% at 1-12 months, 97.70% at 13-24 months, and 87.76% at 25-36 months. The etiology of the tooth's condition significantly affected outcomes, whereas patient age, sex, and tooth maturity did not have a significant impact.

CONCLUSION

Pulpotomy in permanent molars is an effective treatment option for managing carious lesions, especially when performed under GA.

Are antibiotics overprescribed for apical periodontitis in dental practice?

DATA SOURCES

There is a discrepancy in the databases and data sources mentioned by the authors. The abstract references four databases, which differ from those listed in the materials and methods section. According to the methods, the literature search was conducted across three databases: PubMed-MEDLINE, EMBASE, and Scielo. However, the abstract mentions four databases, including MEDLINE/PubMed, Wiley Online Database, Web of Science, and Scopus.

STUDY SELECTION

All relevant articles were searched using specific keywords derived from Medical Subject Headings (MeSH) terms and text words (TW) related to the topic. Following the screening of titles and abstracts, the full texts of the selected studies were reviewed, and inclusion and exclusion criteria were applied. Any disagreements regarding study inclusion were resolved by consensus. Studies that reported data on antibiotic prescription patterns by dentists for the treatment of apical disease were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction was carried out by three independent reviewers, with a fourth author resolving any disagreements. Extracted data included publication details (authors, year of publication), number of respondents, response rate, survey location, and prescriber type (general practitioner, endodontist, or dental surgeon). The primary outcome measured was the percentage of dentists prescribing antibiotics for each form of periapical endodontic disease.

RESULTS

The search strategy identified a total of 96 studies, of which 39 cross-sectional studies met the inclusion criteria. Dentists prescribed antibiotics in 25.8% of cases of symptomatic apical periodontitis (AP) and in 31.5% of asymptomatic AP cases. In instances of acute symptomatic apical abscess with swelling and moderate to severe symptoms, approximately 89% of dentists prescribed antibiotics, compared to nearly 100% of endodontists.

CONCLUSIONS

Endodontists demonstrate more appropriate antibiotic-prescribing practices than general practitioners. Globally, dentists tend to over-prescribe antibiotics for managing apical disease. Therefore, there is a pressing need to enhance antibiotic prescribing practices in the treatment of endodontic infections.

Influence of number of visits on the outcome of endodontic treatment

The success of endodontic treatment (ET) is largely dependent on the application of a strict protocol for disinfecting the root canal system and may be influenced by the number of visits but remains controversial in the literature. This review provides an overview of published studies comparing ET in single and multiple visits. A search was performed in the electronic databases such as PubMed, Cochrane Library, Science Direct, and Google Scholar from 2017 to 2022. Eligibility criteria were randomized clinical trials, reviews, and studies focusing on single- or multivisit techniques. Twenty-four articles were included. The main characteristics, including healing rates, success, and postoperative pain after ET, were extracted from the studies. The results of the studies included in this review showed that single- and multisession ET are similar in terms of healing rates and long-term complications, although both treatment approaches may be associated with short-term postoperative pain.

The Therapeutic Use of Dental Mesenchymal Stem Cells in Human Clinical Trials

Mesenchymal stem cells (MSCs), characterized by their undifferentiated and multipotent nature, can be derived from various sources, including bone marrow, adipose, and dental tissues. Among these, dental MSCs (DSCs) exhibit universal MSC characteristics and are attracting considerable attention for regenerating oral and craniofacial tissues. This review provides a contemporary overview of recently published clinical studies using DSCs for various orodental and maxillofacial regenerative applications, including bone, periodontal, and endodontic regeneration. It also explores the utilization of DSCs in treating systemic conditions, exemplified by their application in managing conditions such as COVID-19 and osteoarthritis. The available evidence underscores the potential of DSCs and their secretome as efficacious tools in regenerative medicine for both dental and nondental clinical applications, supporting the continued promise of stem cell-based therapies. It is nevertheless evident that there are a number of important challenges that restrict the widespread utilization of DSCs, namely, difficulty in standardizing autologous preparations, insufficient cell surface marker characterization, high production costs, and regulatory compliance requirements. Further, the unique requirements of dental applications, especially complex structures such as the periodontium, where temporospatial control over the healing process is required, necessitate the combination of stem cells with appropriate scaffolds according to the principles of tissue engineering. There is currently insufficient evidence to support the clinical translation of DSCs into clinical practice, and phase 3 clinical trials with standardized protocols for cell sourcing, propagation, dosing, and delivery are required to move the field forward. In summary, this review provides a contemporary overview of the evolving landscape of stem cell therapy, offering insights into the latest developments and trends as well as the challenges that need to be addressed for the widespread application of DSC-based cell therapies.

Influence of sonic activation of epoxy-resin and calcium silicate sealer on postoperative pain: a patient-blinded, parallel group, randomized clinical trial

BACKGROUND

This clinical study aims to compare postoperative pain after single-visit root canal treatment of teeth with asymptomatic apical periodontitis using epoxy-resin-based AH Plus and calcium silicate-based Endosequence BC sealers with or without sonic activation.

METHODS

This study included 72 individuals with one first or second mandibular premolar tooth with asymptomatic apical periodontitis. They were randomly divided into four groups according to the root canal sealer (AH Plus or Endosequence BC) and activation protocol (sonic activation or non-activation) (n = 18). The participants were ask to rate their postoperative pain intensity on a NRS scale as none, minimal, moderate, or severe after 24 h, 48 h, 72 h, and 7 days following treatment. Patients were also asked to record the number of prescribed analgesic medication tablets (400 mg of ibuprofen) taken. Statistical analysis were performed using the Mann-Whitney U test, the Friedman test, the Spearman's correlation test, the Chi-square test. Significance level was established at 0.05.

RESULTS

There was no statistically significant difference in postoperative pain scores or analgesic intake between AH Plus and Endosequence BC sealers regardless of the activation protocol (p > 0.05). There was no statistically significant difference in postoperative pain scores between the sonic activation and non-activation groups (p > 0.05). A weak positive correlation was detected between Endoactivator sonic activation and sealer extrusion (r = 0.36).

CONCLUSIONS

AH Plus and EndoSequence BC root canal sealers showed similar results in terms of prevalance and intensity of postoperative pain. Sonic activation and non-activation groups had similar postoperative pain scores.

CLINICAL TRIAL REGISTRATION

The study was retrospectively registered with ClinicalTrials.gov (NCT06403293). Date of Registration: 07/05/24.

Tissue engineering approaches for dental pulp regeneration: The development of novel bioactive materials using pharmacological epigenetic inhibitors

The drive for minimally invasive endodontic treatment strategies has shifted focus from technically complex and destructive root canal treatments towards more conservative vital pulp treatment. However, novel approaches to maintaining dental pulp vitality after disease or trauma will require the development of innovative, biologically-driven regenerative medicine strategies. For example, cell-homing and cell-based therapies have recently been developed in vitro and trialled in preclinical models to study dental pulp regeneration. These approaches utilise natural and synthetic scaffolds that can deliver a range of bioactive pharmacological epigenetic modulators (HDACis, DNMTis, and ncRNAs), which are cost-effective and easily applied to stimulate pulp tissue regrowth. Unfortunately, many biological factors hinder the clinical development of regenerative therapies, including a lack of blood supply and poor infection control in the necrotic root canal system. Additional challenges include a need for clinically relevant models and manufacturing challenges such as scalability, cost concerns, and regulatory issues. This review will describe the current state of bioactive-biomaterial/scaffold-based engineering strategies to stimulate dentine-pulp regeneration, explicitly focusing on epigenetic modulators and therapeutic pharmacological inhibition. It will highlight the components of dental pulp regenerative approaches, describe their current limitations, and offer suggestions for the effective translation of novel epigenetic-laden bioactive materials for innovative therapeutics.

Mind the gap-What is the appropriate time interval between sequential dentine stimuli to elicit a dentine hypersensitivity pain response in clinical studies?

OBJECTIVES

To determine the time interval required for a tooth diagnosed with DH to recover from a stimulus (cold air-blast/tactile) and respond with a similar elicited pain response to a repeat stimulus.

METHODS

A single-centre, non-randomised, clinical study in healthy adult volunteers. Eligible participants with ≥1 tooth with either a qualifying Schiff score ≥2 following cold air-blast or tactile Yeaple score of ≤20 g were allocated to tactile or air-blast group. Following primary stimulation, the designated tooth was restimulated 10, 5, 2 min and immediately after initial pain cessation. Pain was recorded with participant VAS and investigator Schiff for air-blast.

RESULTS

40 participants completed the study per group. There was a significant difference in VAS scores for tactile 4 delay intervals (p < 0.001) but not air-blast stimulus, and a significant difference in mean change in VAS score from immediate to two-minute delay between stimuli (8.0 tactile vs 0.8 air-blast, p = 0.011). VAS scores in response to either stimulus showed very wide variation between participants, but changes over delay intervals within participants were relatively slight. There was a significant progressive decrease in mean Schiff score with shortening delay intervals from 10 min (2.38) to stimulation immediately after pain cessation (2.15), p = 0.018.

CONCLUSIONS

The findings suggest healthy teeth recover after DH stimulation more quickly following an air-blast than tactile stimulus, with around 2 min allowing recovery from both. Many factors including habituation and pain measurement subjectivity need to be considered. It would be prudent for future studies to use of ≥3 min delays.

CLINICAL SIGNIFICANCE

No clinical study has attempted to determine the appropriate interval between successive stimuli in DH patients. The results will impact directly on the conduct of DH trials. These findings suggest the interval could be reduced to around 2-min, but the current standard of 5-min is sufficiently long to give valid results.

A carbon dot nanozyme hydrogel enhances pulp regeneration activity by regulating oxidative stress in dental pulpitis

Preserving pulp viability and promoting pulp regeneration in pulpitis have attracted widespread attention. Restricted by the oxidative stress microenvironment of dental pulpitis, excessive reactive oxygen and nitrogen species (RONS) trigger uncontrolled inflammation and exacerbate pulp tissue destruction. However, modulating redox homeostasis in inflamed pulp tissue to promote pulp regeneration remains a great challenge. Herein, this work proposes an effective antioxidative system (C-NZ/GelMA) consisting of carbon dot nanozymes (C-NZ) with gelatin methacryloyl (GelMA) to modulate the pulpitis microenvironment for dental pulp regeneration by utilizing the antioxidant properties of C-NZ and the mechanical support of an injectable GelMA hydrogel. This system effectively scavenges RONS to normalize intracellular redox homeostasis, relieving oxidative stress damage. Impressively, it can dramatically enhance the polarization of regenerative M2 macrophages. This study revealed that the C-NZ/GelMA hydrogel promoted pulp regeneration and dentin repair through its outstanding antioxidant, antiapoptotic, and anti-inflammatory effects, suggesting that the C-NZ/GelMA hydrogel is highly valuable for pulpitis treatment.

Current Endodontic Practices among Romanian Dental Practitioners: A Cross-Sectional Study

Root canal therapy (RCT) is usually performed in Romania by general dentists (GDPs) because they are more readily available and more reasonably priced than endodontists. Concerns have been raised about the quality of RCTs performed by GDPs, possibly due to insufficient equipment or knowledge; therefore, this study aims to investigate current endodontic practices in Romania. Materials and Methods: A cross-sectional study was conducted via a questionnaire distributed to 400 randomly selected Romanian dentists, with 285 fully validated completed responses (71.25% response rate). Respondents were grouped by speciality, and statistical analysis, including cross-tabulation and the χ2 (chi-square) test, was used, with a significance level set at p ≤ 0.05 for all tests. Results: Significant differences were found in the use of magnification, rubber dam, sodium hypochlorite concentration, and bioceramics (p < 0.001). No significant differences were observed in preferences for measuring working length (p = 0.166) or rotary instrument motion (p = 0.289). Approximately 6% of the respondents used laser technology with no significant difference across specialities (p = 0.571). Additionally, 77.9% preferred using sodium hypochlorite, with no significant difference between groups (p = 0.006) regarding concentration. Conclusions: Most participants, including GDPs, use modern equipment and techniques during RCT, indicating their awareness and competence in current endodontic practices.

An Online Survey on the Current Trends in Root Canal Treatment

Root canal treatment in several regions of Saudi Arabia is commonly administered by general dental practitioners (GDPs) rather than specialized endodontists. The study aimed to compare the endodontic practices and preferences of general dental practitioners with those of endodontists and restorative specialists. A structured questionnaire including 23 questions focussing on fundamental principles and techniques used in contemporary root canal treatment was distributed online to 600 dentists who perform root canal treatments and are registered with the Saudi Dental Society (SDS). Data were gathered for basic demographic and professional details, practices, and preferences in endodontic materials and methods. The collected data were analyzed using SPSS version 21 (Armonk, NY: IBM Corp.). For selected variables, frequency distributions and 95% confidence interval for sample proportions were measured. Associations between categorical variables were examined using cross-tabulation, with statistical significance assessed by the chi-square test of homogeneity or Fisher's exact test when necessary. The survey, with a 59% response rate primarily from participants aged 24-34 years (94.1%) with one to five years of experience (90.4%), revealed that most GDPs referred root canal treatment (RCT) cases due to lack of skills (82.8%), performed restorability assessments (90.9%), preferred Cavit for tooth buildup (87%), consistently used rubber dam isolation (91.5%), treated mainly anterior teeth (91.2%) without magnification (87.9%), used electronic apex locators for working length determination (63.3%), favored stainless steel K files and single cone obturation, while specialists exhibited wider clinical experience, more frequent use of advanced techniques, and higher usage of intracanal medicaments (91.7%) and ethylenediaminetetraacetic acid (EDTA) as irrigant (70.8%). The study provides valuable insights into the endodontic preferences and practices of dentists in the Kingdom of Saudi Arabia, revealing significant differences between general dental practitioners and specialists. The findings highlight critical areas for improvement, such as the need for enhanced training in endodontic skills and better access to modern materials and equipment.

Orthodontic movement after regenerative endodontic procedure in mature permanent tooth associated with dens invaginatus: a case report with 4-year follow-up

BACKGROUND

Regenerative endodontic procedures (REPs) are innovative treatments aimed at restoring damaged dental structures. However, the effect of orthodontic movement on REP-treated teeth is not well understood and may have significant long-term consequences. This study aimed to evaluate the impact of orthodontic movement on a mature permanent tooth associated with dens invaginatus that has undergone a regenerative endodontic procedure (REP).

CASE PRESENTATION

This report describes the case of a 13-year-old healthy male who presented with pulp necrosis and a chronic apical abscess (tooth number 2.2). Following REP according to the American Association of Endodontists' guidelines, the patient began non-extraction orthodontic treatment with fixed appliances after a 9-month healing period, which lasted 17 months in the upper arch. Subsequent follow-ups at 24, 36 and 48 months post-REP revealed an asymptomatic state with minimal cervical discoloration and diminished cold sensitivity. Radiographic analyses revealed periapical healing, mild apical remodeling on tooth 2.2, and moderate apical remodeling on other maxillary incisors. The treated tooth displayed a positive response to both REP and orthodontic treatment, yet further research is required to determine the long-term effects of orthodontics on REP-treated teeth.

CONCLUSION

Orthodontic movement following REPs in mature permanent teeth is feasible and do not seem to prone teeth to orthodontic tooth resorption. Our experience indicates that a 9-month healing period allows successful orthodontic outcomes following REPs. Nonetheless, the predictability of outcomes and the ideal healing period before orthodontic movement is initiated remain to be established.

The efficacy of premixed bioceramic sealers versus standard sealers on root canal treatment outcome, extrusion rate and post-obturation pain: A systematic review and meta-analysis

BACKGROUND

Limited evidence is available regarding the superior clinical properties of bioceramic sealers comparted with traditional standard sealers.

OBJECTIVES

This review aimed to answer the following research questions: 'In healthy patients requiring a root canal treatment (P), what is the efficacy of premixed bioceramic sealers (I) compared with traditional root canal epoxy resin-based sealers (C) in terms of survival, success rates (PICO1) sealer extrusion and resorption (PICO2) post-obturation pain (PICO3) (O)?'

METHODS

Authors independently searched three electronic databases: PubMed (including MEDLINE), Web of Science, Embase and Scopus up to 31 October 2023. This was accompanied by both grey literature and manual search. Detailed selection criteria were applied, namely mature permanent teeth requiring root canal treatment, premixed bioceramic sealer with gutta-percha as an intervention group, a standard filling technique as control group and full-text available in English. A random-effect meta-analysis was used to synthesize the body of evidence regarding the use of bioceramic sealers in root canal treatment and their impact on post-obturation pain. Effect sizes were represented as relative risks on a logarithmic scale for binary outcomes and as mean differences for continuous outcomes.

RESULTS

A total of 941 articles were identified. Fifteen Comparative clinical studies were finally included. Eleven were randomized clinical trials, and four were prospective clinical trials with control group. The follow-up of these studies was not greater than 2 years. No publication bias was observed in any study. No significant differences were observed between the two groups in terms of survival and success rates. A small non-significant lower risk of extrusion was observed for bioceramics. A small, non-significantly lower post-operative-pain within 24-h was observed when bioceramics were used.

DISCUSSION

The majority of current evidence shows inconsistencies in reporting and is of short-term duration. Robust prospective long-term trials are needed in this area to better support future recommendations.

CONCLUSION

This systematic review is the first to analyse several clinical outcomes using premixed sealers. Included studies differed in terms of clinical protocol and operator expertise, but reported a similar outcome when comparing bioceramic versus standard sealers. Tooth survival, treatment outcome, post-operative pain and periapical extrusion were similar and presented no significant differences between the two sealer types.

REGISTRATION

PROSPERO database (CRD42023449151).

Artificial intelligence for detecting periapical radiolucencies: A systematic review and meta-analysis

OBJECTIVES

Dentists' diagnostic accuracy in detecting periapical radiolucency varies considerably. This systematic review and meta-analysis aimed to investigate the accuracy of artificial intelligence (AI) for detecting periapical radiolucency.

DATA

Studies reporting diagnostic accuracy and utilizing AI for periapical radiolucency detection, published until November 2023, were eligible for inclusion. Meta-analysis was conducted using the online MetaDTA Tool to calculate pooled sensitivity and specificity. Risk of bias was evaluated using QUADAS-2.

SOURCES

A comprehensive search was conducted in PubMed/MEDLINE, ScienceDirect, and Institute of Electrical and Electronics Engineers (IEEE) Xplore databases. Studies reporting diagnostic accuracy and utilizing AI tools for periapical radiolucency detection, published until November 2023, were eligible for inclusion.

STUDY SELECTION

We identified 210 articles, of which 24 met the criteria for inclusion in the review. All but one study used one type of convolutional neural network. The body of evidence comes with an overall unclear to high risk of bias and several applicability concerns. Four of the twenty-four studies were included in a meta-analysis. AI showed a pooled sensitivity and specificity of 0.94 (95 % CI = 0.90-0.96) and 0.96 (95 % CI = 0.91-0.98), respectively.

CONCLUSIONS

AI demonstrated high specificity and sensitivity for detecting periapical radiolucencies. However, the current landscape suggests a need for diverse study designs beyond traditional diagnostic accuracy studies. Prospective real-life randomized controlled trials using heterogeneous data are needed to demonstrate the true value of AI.

CLINICAL SIGNIFICANCE

Artificial intelligence tools seem to have the potential to support detecting periapical radiolucencies on imagery. Notably, nearly all studies did not test fully fledged software systems but measured the mere accuracy of AI models in diagnostic accuracy studies. The true value of currently available AI-based software for lesion detection on both 2D and 3D radiographs remains uncertain.

Guidelines for non-surgical root canal treatment

Guidelines were developed by the Australian Society of Endodontology Inc. with the intent to describe relevant aspects of contemporary evidence-based root canal treatment. The document aims to support clinicians by describing a Standard of Practice in the Australian context. The presented guidelines refer to Competence criteria and Quality standards for the main steps in root canal treatment. While the intent is not to replace individual clinical decision-making, it is envisaged that these periodically reviewable guidelines may help to improve clinical outcomes.

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.

Sodium hypochlorite accident diagnosis and management: Analysis from the literature and the French pharmacovigilance database

PURPOSE

Sodium hypochlorite (NaOCl) is considered as the reference irrigation solution in endodontics. However, NaOCl-related accidents may occur, and non-dentist health professionals might under-recognize this rare adverse effect although it is potentially severe, with possible medical and aesthetic sequelae. We performed a literature review to provide to non-dentist healthcare professionals a large picture of symptoms, management and potential consequences of NaOCl accidents.

METHODS

We queried PubMed and the French Pharmacovigilance database and retrieved 76 cases for analysis (70 from 57 published articles, and six from the database).

RESULTS

The analysis showed that patients were mostly women (79%), aged around of 42 years, undergoing upper jawbone (74%) endodontic procedure. NaOCl concentration ranged from 1% to 10%, with 0.5 to 30 mL injected. Most cases (86%) corresponded to an accidental extrusion beyond the root apex to the periapical tissues, followed by tissular injection by error (8%) and extrusion into the maxillary sinus (3%). Local symptoms always occurred within 24 h, mostly pain (99%), edema (89%) and/or ecchymosis (61%). Complications were mainly neurological (29%), necrotic (22%) and cutaneous (9%). Most of patients (76%) fully recovered after medical management but 18 (24%) required surgical management.

CONCLUSION

Any healthcare professional should be aware of the classical symptomatic triad of NaOCl accident with sudden pain, haemorrhage/ecchymosis and swelling, to start or recommend adequate management. Patients should be reassured, but a close follow-up is necessary to avoid delayed complication.

The impact of bone grafting with/without barrier membrane placement on the outcome of apical surgery: A systematic review and meta-analysis

BACKGROUND

Regenerative techniques are increasingly being advocated in endodontic apical surgery (AS) to enhance the healing of periapical lesions. Various grafting and membrane materials are employed as adjuncts to modern AS.

OBJECTIVES

This systematic review aimed to answer the following PICO question: In patients with apical periodontitis (P) what is the impact of bone grafting with/without barrier membrane materials (I) compared with surgery without grafting materials (C) on the outcome of AS evaluated clinically and radiographically (O).

METHODS

A systematic search was conducted in four databases (Embase, Web of Science, PubMed and Cochrane Central Register of Controlled Trials) until 1 August 2023. Google Scholar was also manually searched. Studies with a prospective randomized design were included. Cochrane risk-of-bias (RoB) tool 2.0 assessed bias. Two independent reviewers performed the study selection, data extraction and appraisal of studies. Meta-analysis was performed using R3.5.1 software.

RESULTS

From the identified 2582 studies, eight randomized clinical trials were included for meta-analysis. Two studies had low RoB, while six had some concerns. Analysis revealed significantly better outcomes when surgery involved bone regeneration techniques than conventional surgery (OR = 2.18, 95% CI: 1.32-4.31, p = .004). Subgroup analyses on individual grafts (OR = 0.22, 95% CI: -0.99 to 1.44, p = .720) (OR = -0.09, 95% CI: -1.42 to 1.23, p = .885) and membranes (OR = -1.09, 95% CI: -2.94 to 0.76, p = .247) and their combinations (OR = 0.03, 95% CI: -1.50 to 1.55, p = .970) did not yield any significant results. The type of membrane used did not significantly impact the outcome (OR = -1.09, 95% CI: -2.94 to 0.76, p = .247) nor did altering the combination of graft/membrane.

DISCUSSION

This systematic review examined the effects of bone grafting with/without membrane placement on the outcome of AS. It highlights the potential advantages of regenerative techniques and the need for further research in this area.

CONCLUSIONS

Based on current evidence, bone grafting with/without barrier membrane placement significantly improves healing after AS. Subgroup analysis of resorbable membranes or grafting did not significantly influence the outcome. The combination of membrane and graft was also not significant. Future well-designed, randomized controlled trials in this area are essential before these materials can be recommended for routine use to enhance healing outcomes in AS.

REGISTRATION

PROSPERO (CRD42021255171).

Effects of apical periodontitis treatment on hyperglycaemia in diabetes: A prospective cohort study

AIM

This prospective cohort study was undertaken to evaluate the success rate of root canal treatment (RCT) in type 2 diabetes mellitus (T2DM) patients with targeted level and unachieved targeted level of glycaemic control as well as the impact of RCT on the glucose blood level in T2DM patients.

METHODOLOGY

Patients needing RCT were divided into three groups: these without T2DM, that is, the control group (CG), those with targeted level of glycated haemoglobin HbA1c < 7% (TL A1c) and the third ones with unachieved targeted level (UTL A1c), that is, with HbA1c ≥ 7%. Before RCT, HbA1c and the periapical index (PAI) score were assessed, as well as 1 year later.

RESULTS

Our results showed less favourable treatment results of RCT such as a reduction of radiographic lesions in T2DM patients, particularly in subjects with UTL A1c. The intergroup analysis of PAI score at the 12-month follow-up revealed a significant difference in TL A1C (p = .022) and CG (p = .001) with respect to UTL A1c. Total number of healed teeth (PAI≤2) at the 12-month after RCT in UTL A1c was significantly lower in comparison to CG (p = .008). Contrariwise, RCT may improve the glycaemic control in diabetic patients with UTL A1c after 12 months of posttreatment. Regression analysis showed that UTL A1c patients were more likely to have AP persistence after endodontic treatment (OR = 4.788; CI: 1.157-19.816; p = .031).

CONCLUSIONS

T2DM retards the AP healing and conversely AP contributes to increasing the inflammatory burden in T2DM. RCT reduces the cumulative inflammatory burden in T2DM and thus may contribute to improvement of glycaemic control particularly in patients with UTL A1c.

Fifteen years of engine-driven nickel-titanium reciprocating instruments, what do we know so far? An umbrella review

Numerous systematic reviews (SRs) have produced conflicting findings on engine-driven nickel-titanium reciprocating instruments (reciprocating instruments) since Yared's seminal study 15 years ago. This umbrella review analysed SRs examining the clinical and laboratory evidence regarding reciprocating instruments for root canal treatment. SRs that evaluated qualitatively and/or quantitatively the outcomes postoperative pain, oral health-related quality of life (OHRQoL), shaping ability, debris extrusion, microbial load, endotoxins reduction, cyclic fatigue, file fracture, dentinal cracks and root canal filling removal were included. The AMSTAR 2 tool was used to evaluate SRs quality, while the ROBIS tool to assess risk of bias (RoB). Forty SRs were included. The SRs revealed predominantly 'high' RoB and 'critically low' quality. Most focused on technical outcomes, exhibiting significant methodological and statistical heterogeneity. Findings suggest comparable efficacy between reciprocating and rotary instruments. However, due to the scarcity of high-quality evidence, future well-designed studies and reviews considering core outcome measures are needed.

Effects of Green Tea Extract Epigallocatechin-3-Gallate on Oral Diseases: A Narrative Review

OBJECTIVES

Oral diseases are among the most prevalent diseases globally. Accumulating new evidence suggests considerable benefits of epigallocatechin-3-gallate (EGCG) for oral health. This review aims to explore the role and application of EGCG in main oral diseases.

METHODS

This narrative review thoroughly examines and summarizes the most recent literature available in scientific databases (PubMed, Web of Science, Scopus, and Google Scholar) reporting advances in the role and application of EGCG within the dental field. The major keywords used included "EGCG", "green tea extract", "oral health", "caries", "pulpitis", "periapical disease", "periodontal disease", "oral mucosa", "salivary gland", and "oral cancer".

CONCLUSIONS

EGCG prevents and manages various oral diseases through its antibacterial, anti-inflammatory, antioxidant, and antitumor properties. Compared to traditional treatments, EGCG generally exhibits lower tissue irritation and positive synergistic effects when combined with other therapies. Novel delivery systems or chemical modifications can significantly enhance EGCG's bioavailability, prolong its action, and reduce toxicity, which are current hotspots in developing new materials.

CLINICAL SIGNIFICANCE

this review provides an exhaustive overview of the biological activities of EGCG to major oral diseases, alongside an exploration of applications and limitations, which serves as a reference for preventing and managing oral ailments.

Coronal and Root Canal Microbiota in Apical Periodontitis with Different PAI

Apical periodontitis is an inflammatory disease triggered by oral pathogens invading necrotic root canals. The aim of this study was to evaluate the coronal and root canal bacterial community profiles in primary endodontic infections with different periapical (PAI) indices in comparison to oral mucosa controls. A total of 31 patients with primary apical periodontitis, 14 with PAI-1 and 17 with PAI-3 were recruited. Microbial specimens from mucosa (control samples) and endodontic necrotic tissues were collected in each patient. Microbiota composition was studied through 16S ribosomal RNA gene amplicon sequencing analysis. Overall, 2953 taxa from 168 different genera of 451 various microbial species were retrieved in the controls and PAI-1 and PAI-3 groups. Firmicutes is the predominant phylum in the oral controls (34.5%) and PAI-1 (44.4%) groups, while Bacteroidetes is predominant in PAI-3 (38.6%). The Proteobacteria (21.5%) and Fusobacteria (12.5%) relative abundance is higher in oral controls while that of Synergistetes is higher in the PAI-1 (3.5%) and PAI-3 (2.5%) groups, being almost absent in controls (less than 0.1%). Most of the increased bacterial species found in the PAI groups were strict anaerobes. A diminished microbial diversity was found in apical periodontitis with higher PAI. These samples were also characterized by an increase in bacteria belonging to phyla and genera with an increased anaerobic character.

An in vitro study on the influence of laser-activated irrigation on infiltration and leakage of a dual curing-resin cement as an endodontic sealer

Objectives

The study aims to investigate the effects of laser-activated irrigation on infiltration and microleakage of a dual-curing resin cement applied as a root canal sealer.

Methods

Thirty-eight extracted upper molars were attributed to four experimental groups. Roots were mechanically enlarged and disinfected (NaOCl). Control samples (n = 11) were irrigated with conventional needles and three different lasers were used to activate the irrigant in the other groups (n = 9): 2.94 µm Er:YAG laser, 9,300 µm CO2 laser and 808 nm diode laser with a modified black coated laser tip. Final irrigation was performed in each group with ethylenediaminetetraacetic acid (EDTA), sodium hypochlorite (NaOCl) and sodium chloride (NaCl) activated with lasers and in the control without activation.Dentin tubules were then labeled with a red fluorophore (Rhodamine B) and the root canals were sealed with a dual-curing resin cement (Paracore). The cement fixed the dye on the sealed and infiltrated dentin parts. To remove the Rhodamine not fixed by the cement, roots were then sectioned horizontally and immersed in hydrogen peroxide (H2O2). The empty dentin tubules spaces were then labeled with a green fluorophore (Fluorescein) allowing the visualization of infiltration and microleakage by confocal microscopy.

Results

Percentages of infiltration were significantly higher in the middle root third of the control and Er:YAG laser-activated samples compared to CO2 or diode laser groups. Microleakage was present in all experimental groups but significantly less after CO2 laser activation.

Conclusion

Laser-activated irrigation impacted resin cement infiltration and microleakage dependent on the applied wavelength. Er:YAG laser activation led to higher values of infiltration and microleakage compared to CO2 and diode lasers.

Elective full pulpotomy in mature permanent teeth diagnosed with symptomatic irreversible pulpitis: a two years retrospective study

AIM

To investigate the outcome of elective full pulpotomy, using calcium silicate-based cements (CSBC), after 2 years, in symptomatic mature permanent teeth with carious lesions, diagnosed as irreversible pulpitis, and analyse the capacity of Wolters et al. (2017) classification to predict the likelihood of treatment failure.

METHODS

The treatment records of 56 patients with symptomatic mature teeth with carious lesions, diagnosed as irreversible pulpitis and treated by elective full pulpotomy, using CSBCs as pulp capping materials, were reviewed. Thirteen teeth were excluded. The remaining 43 teeth were evaluated retrospectively at 24 months. Fisher`s exact test with the Lancaster's mid-P adjustment was used to assess different outcomes amongst the diagnostic categories.

RESULTS

Four of the cases failed before 24 months and required root canal treatment (RCT). Overall success rate at 2 years was 90.7% (39 of 43). An inverse, but non-significant, correlation was observed between the severity of pulpitis according to the Wolters classification and the treatment success rate (p > 0.05). The type of CSBC used was associated to the success rate (OR = 10.5; 95% C.I. = 0.5 - 207.4; p = 0.027), being 82% with Endosequence and 100% with Biodentine. Postoperative pain associated significantly to lower success rate (66.7%) (Odds ratio = 8.0; 95% C.I. = 0.7 - 95.9; p = 0.047).

CONCLUSIONS

Elective full pulpotomy using a CSBC was a successful choice for the treatment of mature permanent teeth with symptoms indicative of irreversible pulpitis. There were no significant differences between the success rate of mild, moderate and severe pulpitis. Postoperative pain could be considered a risk marker for failure of full pulpotomy. The term "irreversible pulpitis" should be re-signified to indicate the need for access to the pulp chamber, rather than an indication for extraction or RCT.

Next-generation antibacterial nanopolymers for treating oral chronic inflammatory diseases of bacterial origin

BACKGROUND

'Periodontitis' refers to periodontal destruction of connective tissue attachment and bone, in response to microorganisms forming subgingival biofilms on the root surface, while 'apical periodontitis' refers to periapical inflammatory processes occurring in response to microorganisms within the root canal system. The treatment of both diseases is based on the elimination of the bacterial challenge, though its predictability depends on the ability of disrupting these biofilms, what may need adjunctive antibacterial strategies, such as the next-generation antibacterial strategies (NGAS). From all the newly developed NGAS, the use of polymeric nanotechnology may pose a potential effective approach. Although some of these strategies have only been tested in vitro and in preclinical in vivo models, their use holds a great potential, and therefore, it is relevant to understand their mechanism of action and evaluate their scientific evidence of efficacy.

OBJECTIVES

To explore NGAS based on polymeric nanotechnology used for the potential treatment of periodontitis and apical periodontitis.

METHOD

A systemic search of scientific publications of adjunctive antimicrobial strategies using nanopolymers to treat periodontal and periapical diseases was conducted using The National Library of Medicine (MEDLINE by PubMed), The Cochrane Oral Health Group Trials Register, EMBASE and Web of Science.

RESULTS

Different polymeric nanoparticles, nanofibres and nanostructured hydrogels combined with antimicrobial substances have been identified in the periodontal literature, being the most commonly used nanopolymers of polycaprolactone, poly(lactic-co-glycolic acid) and chitosan. As antimicrobials, the most frequently used have been antibiotics, though other antimicrobial substances, such as metallic ions, peptides and naturally derived products, have also been added to the nanopolymers.

CONCLUSION

Polymeric nanomaterials containing antimicrobial compounds may be considered as a potential NGAS. Its relative efficacy, however, is not well understood since most of the existing evidence is derived from in vitro or preclinical in vivo studies.

The trend of radiographic healing after root canal treatment in teeth with apical periodontitis based on cone-beam computed tomography: A 4-year longitudinal study

OBJECTIVES

The aim of this study was to observe the radiographic healing of periapical lesions after root canal treatment via volumetric measurements based on cone-beam computed tomography (CBCT) over 4 years.

METHODS

In total, 162 single-root teeth from patients with chronic periapical periodontitis who underwent primary root canal treatment were included in this retrospective study. Follow-up visits were scheduled at 1, 2, and 4 years after treatment. The volume of radiolucency at pretreatment and follow-up were measured, and the radiographic outcomes were classified into 4 categories: absence, reduction, uncertain or enlargement. Reduction or enlargement was considered when the volumetric change in radiolucency was 20 % or more.

RESULTS

During the 4-year follow-up period, 128 teeth were reviewed at least once, including 3 extracted teeth. Of the remaining 125 teeth, the volume of radiolucency was reduced in 116 teeth (90.6 %), uncertain in 5, and enlarged in 4 teeth during 1 to 4 years after treatment. Among the 43 teeth with reduced radiolucency at 1 year after treatment, 42 (97.7 %) had continuing reduced lesions at 4 years. In the 2 teeth with enlarged radiolucency at 1 year, the volume of radiolucency doubled at 4 years. Cox regression analysis revealed that the preoperative radiolucency size was a risk factor for persistent periapical radiolucency.

CONCLUSIONS

The efficacy of root canal treatment for apical periodontitis was predictable. When the radiolucency changed by 20 % or more in volume on CBCT scans at 1 year after treatment, reversal of the radiographic healing tendency was rare.

CLINICAL SIGNIFICANCE

The volumetric changes in radiolucency on CBCT could reflect trends in the healing process and may foster early clinical decision-making.

Factors influencing treatment decisions in permanent mature teeth with irreversible pulpitis: a questionnaire-based study

BACKGROUND

Decision-making in dentistry is a complex process, and this study evaluated factors that influence dentists' approaches in permanent mature teeth with irreversible pulpitis.

METHODS

An online questionnaire was distributed to a group of dental practitioners. The questionnaire surveyed dentists' opinions about the management of vital permanent teeth with irreversible pulpitis including a case scenario.

RESULTS

Data from 262 respondents were analysed. Barriers to perform vital pulp therapy (VPT) included presuming it an inappropriate long-term treatment (29.7%), lack of knowledge, insufficient access to materials, inadequate training and lack of confidence. Patient's preference (79.44%) and tooth restorability (91%) were the most frequently reported factors influencing treatment decisions. Dentists aged 25-35 years and who have 1-5 years of experience ranked extraction as a more successful treatment (P = 0.008; P = 0.003, respectively). Non-Australian graduates ranked pulpotomy to be a more successful procedure (P = 0.007), and public sector/hospital practitioners favoured extraction more than practitioners from other sectors (P = 0.003). Postgraduates/specialists preferred pulpotomy (P = 0.012) more than general dentists. Participants' clinical approaches for the management of symptomatic irreversible pulpitis: root canal treatment (45.0%), indirect pulp capping (22.9%), direct pulp capping (15.8%), pulpotomy (17.1%) and extraction (6.3%).

CONCLUSIONS

Female, more experienced, overseas-educated dentists and endodontists preferred VPT for irreversible pulpitis in permanent mature teeth more than other participants. © 2024 Australian Dental Association.

The management of deep carious lesions and the exposed pulp in fully developed and immature teeth with irreversible pulpitis: a questionnaire-based study among Greek dentists

OBJECTIVES

The study aimed to identify the preferred management techniques used by dentists in Greece for treating deep carious lesions or pulp exposure during the removal of carious tissue in teeth with irreversible pulpitis. Additionally, the study sought to explore how patient-related factors (such as age and symptoms) and operator-related factors (like material choice and the use of antibiotics) influence these management decisions.

MATERIALS AND METHODS

The questionnaire, developed by five investigators, was divided into two parts: the first gathered respondent demographics, and the second presented clinical scenarios of deep carious lesions, requesting treatment strategies, materials used, and antibiotic prescription practices. The scenarios described patients with intense spontaneous pain and very deep carious lesions, differentiated by age and tooth development status.Data collection was via Google Drive, with analysis performed using SPSS 28, Chi-square, and Fisher's exact tests, with significance set at p < 0.05.

RESULTS

The study polled 453 Greek dentists about their treatment choices, for deep carious lesions in mature and immature teeth with irreversible pulpitis The majority favored root canal treatment for mature teeth, however quite a few opted for partial or cervical pulpotomy. MTA emerged as the preferred capping material, emphasizing its biocompatibility. Hemostasis management varied, with saline and sodium hypochlorite as popular choices. In cases of immature teeth, a shift towards vital pulp therapy was evident, reflecting a preference for preserving healthy pulp to avoid complex procedures.

CONCLUSIONS

Challenges identified include varying treatment preferences, the significance of bleeding control in vital pulp therapy, and the limited use of antibiotics for irreversible pulpitis. While the study has limitations, including sample size and potential biases, its findings offer valuable insights into the decision-making processes of Greek dentists.

CLINICAL RELEVANCE

Future research and ongoing education within the dental community could contribute to standardizing treatment approaches and optimizing outcomes for patients with deep carious lesions and irreversible pulpitis.