A new classification of endodontic-periodontal lesions

Knowledge, attitudes, and practices toward the treatment of endodontic-periodontal lesions among oral health care providers: a multi-center cross-sectional study

BACKGROUND

This study aimed to evaluate the knowledge, attitudes, and practices (KAP) of oral healthcare providers concerning the treatment of endodontic-periodontal lesions (EPLs) and investigate the relationships among the KAP dimensions using correlation analysis and structural equation modeling (SEM).

METHODS

This cross-sectional study enrolled dental healthcare professionals between February 2024 and June 2024, with questionnaire data collected in Hangzhou and Shaoxing, China. Data were collected using a self-administered questionnaire that gathered demographic information and KAP scores.

RESULTS

A total of 281 valid questionnaires were analyzed. Among the participants, 185 (70.08%) were doctors, and 58 (59.85%) had attended relevant academic conferences or training sessions. The mean scores for knowledge, attitude, and practice were 10.06 ± 3.31 (possible range: 0-18), 25.58 ± 2.29 (possible range: 7-35), and 15.70 ± 3.23 (possible range: 5-25), respectively. The SEM revealed that education (β = 0.013, P = 0.013), professional title (β = 0.64, P < 0.001), participation in related research projects (β = -1.84, P < 0.001), and number of patients treated (β = 1.41, P < 0.001) directly influenced knowledge. Knowledge (β = 0.24, P < 0.001) and research participation (β = -0.79, P = 0.026) directly affected attitude. Both knowledge (β = 0.26, P < 0.001) and attitude (β = 0.19, P = 0.023) directly impacted practice. Additionally, education (β = 0.23, P = 0.021), professional title (β = 0.15, P = 0.001), research participation (β = -0.44, P = 0.001), and number of patients treated (β = 0.34, P < 0.001) indirectly influenced attitude, while indirect effects on practice were noted for knowledge (β = 0.04, P = 0.034), education (β = 0.30, P = 0.023), professional title (β = 0.20, P = 0.001), research participation (β = -0.73, P < 0.001), and number of patients treated (β = 0.44, P < 0.001).

CONCLUSIONS

Oral healthcare providers demonstrated limited knowledge, generally positive attitudes, and relatively inactive practices in the treatment of EPLs. To enhance clinical outcomes, targeted educational initiatives and hands-on training should be prioritized to address knowledge gaps and facilitate the translation of positive attitudes into more active and effective clinical practices.

Impact of type 2 diabetes mellitus on the prevalence of apical periodontitis in endodontically treated and untreated teeth

Apical periodontitis (AP) is a common dental condition that can be influenced by diabetes mellitus. This study aimed to investigate the impact of type 2 diabetes mellitus (T2DM) on the prevalence and severity of AP, considering the adequacy of endodontic treatments. A total of 180 patients selected based on specific dental criteria from a private clinic in Oradea, Romania, were included in this study. Clinical data were collected through medical records and panoramic radiographs. Statistical analyses were conducted using SPSS software, employing the Fisher test, Mann-Whitney test, and binary logistic regression to determine correlations between T2DM and AP in both endodontically treated and non-treated teeth. Additionally, we examined the relationship between diabetes and AP in teeth that received adequate root canal treatment (RCT), as well as the correlation of AP with the adequacy of endodontic treatment. Non-treated teeth were significantly more likely to have AP in patients with T2DM than in non-diabetic patients (OR = 5.3, P < 0.001). No significant difference in AP prevalence was observed between treated teeth in diabetic and non-diabetic patients. Inadequate RCT was associated with a higher incidence of AP, regardless of diabetes status (OR = 26.9, P < 0.001). The study concludes that DM significantly increases the risk of AP in untreated teeth, with diabetic patients showing a higher prevalence of AP than non-diabetic patients. However, this increased risk is not observed in adequately treated teeth. The quality of RCT is critical, as inadequate RCT is linked to a higher incidence of AP, regardless of diabetes status.

Assessment of Practitioners' Knowledge of the Diagnostic and Therapeutic Approach to Endo-Periodontal Lesions in Saudi Arabia

INTRODUCTION

Endodontic-periodontal diseases frequently pose significant challenges for clinicians in terms of diagnosis, management, and prognosis. Practitioners' knowledge of endo-periodontal lesion (EPL) diagnosis is essential for formulating appropriate treatment plans. This study aimed to evaluate the knowledge of diagnostic and therapeutic approaches to EPLs among dental practitioners in Saudi Arabia.

METHODS

The study used a cross-sectional survey among Saudi Arabian dental practitioners using a self-administered questionnaire. The statistical methods used included descriptive analysis, Pearson's chi-square test, Fisher's exact test, and binary logistic regression.  Results: The study included 312 respondents, with 95 (30.4%) females and 217 (69.6%) males. The majority were aged 25 to 30 (n = 155, 49.7%). Significant associations were found between participant knowledge and the following variables: age (P < 0.001), organization (P = 0.005), employment (P = 0.001), professional experience (P < 0.001), postgraduate degree (P = 0.002), specialty (P < 0.001), Saudi Commission for Health Specialities (SCHS) rank (P = 0.004), and continuing training (P = 0.043). Additionally, individuals aged 36-40 were 4.3 times more likely to have good knowledge compared to those aged 25-30 (adjusted odds ratio [AOR] = 4.27, P = 0.020), and lecturers were 4.4 times more likely to have good knowledge compared to interns (AOR = 4.40, P = 0.054).

CONCLUSION

This indicates that the practitioners' overall knowledge was above average and that they possess a fundamental understanding of EPLs. These findings have valuable effects on clinical practice, suggesting that evidence-based guidelines and targeted educational programs can enhance the practitioners' diagnostic accuracy and treatment strategies for EPLs, ultimately improving patient outcomes and clinical efficacy.

Expert consensus on the diagnosis and therapy of endo-periodontal lesions

Endo-periodontal lesions (EPLs) involve both the periodontium and pulp tissue and have complicated etiologies and pathogenic mechanisms, including unique anatomical and microbiological characteristics and multiple contributing factors. This etiological complexity leads to difficulties in determining patient prognosis, posing great challenges in clinical practice. Furthermore, EPL-affected teeth require multidisciplinary therapy, including periodontal therapy, endodontic therapy and others, but there is still much debate about the appropriate timing of periodontal therapy and root canal therapy. By compiling the most recent findings on the etiology, pathogenesis, clinical characteristics, diagnosis, therapy, and prognosis of EPL-affected teeth, this consensus sought to support clinicians in making the best possible treatment decisions based on both biological and clinical evidence.

Assessment of Risk Factors and Prognostic Predictors for Endo-Perio Lesions in Indian Cohorts: An Observational Study

INTRODUCTION

Endodontic and periodontal tissues exhibit a significant interrelationship, whereby pathologies affecting one tissue can precipitate the involvement of the other. The primary objective of this study was to assess the risk factors associated with endo-perio lesions (EPLs). The secondary objective was to assess the prognostic predictors for such lesions and the prevalence rate of EPLs involving both pulpal and periodontal tissues in Indian cohorts.

MATERIALS AND METHODS

A prospective observational study was conducted on 2170 teeth with EPLs in Indian adults aged > 18 years. A detailed history of smoking, tobacco chewing, and the development of EPLs was obtained from all patients. Detailed periodontal and endodontic examinations were conducted by two calibrated examiners. Intraoral periapical radiographs (IOPAs) were obtained to diagnose EPLs. The chi-square test of association was used to analyze the association between independent and dependent variables, and the strength of association was presented by Pearson contingency coefficient (r). Logistic regression analysis was performed to identify reliable factors for diagnosing EPLs. A statistical significance threshold of 0.05 was established.

RESULTS

The prevalence of EPLs involving pulpal and periodontal tissues was 29.49%. Type 1 lesions (EPLs involving only pulpal tissue) were most commonly seen at 41-45 years of age, type 2 lesions (EPLs involving primary pulpal and secondary periodontal tissue), and type 3 lesions (EPLs involving only periodontal tissue) at 26-30 years of age, and type 4 lesions (EPLs involving primary periodontal and secondary pulpal tissue) at 31-35 years of age. The pulp was found to be non-vital in all cases of type 3 lesions, and faulty restoration or improper root canal treatment (RCT) was the main risk factor for such lesions. Occupational trauma was found to be the most common risk factor for type 3 and type 4 lesions.

CONCLUSION

Smoking, age, tooth type, occlusal trauma, faulty restorations and RCT, presence of caries, periapical pathology, periodontitis, bone loss, and pulp vitality were significantly associated with EPLs. Pulp vitality and bone loss were two prognostic predictors of EPLs.

Endo-Perio Lesions and Dentists' Treatment Approach: A Survey

BACKGROUND Endo-perio lesions are a great challenge for dentists. The aim of this study was to evaluate the treatment approach of dental practitioners to endo-perio lesions by considering the current endo-perio classification. MATERIAL AND METHODS An online survey was prepared, consisting of questions about the treatment approach to 3 simulated cases with endo-perio lesions, shown on periapical radiography. Details of the patient's age, presence of systemic disease, smoking, and how the single- or multi-rooted tooth would affect the treatment plan were also included in the simulated cases presented in the survey. The survey was sent to 1500 dentists via e-mail, WhatsApp, and social media platforms. The chi-square test was used for comparison of data. Significance was evaluated at P<0.05. RESULTS In total, 338 dentists participated in the survey, including general dentists, endodontists, and periodontists. Fifty-three percent of participants stated that they would perform root canal treatment and initial periodontal treatment simultaneously, when both treatments were required. In cases classified as grade 3, most general dentists, endodontists, and periodontists answered that they would prescribe systemic antibiotics if there was diffuse extra-oral swelling (P<0.05). Moreover, in grade 3 cases, more general dentists chose the option "extraction" as the best choice, compared with endodontists and periodontists, who did not choose extraction as often (P<0.05). CONCLUSIONS According to the results of this study, general dentists, endodontists, and periodontists generally follow different approaches to endo-perio lesions. A consensus is needed on this issue to develop a successful multidisciplinary approach to endo-perio lesions.

Successful Management of a Tooth With an Endodontic-Periodontal Lesion Using a Bone Graft

As periodontal and endodontic tissues have a close association, they come into close touch and have a lot of possible places for communication. In a clinical setting, this correlation promotes infection spread and results in the typical endo-perio lesion appearance. Because the two tissues are in close touch with one another, managing such lesions can be difficult. The success of treatment depends on a thorough examination and careful planning, with the sole focus on repair and regeneration. In these situations, bone graft materials with such characteristics have demonstrated encouraging outcomes. The treatment outcome along with a follow-up for a case of an endo-perio lesion with furcation involvement is shown in the accompanying case report. In treating such instances, a multidisciplinary approach is necessary, emphasizing regeneration.

A retrospective study on the prognostic factors and success, survival, and failure outcomes of treated endodontic-periodontal lesions

OBJECTIVES

The objective of this retrospective study was to determine possible prognostic factors of endodontic-periodontal lesions and to compare success, survival, and failure outcomes of treated endodontic-periodontal lesions across different treatment modalities, demographic variables, and anatomical tooth variations.

MATERIALS AND METHODS

Data was collected from patient records in the patient management system (Salud, Titanium Solutions) from the Griffith University Dental Clinic between January 2008 and December 2021. The search strategy used the terms "endodontic periodontal lesion," "periodontal endodontic lesion," "endo perio lesion," "perio endo lesion," and "EPL." The 88 cases which met inclusion and exclusion criteria were analyzed.

RESULTS

The overall success rate was 46.6%, with 21.6% of teeth surviving and 31.8% of teeth failing. Bone loss extending to the apical third (OR = 0.3, 95% CI [0.104, 0.866]), and probing depths of 5-7 mm (OR = 0.147, 95% CI [0.034, 0.633]) and 8-10 mm (OR = 0.126, 95% CI [0.029, 0.542]) were associated with a statistically significant lower odds of success (p < .05). A history of no periodontal disease (OR = 7.705, 95% CI [1.603, 37.037]) was associated with a statistically significant higher odds of success (p < .05).

CONCLUSION

Practitioners should be aware of bone loss to the apical third, deep probing depths, and a history of periodontal disease as possible prognostic factors that can affect the success rate when treating endodontic-periodontal lesions. Further research with more stringent control over operator factors should be done to investigate these variables.

Periodontitis Continuum: Antecedents, Triggers, Mediators, and Treatment Strategies

Periodontitis (PD) is a chronic inflammatory disease of the periodontium characterized by the formation of gingival pockets and gingival recession. The local inflammatory environment can lead to the destruction of the extracellular matrix and subsequent bone loss. The pathophysiology of PD involves interactions between genetic predisposition, lifestyle, environmental factors, the oral microbiota condition, systemic health disorders, innate and adaptive immune responses, and various host defenses. The review highlighted the importance of the oral cavity condition in systemic health. Thus, a correlation between harmful oral microbiota and cardiovascular disease (CVD)/diabetes/ arthritis, etc, progressions through inflammation and bacterial translocation was highlighted. Antecedents increase an individual's risk of developing PD, trigger initiate microbe-host immunologic responses, and mediators sustain inflammatory interactions. Generally, this review explores the antecedents, triggers, and mediators along the pathophysiological continuum of PD. An analysis of modern approaches to treating periodontitis, including antibiotics for systemic and local use, was carried out. The potential role of natural ingredients such as herbal extracts, phytoconstituents, propolis, and probiotics in preventing and treating PD was highlighted.

Influence of intracanal medicaments on the periodontal and periapical healing in concurrent endodontic-periodontal lesions with/without communication: a systematic review and meta-analysis

OBJECTIVES

The purpose of this review is to determine the effectiveness of intracanal medicament (ICM) on periodontal and periapical healing (PH) of concurrent endodontic-periodontal lesions with/without communication in permanent teeth.

MATERIALS AND METHODS

The pre-defined protocol was registered in PROSPERO, and a literature search using keywords was conducted on PubMed, Scopus, Cochrane, Embase electronic databases, and Gray literature and was hand-searched until August 2023. Two reviewers independently screened the title and abstracts using the inclusion criteria. Randomized or non-randomized clinical trials, cohort studies, and case-control studies were included in the review. The same reviewers extracted the study-level data and assessed the risk of bias using the Cochrane Risk of Bias 2.0 and the Newcastle-Ottawa Scale (NOS) independently. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence. Random effects meta-analysis was performed on eligible studies using Revman software.

RESULTS

A total of 598 records were identified from the database search; seven studies met the inclusion criteria and were included in the review. Four randomized clinical trials, two prospective cohorts, and one retrospective case-control study with 362 patients were included. Calcium hydroxide (CH) was the most commonly used ICM, followed by using chlorhexidine gel in four studies. Periodontal therapy was performed as initial scaling and root planning (SRP) in all studies, along with open flap debridement (OFD) in three randomized clinical trials. The time lapse between two treatment protocols was variable (ranging from 1 week to 3 months). All studies exhibited a decrease in probing depth (PD) and an increase in clinical attachment level (CAL) after the treatment. Meta-analysis showed insignificant differences between different ICM materials, and the certainty of evidence was low.

CONCLUSION

In patients with/without concurrent endodontic-periodontal lesions, intracanal medication improved clinical periodontal parameters following endodontic therapy. In terms of influence on periapical healing, the results were inconclusive.

CLINICAL RELEVANCE

Two-visit RCT may be considered since it allows for the placement of an ICM in endodontic-periodontal lesions with/without communication. Sufficient time should be allowed after endodontic therapy for any potential periodontal regeneration to occur.

Endo-Perio Relationship Knowledge, Understanding, and Confidence Among Dentists

PURPOSE

Proper knowledge and confidence regarding Endo-Perio relationship plays an important role in correct clinical decisions and management of these conditions. The aim of this study is to assess dentists' knowledge and understanding, in addition, their confidence regarding Endo-Perio relationship, consequently, to investigate the prevalence of misconceptions.

METHODS

This cross-sectional study, conducted from December 2021 to March 2022, utilized voluntary anonymous questionnaire, distributed among general dentists, graduates of King Abdulaziz University, Faculty of Dentistry, Jeddah, Saudi Arabia, year of 2021 (n = 151). The questionnaire had two parts, demographic and 13 closed ended scientific questions to assess knowledge and understanding with 4 points Likert scale after each question to assess confidence and misconceptions. Descriptive statistics and Chi-square test at a statistical significance of P-value <0.05 were conducted to analyze the data using SPSS.

RESULTS

Total of 98 participants completed the questionnaire setting a response rate of (64.9%). Only (21.4%) had sufficient overall knowledge and understanding regarding Endo-Perio relationship with no significant association found between knowledge and gender (p = 0.8). A little more than one-third of our participants (37.83%) were overly confident; false confident, thus, had misconceptions.

CONCLUSION

Our study revealed that the majority of our participants had deficient knowledge regarding Endo-Perio relationship. Thus, to compensate for this reported deficiency, changing teaching strategies and implementing continuing education courses are suggested. More studies assessing the interaction between knowledge and confidence in different dental topics are needed.

Time-lapse between periodontal regeneration surgery and root canal therapy in sever combined periodontal-endodontic lesions

Objective

The purpose of this study was to evaluate the time-lapse of periodontal regeneration surgery of combined periodontal-endodontic lesions (PEL) after root canal therapy (RCT) to guide the clinical treatment.

Methods

26 patients (28 teeth) with severe combined PEL were equally divided into 4 groups (n = 7); the control group included patients who underwent periodontal regeneration surgery with no prior RCT and the remaining three experimental groups including patients who received periodontal regeneration surgery post-RCT either immediately or after 3 and 6 months. The probing depth, clinical attachment loss, and periodontal bone density were measured before or after 3, 6, and 12 months post-RCT, respectively.

Results

Periodontal regeneration surgery could improve the PD (Probing Depth), CAL (Clinical Attachment Loss), BD (Bone Mineral Density) values irrespective of whether the RCT was performed within 12 months or not. However, obviously improved PD, CAL and BD were observed when surgery was performed post-RCT. The time lapse between RCT and periodontal regeneration surgery had no obvious effects on the periodontal index in 3 months after the surgery. Moreover, these periodontal indexes tend to stabilize in 3 to 6 months after the surgery with no significant differences.

Conclusion

Although there were no obvious impacts of time lapse between RCT and periodontal regeneration surgery on the severe PEL, an earlier periodontal surgery might contribute to the healing of periodontal lesions.

Bioceramic Cements: Supporting in Remineralization of Osteolytic Lesions in Endodontic-periodontal Diseases: A Report of Two Cases

Bioceramic cements used for filling root canals in cases of endo-perio lesion of endodontic origin seem to be promising due to having the potential of promoting faster and more predictable healing of the periapical lesion as they stimulate osteogenesis. An effective treatment plan depends on the precise diagnosis of endo-perio lesions. The origin of an infection, being exclusive to the root canal, from the periodontium, or both, is extremely important for devising the treatment plan. In both cases, no clinical evidence of periodontal disease (bleeding, calculus, etc.) was found; however, primary endodontic lesions with the possibility of drainage through the gingival crevice were present. In addition to the disinfection strategies used during the root canal treatments, the bioceramics Bio C Sealer, Bio C Repair and Bio Root RCS were used to fill in the root canals. Both cases presented an impressive bone gain within 8 months for case 1 and 5 months for case 2. Regarding case 1, in the palatal root canal an apical plug with a bioceramic repair cement was used. Based on the literature studied, it can be concluded that after adequate disinfection of the root canals, using bioceramic cements in filling the root canals shows the potential of supporting capabilities in remineralization of osteolytic lesions in endo-perio diseases.

Histological characteristics of dental pulp in teeth with periodontal problems and healthy teeth

Background

Chronic periodontitis is the most common type of periodontitis, which is associated with calculus and plaque accumulation. Several studies have indicated that uncured periodontitis can affect the dental pulp. However, this relationship is controversial. This study aimed to compare histopathological results obtained from the dental pulp in teeth with periodontal problems and healthy teeth.

Methods

In this study, 23 teeth with periodontal problems and 23 healthy teeth were extracted. After cutting off 2 mm from the root apex, the teeth were sectioned into apical, middle, and coronal thirds. Then, the specimens were evaluated in both groups based on histopathological features.

Results

According to the evaluations, in the middle third, the amount of inflammation was only statistically significant in the group that consisted of teeth with periodontal problems (P=0.014). There was no significant difference in fibrosis and blood vessel diameter between the two groups. Necrosis in the middle (P=0.002) and coronal thirds (P=0.004) of teeth with periodontal problems was more than the healthy teeth. The lack of odontoblastic integrity in all the sections of teeth with periodontal problems was more than that in healthy teeth (P=0.0001).

Conclusion

Inflammation of the periodontium in chronic periodontitis can lead to histological changes in the pulp, including an increase in inflammation, necrosis, and loss of odontoblastic integrity.

Personalized Medicine Based on the Pathogenesis and Risk Assessment of Endodontic-Periodontal Lesions

Endodontic-periodontal lesions (EPLs) are chronic inflammatory lesions in the mouth caused by multiple factors. Both periapical and marginal periodontitis are characterized by infection and inflammation around the affected teeth, suggesting that the theory of complex systems might describe the progression of EPL. The diagnosis and treatment of EPLs are complicated by variations of this condition and difficulties distinguishing EPLs from other diseases. Technological advances in diagnostic and treatment methods, including cone beam computed tomography, microscopy, mineral trioxide aggregates, and periodontal regenerative treatment, have improved outcomes, even in untreatable teeth. However, treating EPLs with iatrogenic problems and/or severe periodontitis remains challenging. Assessing the risk of each EPL based on the possible pathogenesis of each EPL is essential for determining individualized treatment and optimizing personalized medicine for individual patients.

The Microbiota Profile Analysis of Combined Periodontal-Endodontic Lesions Using 16S rRNA Next-Generation Sequencing

OBJECTIVE

The primary aim of this investigation was to analyze the microbiome in patients with combined periodontal-endodontic lesions.

METHOD

Patients with loose and/or painful teeth referred for treatment from March 2020 to December 2020 in the First People's Hospital of Jinzhong were recruited. Samples were collected from teeth diagnosed as chronic periodontics (PE), ulcerative pulpitis (PU), and retrograde pulpitis (RE). Genomic DNA was extracted. The quantitative polymerase chain reaction, targeting the 16S ribosomal RNA (rRNA), was adopted for the quantification of bacteria. Then, the V3-V4 hypervariable regions of the 16S rRNA gene were amplified and subjected to next-generation sequencing. The statistical analysis was performed by R software (V3.5.1).

RESULTS

A total of 57 qualified samples were collected from 48 patients and analyzed (7 PE, 21 PU, and 19 RE). By linear discriminant analysis effect size, Kingella and Barnesiella were significantly increased in the periodontal pocket of retrograde pulpitis (RE-PE), compared with PE. The relative abundance of Clostridiales Incertae Sedis XI, Fusobacteriaceae, Fusobacterium, Parvimonas, Micrococcaceae, and Rothia was significantly increased in the pulp of retrograde pulpitis (RE-PU) than PU and RE-PE. Prevotella, Leptotrichia, Porphyromonas, Streptococcus, and Fusobacterium are consistently at a high abundance, across PU, RE-PE, and RE-PU.

CONCLUSION

The current study highlighted the evidence that a specific microbial community is associated with the occurrence of retrograde pulpitis. The microenvironment of the root canal and pulp chamber will select microbiota. This study offered insights into the pathogenesis of retrograde pulpitis.

Next-Generation Sequencing Analysis of Root Canal Microbiota Associated with a Severe Endodontic-Periodontal Lesion

A patient with an unusual endo-periodontal lesion, without coronal decay or damage, likely caused by a deep periodontal lesion with subsequent endodontic bacterial migration, required medical care. Next-generation sequencing (NGS) was used to assess the endodontic microbiota in vestibular and palatal canals after tooth extraction, evidencing a predominant population (Fusobacterium nucleatum) in one endodontic canal, and a mixed bacterial population with six major populations almost equally distributed in the other endodontic canal (F. nucleatum, Porphyromonas gingivalis, P. endodontis, Parvimonas, Peptostreptococcus stomatis, Prevotella multiformis). These data could suggest different, separated ecologic niches in the same endodontic system, with potentially different pathogenicity levels, clinical manifestations and prognoses for every single canal of the same tooth.

Putative periodontal pathogens in persisting periodontal pockets of endodontic origin

Background:

The microbial profile of endodontically treated teeth, presenting with a persisting deep periodontal pocket, secondary to a primary endodontic lesion, draining through the gingival crevice, has received very less attention. This observational study was done to evaluate if these sites with persisting pockets of endodontic origin persist because they have acquired bacteria which are considered as putative periodontal pathogens.

Materials and Methods:

Subgingival plaque samples were collected from fifty patients diagnosed with a primary endodontic and a secondary periodontal lesion that persisted even after completion of the root canal treatment. Clinical parameters such as probing pocket depth, clinical attachment level, plaque index, furcation, and tooth mobility were recorded. Real-time polymerase chain reaction was used to determine the possible association between six bacteria, which are frequently associated with periodontal and endodontic lesions.

Results:

The mean cycle threshold value for Treponema denticola (Td) was found to be 33.74, and for Enterococcus faecalis (Ef), it was 34.39. With regard to clinical attachment loss, Td (P < 0.04) and Parvimonas micra (P < 0.05) had a significant correlation.

Conclusion:

Ef (92%) and Td (86%) were found to be most prevalent. Porphyromonas gingivalis and Tannerella forsythia were in minimal to nonexistent levels.

Role of adjunctive therapy with subantimicrobial doses of doxycycline in glycemic control (HbA1c) in patients with diabetes and endo-periodontal lesions to prevent sinus complications

The present study aimed to analyze local and regional changes in regards to odontogenic sinusitis in subjects with endo-periodontal lesions and diabetes mellitus and to investigate the effect on the level of glycemic control (glycated hemoglobin) that could be generated by adjunctive therapy with subantimicrobial doses of doxycycline. This study was performed on 51 subjects with diabetes who were divided into two therapeutic groups: 31 patients with diabetes (the study group) who underwent conventional endo-periodontal therapy and subantimicrobial doses of doxycycline and 20 patients with diabetes who followed only conventional endo-periodontal therapy (the control group). Patients underwent endodontic and periodontal clinical examination, with retro-dental-alveolar radiographs and CBCT examinations. For each patient, glycated hemoglobin A1c (HbA1c) was determined. This evaluation was performed at the beginning of the study, as well as 3, 6 and 12 months after baseline. A significant percentage of patients, both in the study group and in the control group, showed radiological signs of odontogenic sinusitis, totaling 29 patients (56.86%). Periodontal parameters revealed lower levels in patients who underwent the regimen which consisted of subantimicrobial doses of doxycycline; these results were maintained over the study period. Moreover, we demonstrated significantly reduced glycated hemoglobin levels throughout the study (12 months) in the doxycycline-treated group. This fact has far-reaching effects in the sphere of loco-regional complications as well, and the risk of odontogenic sinusitis can be significantly reduced.

Focal Infection and Periodontitis: A Narrative Report and New Possible Approaches

The "focal infection theory" is a historical concept based on the assumption that some infections may cause chronic and acute diseases in different districts of the body. Its great popularity spanned from 1930 to 1950 when, with the aim to remove all the foci of infection, drastic surgical interventions were performed. Periodontitis, a common oral pathology mainly of bacterial origin, is the most evident example of this phenomenon today: in fact, bacteria are able to migrate, develop and cause health problems such as cardiovascular and respiratory diseases, diabetes, and osteoporosis. The aim of this narrative report is to verify the hypothesis of the association between oral infections and systemic diseases by different ways of approach and, at the same time, to propose new kinds of treatment today made possible by technological progress. The analysis of the literature demonstrated a strong relationship between these conditions, which might be explained on the basis of the recent studies on microbiota movement inside the body. Prevention of the oral infections, as well as of the possible systemic implications, may be successfully performed with the help of new technologies, such as probiotics and laser.

Treatment of an Endo-Perio Lesion with Ozone Gas in a Patient with Aggressive Periodontitis: A Clinical Case Report and Literature Review

The pulp and periodontium have obvious relationships that have been described in many studies. Pulp infections may affect periodontal tissues and vice versa. Teeth with endo-perio lesions have a worse prognosis than isolated endodontic or periodontal lesions. Elimination of endodontic and periodontal infections is essential for successful treatment, so co-operation between endodontists and periodontists is necessary. In this clinical case, a 44-year-old male presented with primary periodontal disease with secondary endodontic involvement in his lower right canine because of aggressive periodontitis. There was 10 mm of clinical attachment loss and 8 mm periodontal pocket mesial from the tooth and bone radiolucency periapical and lateral from the root. Periodontal therapy was followed by endodontic treatment. Periodontal therapy included root scaling and planing, treatment of the periodontal pocket with ozone gas, systemic antibiotics, oral hygiene instructions, and chlorhexidine rinsing. Endodontic therapy included root canal instrumentation with rotary endodontic files, irrigation, root canal treatment with ozone gas, and obturation with lateral compaction. Radiographs at a 6-month follow-up appointment showed complete healing of the periapical lesion and alveolar bone lateral to the root. Using an interdisciplinary approach to treat endo-perio lesions provides favorable clinical outcomes. Ozone therapy is beneficial for the successful treatment of endo-perio lesions with narrow periodontal pockets in patients with aggressive periodontitis and poor prognosis.

Successful Management of Teeth with Different Types of Endodontic-Periodontal Lesions

Endodontic-periodontal diseases often present great challenges to the clinician in their diagnosis, management, and prognosis. Understanding the disease process through cause-and-effect relationships between the pulp and supporting periodontal tissues with the aid of rational classifications leads to successful treatment outcomes. In this report, we present several treatment modalities in patients with different endodontic-periodontal lesions. A modification to the new endodontic-periodontic classification, Al-Fouzan's classification, was also added. The first case was classified as retrograde periodontal disease (i.e., primary endodontic lesion with drainage through the periodontal ligament). The second case was diagnosed as an iatrogenic periodontal lesion caused by root perforation. The third case was diagnosed as an iatrogenic periodontal lesion caused by tooth trauma due to orthodontic treatment. The first two cases were managed with a nonsurgical approach, whereas the third case was managed with nonsurgical and surgical approaches. All patients showed complete healing of soft and hard tissue lesions. A thorough understanding of the disease history and the patient's signs and symptoms, complete examination with full investigation, and the use of a systematic step-by-step approach in the management of such challenging endodontic-periodontal lesions with regular recall visits were very useful and successful.

Endo-Perio Lesion and Uncontrolled Diabetes

This work is to discuss the management of an endo-perio lesion, which represents a challenge to clinicians when it comes to diagnosis and prognosis of the involved teeth and especially with an altered general condition. A 50-year-old female patient with uncontrolled diabetes type 2 is suffering from a purulent discharge coming from the upper right canine. Endodontic and periodontal treatments were realized with 36 months radiological and clinical follow-up with the collaboration of her internist doctor.

[Time lapse between endodontic and periodontal treatments of combined periodontal-endodontic lesion: a systematic review]

OBJECTIVE

This study aims to evaluate the time lapse between the endodontic and periodontal treatments of the combined periodontal-endodontic lesion to guide the clinical treatment.

METHODS

A systemic literature search was performed in articles published from 1980 to March 2017 using the electronic databases, including PubMed, EMbase, Cochrane, Web of Science, CNKI, CBM, and Wanfang Databases.

RESULTS

After screening, two randomized controlled trials, two prospective case series studies, and eight case reports were ultimately included. All clinical studies and case reports were treated with root canal therapy and periodontal nonsurgical or periodontal surgical treatment, with root canal therapy as the initial treatment step. Changes in the periodontal probing depth and attachment loss were reported in all clinical studies and case reports.

CONCLUSIONS

An observational period between the endodontic and periodontal nonsurgical treatments may not be required. However, given that the quality of several included studies was limited, and the number of randomized controlled trials was small, a large number of randomized controlled trials are needed to verify this result.

Sustained antimicrobial activity and reduced toxicity of oxidative biocides through biodegradable microparticles

The spread of antibiotic-resistant pathogens requires new treatments. Small molecule precursor compounds that produce oxidative biocides with well-established antimicrobial properties could provide a range of new therapeutic products to combat resistant infections. The aim of this study was to investigate a novel biomaterials-based approach for the manufacture, targeted delivery and controlled release of a peroxygen donor (sodium percarbonate) combined with an acetyl donor (tetraacetylethylenediamine) to deliver local antimicrobial activity via a dynamic equilibrium mixture of hydrogen peroxide and peracetic acid. Entrapment of the pre-cursor compounds into hierarchically structured degradable microparticles was achieved using an innovative dry manufacturing process involving thermally induced phase separation (TIPS) that circumvented compound decomposition associated with conventional microparticle manufacture. The microparticles provided controlled release of hydrogen peroxide and peracetic acid that led to rapid and sustained killing of multiple drug-resistant organisms (methicillin-resistant Staphylococcus aureus and carbapenem-resistant Escherichia coli) without associated cytotoxicity in vitro nor intracutaneous reactivity in vivo. The results from this study demonstrate for the first time that microparticles loaded with acetyl and peroxygen donors retain their antimicrobial activity whilst eliciting no host toxicity. In doing so, it overcomes the detrimental effects that have prevented oxidative biocides from being used as alternatives to conventional antibiotics.

STATEMENT OF SIGNIFICANCE

The manuscript explores a novel approach to utilize the antimicrobial activity of oxidative species for sustained killing of multiple drug-resistant organisms without causing collateral tissue damage. The results demonstrate, for the first time, the ability to load pre-cursor compounds into porous polymeric structures that results in their release and conversion into oxidative species in a controlled manner. Until now, the use of oxidative species has not been considered as a candidate therapeutic replacement for conventional antibiotics due to difficulties associated with handling during manufacture and controlling sustained release without causing undesirable tissue damage. The ultimate impact of the research could be the creation of new materials-based anti-infective chemotherapeutic agents that have minimal potential for giving rise to antimicrobial resistance.

Surgical Anatomy and Microvascular Surgical Technique Relevant to Experimental Renal Transplant in Rat Employing Aortic and Inferior Venacaval Conduits

OBJECTIVES

Rat models of renal transplant are used to investigate immunologic processes and responses to therapeutic agents before their translation into routine clinical practice. In this study, we have described details of rat surgical anatomy and our experiences with the microvascular surgical technique relevant to renal transplant by employing donor inferior vena cava and aortic conduits.

MATERIALS AND METHODS

For this study, 175 rats (151 Lewis and 24 Fisher) were used to establish the Fisher-Lewis rat model of chronic allograft injury at our institution. Anatomic and technical details were recorded during the period of training and establishment of the model.

RESULTS

A final group of 12 transplanted rats were studied for an average duration of 51 weeks for the Lewis-to-Lewis isografts (5 rats) and 42 weeks for the Fisher-to-Lewis allografts (7 rats). Functional measurements and histology confirmed the diagnosis of chronic allograft injury.

CONCLUSIONS

Mastering the anatomic details and microvascular surgical techniques can lead to the successful establishment of an experimental renal transplant model.

Multidisciplinary management of concomitant pulpal and periodontal lesion: A case report

In this case report, the management of a concomitant endodontic-periodontal lesion case is described. A 31-year-old patient presented with symptomatic apical periodontitis of tooth #36 due to failed endodontic treatment and a generalized aggressive periodontitis. Following full-mouth scaling and root-planing, a root-canal retreatment (tooth #36) was initiated. While the distal and mesio-buccal canals were successfully treated, a transportation perforation of the mesio-lingual canal occurred and was repaired by the MTA. An apical microsurgery of the mesial root combined with surgical periodontal debridement for the lower left quadrant was performed. Three weeks later, resective and regenerative periodontal surgeries of the other 3 quadrants were accomplished. Because of the 6-month post-operative healing, the regenerative periodontal surgery for the lower-left quadrant was performed. The 6-month post-operative recall showed complete healing of the mesial root lesion and reduction of the distal root lesion. The multidisciplinary approach and advanced armamentarium contributed to favourable outcome.

Investigations of the prevalence and virulence of Candida albicans in periodontal and endodontic lesions in diabetic and normoglycemic patients

Pulpal and periodontal tissues have similar microbiota that allows cross-contamination between the pulp and periodontal tissues.

Failure of Cone-Beam Computed Tomography in Detection of Fiber Post Perforation

Detection of iatrogenic root perforation during post-space preparation especially in labiolingual plane can be challenging due to the two-dimensional nature of conventional radiography; this can be even more challenging if the cemented post is radiolucent. Cone-beam computed tomography (CBCT) scans were shown to be a valuable diagnostic aid in diagnosis of such cases. However, in this case, the application of CBCT did not help in diagnosis of a labial fiber post perforation in a maxillary central incisor which was finally detected through exploratory surgery.