Controversies in Endodontics

The Hidden World Within: Microbial Dynamics in Root Canal Systems

Several hundred different microbial taxa have made the oral cavity their home because of their evolution in multiple species communities within the special ecosystem. On the other hand, the dental pulp or internal tissue of the tooth is a connective tissue that is physiologically sterile and where any microbial infiltration is a harmful indication. It causes the pulp tissue to become inflamed, which leads to the death of the pulp and diffuses infection with inflammation to the peri-radicular tissues. Comprehending the biology of biofilms, the microbial makeup, and the host's reaction to infections in the pathobiology of root canal infections has received a lot of attention throughout the last few decades. Such comprehensive knowledge is required to design preventive medicines as well as clinically effective treatment regimens. Surprisingly, clinical approaches have concentrated more on radiographically perfecting channel preparation than on debridement of these intricate root canal systems, despite the clear realization that root canal infections are biofilm mediated. Since the present comprehension of the microbial etiopathogenesis of apical periodontitis highlights the significance of focusing on procedures such as "canal cleaning" and chemo-mechanical disinfection, the exclusive purpose of endodontic therapy is mainly missed while discussing "canal shaping." We thoroughly examine the state of our knowledge of the composition and functional traits of the root canal microbiome in this review. We also go into the difficulties with root canal disinfection and the cutting-edge approaches that try to solve these difficulties. In conclusion, we present essential guidance for prospective research areas, underscoring their significance as crucial considerations in the field of frontiers in oral health.

Controversies in Dental Traumatology

The management of traumatic dental injuries is more a shade of gray than it is black and white because not all treatment procedures used for dental trauma management are fully evidence based. This chapter has highlighted some of the gray areas related to the treatment and outcome of traumatic dental injuries. Significant controversies in the management of luxation and avulsive injuries have been brought out. Adjunctive treatment such as antibiotic usage, tetanus vaccination, and pain management is also addressed.

Complex Evaluation of Nanocomposite-Based Hydroxyapatite for Biomedical Applications

A magnesium-doped hydroxyapatite in chitosan matrix (MgHApC) sample was developed as a potential platform for numerous applications in the pharmaceutical, medical, and food industries. Magnesium-doped hydroxyapatite suspensions in the chitosan matrix were obtained by the coprecipitation technique. The surface shape and morphological features were determined by scanning electron microscopy (SEM). The hydrodynamic diameter of the suspended particles was determined by Dynamic light scattering (DLS) measurements. The stability of MgHApC suspensions was evaluated by ultrasonic measurements. The hydrodynamic diameter of the MgHApC particles in suspension was 29.5 nm. The diameter of MgHApC particles calculated from SEM was 12.5 ± 2 nm. Following the SEM observations, it was seen that the MgHApC particles have a spherical shape. The Fourier-transform infrared spectroscopy (FTIR) studies conducted on MgHApC proved the presence of chitosan and hydroxyapatite in the studied specimens. In vitro antimicrobial assays were performed on Escherichia coli ATCC 25922, Staphylococcus aureus ATCC 25923, Pseudomonas aeruginosa ATCC 27853, and Candida albicans ATCC 10231 microbial strains. The antimicrobial experiments showed that MgHApC exhibited very good antimicrobial properties against all the tested microorganisms. More than that, the results of the in vitro studies revealed that the antimicrobial properties of the samples depend on the incubation time. The evaluation of the sample's cytotoxicity was performed using the human colon cancer (HCT-8) cell line. Our results suggested the great potential of MgHApC to be used in future applications in the field of biomedical applications (e.g., dentistry, orthopedics, etc.).

Treatment outcome of partial pulpotomy using two different calcium silicate materials in mature permanent teeth with symptoms of irreversible pulpitis: A randomized clinical trial

AIM

To assess the clinical and radiographic outcome of partial pulpotomy by comparing MTA Angelus and Total Fill BC, as pulpotomy agents, in mature teeth with deep caries and symptoms indicative of irreversible pulpitis.

METHODOLOGY

The study was designed as a parallel-two arm, double-blind, randomized superiority clinical trial registered at www.

CLINICALTRIALS

gov (NCT04870398). Symptomatic mature permanent teeth with deep caries fulfilling the inclusion criteria were randomly treated using either MTA Angelus or Total Fill BC. A partial pulpotomy was performed and following complete haemostasis, the capping material was placed over the remaining pulp tissue and a postoperative periapical radiograph was taken. Clinical and radiographic follow-up evaluation was performed for a median time of 2 years, whereas levels of pain intensity were evaluated preoperatively and for 7 days after intervention using Visual Analogue Scale. For the primary outcome (failure/success of treatment), the Kaplan-Meier survival curves for the capping materials were plotted and a log-rank test for equality of survivor functions was applied. A multivariable random effects Cox Regression model was also applied. For the secondary outcome (postoperatively reported pain), a multivariable mixed effects ordinal logistic regression was structured.

RESULTS

One hundred and thirty-seven teeth in 123 patients underwent partial pulpotomy using randomly either MTA Angelus (N = 74) or Total Fill BC (n = 63). The percentage failure for MTA Angelus and Total Fill BC was 10.8% (8/74) and 17.5% (11/63), respectively, but the difference was not statistically significant [adjusted HR: 1.83; 95% confidence interval (CI): 0.68, 4.91; p = .23]. Weak evidence was found that secondary caries involvement may impose a 3.54 times greater hazard for treatment failure (adjusted HR: 3.54; 95% CI: 1.00, 12.51; p = .05). For each passing minute of procedural bleeding control, there was also a 57% higher hazard for treatment failure (adjusted HR: 1.57; 95% CI: 0.99, 2.48; p = .05). The odds for higher postoperative pain were 4.73 times greater for the Total Fill BC compared to MTA Angelus (adjusted OR: 4.73; 95% CI: 2.31, 9.66; p < .001).

CONCLUSIONS

Both materials exhibited similar and favourable outcome rates after partial pulpotomy in teeth with deep caries and symptoms of irreversible pulpitis. Total Fill BC was associated with a higher level of postoperative pain intensities.

Prevalence of Teaching Apical Patency and Various Instrumentation and Obturation Techniques in United States Dental Schools: Two Decades Later

INTRODUCTION

Maintaining apical patency has been advocated to minimize canal transportation, ledge formation, and loss of working length, despite increasing debris extrusion. A previous study in 1997 by Cailleteau and Mullaney reported 50% of United States dental schools taught patency. This present study aimed to evaluate recent trends in endodontic education in United States dental schools, in relation to the prevalence of maintaining apical patency and examining the primary methods of working length determination, instrumentation, obturation, and temporization.

METHODS

A survey of 20 questions was distributed to 65 schools via e-mail and was available from July 2021 to September 2021.

RESULTS

Seventy-three percent of the 46 responding schools reported that they teach patency, with 8% of this number reporting that they do so exclusively to endodontic residents. Notably, a significantly lower number of schools reported teaching patency exclusively to endodontic students compared with the Cailleteau and Mullaney study despite a significantly higher percentage of schools teaching patency overall. The most common method used to determine working length was an electronic apex locator at the 0.5 reading. Vortex Blue was the most commonly used file system used by both predoctoral and postdoctoral programs. Lateral condensation was the primary obturation technique taught in predoctoral programs, whereas warm vertical condensation was the primary obturation technique in postdoctoral programs. The study also found that 57% of schools reported using intraorifice barriers, and the most common temporary filling was glass ionomer.

CONCLUSIONS

A greater portion of schools teaches patency compared with the previous study in 1997. The data collected in this survey may serve as a baseline for similar studies in the future regarding changes in endodontic education over time.

The treatment of mature permanent teeth with irreversible pulpitis by cervical pulpotomy: A systematic review

Pulpotomy has been used in primary teeth and immature permanent teeth. However, with the advent of new bioactive material, the procedure is shifting towards permanent teeth with mature apices of roots. The objective of this systematic review was to evaluate the success of pulpotomy on mature permanent teeth with acute irreversible pulpitis and to compare it with root canal treatment or between the effectiveness of the bioactive material used. The following databases were searched: PubMed, Cochrane Library: Cochrane Central Register of Controlled Trials, Embase, ClinicalTrials.gov, International Clinical Trials Registry Platform. After using the keywords predefined, the electronic search yielded a total of 86 articles. After undergoing a thorough screening and eligibility process, only four articles were finally selected. Unexpectedly, pulpotomy demonstrated a better tendency for success in such cases over the years. This shows that pulpotomy is not inferior to root canal treatment for permanent treatment of irreversible pulpitis. In addition, the results obtained showed that pulpotomy is rapid, biologically reliable and more cost-effective in all situations compared to root canal therapy. Complete pulpotomy appears to have a high success rate as a permanent treatment of irreversible pulpitis and could be considered as an alternative to root canal therapy. Pulpotomy is not inferior to root canal treatment for a permanent treatment of irreversible pulpitis. In addition, the results obtained have shown that complete pulpotomy is faster and more profitable in all situations compared to root canal treatment. Furthermore, with the advent of new so-called bioactive materials, the use of this therapeutic is increasingly considered. This is why a review based on studies of reliable articles is above all necessary to be able to generalise the indication of this therapy.

Vital Pulpotomy on immature lower first permanent molars using Portland cement, a case of failure and success-case report with 2 years follow-up

Key clinical message

While the importance of vital pulp therapy comes from its ability to promote pulp healing allowing the tooth to continue its development and giving the patient a more convenient treatment, dental practitioners should be more aware of the minor mistakes which they might commit during treatment procedures that could reflect negatively on the treatment's outcome. Developing behavior management skills as well as learning from reported mistakes are beneficial to practitioners to provide a more precise and successful treatment.

Abstract

Vital pulp therapies are known to preserve tooth development and give pulp tissues a chance to heal. Despite the progress of biocompatible materials used in this field, these treatments are still facing some failure for several known and unknown reasons that might not only be related to the material used. This case report presents and discusses the possible reasons for the success of one vital pulpotomy procedure and the failure of another, both conducted on two immature lower first permanent molars of the same patient, in an attempt to conclude what led to both results.

Guided Endodontic Surgery: A Narrative Review

Background and objectives: Endodontic surgery has evolved over the last two decades. The use of state-of-the-art guided endodontic surgical procedures produces a predictable outcome in the healing of lesions of endodontic origin. The main objective of this review paper is to define and characterize guided surgical endodontics as well as its benefits and drawbacks by reviewing the most recent relevant scientific literature. Methods: A literature search was conducted using multiple databases comprising of MEDLINE (via PubMed), EMBASE, and Web of Science. The terms used for the search were ‘guided endodontics’, ‘surgical endodontics’, and ‘endodontic microsurgery’. Results: In total, 1152 articles were obtained from the analysis of the databases. Unrelated articles from the available full text of 388 articles were excluded. A total of 45 studies were finally included in the review. Conclusions: Surgical-guided endodontics is a relatively new area of study that is still maturing. It has many applications such as root canal access and localization, microsurgical endodontics, endodontic retreatment, and glass fiber post removal. Additionally, it does not matter how experienced the operator is; the procedure can be completed for the patient in less time and provides greater accuracy and safety than conventional endodontics.

Factors that influence the outcome of pulpotomy in permanent teeth

The promotion of minimally invasive treatments focussed on the maintenance of pulp vitality has become a priority area in Endodontics. These vital pulp treatments (VPT) include partial and full pulpotomy, during which diseased coronal pulp tissue is removed prior to placement of a capping biomaterial and restoration. Traditionally, pulpotomies were confined to the treatment of carious primary and traumatized permanent teeth. However, these treatments have now been proposed as definitive solutions for cariously exposed permanent teeth with mild symptoms or even symptoms indicative of irreversible disease. Until recently, it was recommended that carious exposure of mature permanent teeth be managed by root canal treatment. The promotion of pulpotomy as an alternative treatment has opened up a wave of laboratory and clinical research aimed at improving therapies or evaluating clinical outcomes. In modern evidence-based endodontics, it is imperative that the outcomes of both partial and full pulpotomy are considered and important prognostic factors identified, so that improvements can be made to aid clinical decision-making and to direct new research. In this narrative review, the outcomes of partial and full pulpotomy are discussed, before analysis of patient, intraoperative and postoperative factors that influence the outcome of the pulpotomy procedure. The review highlights that although partial and full pulpotomy for the treatment of even pulpal disease are highly successful procedures, this is based on low-quality evidence with a lack of prospective, comparative trials investigating potential prognostic factors. Based on current evidence, it appears that age, gender, tooth type, root development and intraoperative pulpal haemorrhage do not impact significantly on pulpotomy outcome, whilst others such as caries depth, inflammatory status of the pulp, capping material, level of inflammatory pulpal-biomarkers and the final restoration integrity do. Other factors, including the influence of exposure type, periodontal condition, pulpal lavage, magnification, operator experience, isolation of the operating field and type of pulpotomy, require further experimental investigation before definitive conclusions can be made relating to the success of the pulpotomy procedure. Finally, there is not only a need for future well-designed prospective research addressing these issues but also a widening of our understanding of outcome to include patient-reported as well as clinician-reported outcomes.

Factors that affect the outcomes of root canal treatment and retreatment-A reframing of the principles

This paper undertakes a broad and comprehensive synthesis of relevant clinical, biological, biomechanical, technical and healthcare services data to understand the factors affecting outcomes of periapical healing after root canal (re)treatment. The medical and dental evidence-based era (1980-present) is contextualized with the earlier evidence drive in endodontics (1911-1940) triggered by the focal infection era. The current evidence-based approach has a sharper focus on evidence quality and derivation of practice guidelines. Contrary views question whether guideline-driven, or expertise-development-driven endeavours would best serve outcome improvement in society. The endodontic discipline functions in a broad healthcare framework and sustains industrial, economic and trend pressures that may be deemed to influence outcomes. The nature of root canal treatment and the challenges in determining the factors that affect its outcomes is discussed. The factors potentially affecting periapical healing after root canal treatment are classified into pre-operative, intra-operative and postoperative groups. These categories subsume multiple elements with interactive influences, creating a complex picture, further confounded by some apparently surprising, counter-intuitive and contradictory findings. The technical versus biological conundrum in root canal treatment continues to cause cognitive dissonance. However, due reflection and cross-discipline-synthesis resolve the apparent data conflicts into a very simple, consistent and plausible picture of how root canal treatment works and the key factors that affect periapical healing. Root canal retreatment is considered mainly in the context of its differences from primary treatment as the majority of factors influencing outcomes are common to both. The exceptional difference is that retreatments have a proportionately reduced probability of healing by virtue of compromised apical root canal ramification access or modified host/infection interactions. Root canal (re)treatment outcomes are dominantly influenced by the nature of prior dynamic host/infection interaction (pre-operative patient factors) and how the direction of this dynamic is influenced by two factors: (1) the active efficacy of the operators' root canal treatment protocol to sustain a microbial ecological shift (intra-operative treatment factors) and dampen periapical inflammation; and (2) the passive ability of the functional tooth (and its restoration margin) to maintain its integrity to resist infection reversal (postoperative restorative factors).

DENTAL PATIENT-REPORTED OUTCOMES IN ENDODONTICS - A NARRATIVE REVIEW

Recently in oral health care settings, the focus of assessing treatment outcomes has shifted from the perspective of the clinician towards that of the patient. Endodontology is a specialty of dentistry concerned with the prevention and treatment of pulp and periapical diseases. Research in endodontology and its associated treatment outcomes have focused mainly on clinician-reported outcomes (CROs) and not dental patient-reported outcomes (dPROs). As a result, there is a need to emphasize the importance and relevance of dPROs to researchers and clinicians. The aim of this review is to present an overview of dPROs and dPROMs within endodontics in an attempt to create a better understanding of the patient experience, highlight the need to place the patient at the center of treatment, enhance patient care and encourage more research into dPROs. The key dPROs following endodontic treatment include pain, tenderness, tooth function, need for further intervention, adverse effects (exacerbation of symptoms, tooth discoloration) and Oral Health-Related Quality of Life. dPROs are important following endodontic treatment because they assist clinicians and patients when they discuss and select the most appropriate management options, help clinicians make decisions on pre-operative assessment, prevention and treatment, and improve the methodology and design of future clinical studies. Clinicians and researchers in endodontology should prioritize patient welfare and undertake routine analyses of dPROs using appropriate and robust measures. Due to the lack of agreement over the reporting and definition of endodontic treatment outcomes, a comprehensive project to define a ``Core Outcome Set for Endodontic Treatment Methods (COSET)'' is currently ongoing. In the future, a new and exclusive assessment tool should be developed to reflect the viewpoints of patients receiving endodontic treatment more accurately.

Linking Dentistry and Chronic Inflammatory Autoimmune Diseases – Can Oral and Jawbone Stressors Affect Systemic Symptoms of Atopic Dermatitis? A Case Report

Background

This case report demonstrates the value of ultrasound measurements, and immunological and toxicological diagnostics in addition to current x-ray imaging procedures to diagnose hidden oral and maxillofacial infections. Using a clear scheme shows the procedure of the authors’ steps. The positive impact on the patient’s dermatological clinical picture is shown. Functional regeneration using metal-free ceramic implants and autologous bone augmentation is demonstrated. After a healing period, a postoperative control took place.

Question

Are chronic inflammatory and chronic toxic stressors from the oral region affecting the patient’s state of health and dermatological symptoms?

Patients and Methods

A 52 year old female suffering from neurodermatitis, who had been therapy-resistant for several years, was rehabilitated by oral surgery and prosthetics. Radiological examinations with orthopantomogram (OPG) and three-dimensional imaging (DVT/CBCT) were inconclusive for possible jawbone inflammatory sites. Immunological, toxicological diagnostics and trans-alveolar bone densitometry with ultrasound (TAU), were able to show immunological and toxicological stressors and areas of reduced bone density. Bone densitometry with ultrasound raised the suspicion of silent inflammations in the jawbone with potentially increased cytokine levels.

Results

For the patient incompatible materials, teeth with increased toxin exposure and surrounding softened, fatty, ischaemic bone was removed. Histologies and cytokine profiles were obtained. The resulting defects were functionally regenerated using ceramic implants and autologous augmentation. The cytokine profiles showed significantly elevated RANTES/CCL5, confirming the need for surgical intervention. The patient’s atopic dermatitis improved significantly in this case.

Summary

Individualized immunological and toxicological diagnostics and trans-alveolar bone density bone densitometry with ultrasound (TAU) identified immunological and toxicological stressors as well as reduced bone density with increased cytokine levels. A therapy-resistant neurodermatitis improved significantly after treatment.

Conclusion

This case report illustrates the need for patient-specific and individualized examinations that link dentistry more closely with other medical conditions in order to clarify possible interactions.

Preclinical Testing of Boron-Doped Diamond Electrodes for Root Canal Disinfection—A Series of Preliminary Studies

While numerous approaches have meanwhile been described, sufficient disinfection of root canals is still challenging, mostly due to limited access and the porous structure of dentin. Instead of using different rinsing solutions and activated irrigation, the electrolysis of saline using boron-doped diamond (BDD) electrodes thereby producing reactive oxygen species may be an alternative approach. In a first step, experiments using extracted human teeth incubated with multispecies bacterial biofilm were conducted. The charge quantities required for electrochemical disinfection of root canals were determined, which were subsequently applied in an animal trial using an intraoral canine model. It could be shown that also under realistic clinical conditions, predictable disinfection of root canals could be achieved using BDD electrodes. The parameters required are in the range of 5.5 to 7.0 V and 9 to 38 mA, applied for 2.5 to 6.0 min with approximately 5 to 8 mL of saline. The direct generation of disinfective agents inside the root canal seems to be advantageous especially in situations with compromised access and limited canal sizes. The biologic effect with respect to the host reaction on BDD-mediated disinfection is yet to be examined.

Root Canal Obturation by Electrochemical Precipitation of Calcium Phosphates

Achieving adequate disinfection and preventing reinfection is the major goal in endodontic treatment. Variation in canal morphology and open porosity of dentine prevents achieving complete disinfection. Questionable biocompatibility of materials as well as a lack of sealing ability questions the usefulness of current obturation methods. With a novel disinfection approach based on the use of boron-doped diamond (BDD) electrodes having shown promising results it was the goal of this series of experiments to investigate the possibility of BDD-mediated in situ forming of a biocompatible obturation material. A combination of calcium phosphate and maleic acid was used as precursor solution while Ion Chromatography Mass Spectrometry (IC-MS), Raman spectroscopy (RAMAN), X-ray diffraction (XRD), energy dispersive X-ray spectroscopy (EDX), scanning electron microscopy (SEM), dye penetration and micro-computed tomography (µCT) were applied for characterizing the precipitate. It was possible to achieve a BDD-mediated precipitation of brushite in a clinically applicable timeframe. However, tight sealing of the canal system based on brushite could not be achieved.

Reframing Perceptions in Restorative Dentistry: Evidence-Based Dentistry and Clinical Decision-Making

Objectives

The worldwide interest of both dentists and patients in esthetic dentistry has affected decision-making in dental practice. The aim of this study was to investigate contemporary dental practice in restorative dentistry and the relationship between evidence-based dentistry in caries research and decision-making in clinical practice in restorative dentistry.

Methods

The study was conducted through a structured questionnaire distributed randomly at the Jordanian Dental Association registered dentists in Jordan. The questionnaire aimed to clarify the degree of knowledge and practice of evidence-based dentistry in caries research the dentists hold regarding clinical decision-making in restorative dentistry.

Results

The majority of the surveyed dentists (77%) treat teeth with irreversible pulpitis with root canal treatment rather than vital pulp therapy. 13.8% routinely insert a post and 23% routinely crown the tooth after root canal treatment regardless of the remaining tooth structure. Badly damaged teeth are treated with full crowns in 72% of the cases. Regarding Hollywood smile or smile makeover, the majority of dentists choose conservative approaches, and implants were the first choice to replace missing teeth for 93.8% of the surveyed dentists.

Conclusion

A higher degree of implementation of evidence-based dentistry in clinical decision-making was found in Prosthetic Dentistry than in Endodontics. Yet, the gap between evidence-based data and clinical practice needs bridging. More emphasis on communicating these data to educators to integrate them into the dental curriculum is a must.

Present status and future directions - microbiology of endodontic infections

Apical periodontitis has a microbial aetiology and is one of the most common inflammatory diseases that affect humans. Fungi, archaea and viruses have been found in association with apical periodontitis, but bacteria are by far the most prevalent and dominant microorganisms in endodontic infections. Bacterial infection of the root canal system only occurs when the pulp is necrotic or was removed for previous treatment. In some specific cases, including acute and chronic abscesses, the bacterial infection may reach the periradicular tissues. Intracanal bacteria are usually observed as sessile multispecies communities (biofilms) attached to the dentinal root canal walls. Infection in the main root canal lumen can spread to other areas of the root canal system. Although more than 500 bacterial species have been detected in endodontic infections, a selected group of 20 to 30 species are most frequently detected and may be considered as the core microbiome. There is a high interindividual variability in the endodontic microbiome in terms of species composition and relative abundance. Obligate anaerobic species are more abundant in the intraradicular bacterial communities of teeth with primary apical periodontitis, while both anaerobes and facultatives dominate the communities in post-treatment apical periodontitis. Bacterial interactions play an essential role in determining the overall virulence of the community, which has been regarded as the unit of pathogenicity of apical periodontitis. This article reviews the microbiologic aspects of endodontic infections and provides perspectives for future research and directions in the field.

Effect of Magnesium on Dentinogenesis of Human Dental Pulp Cells

Introducing therapeutic ions into pulp capping materials has been considered a new approach for enhancing regeneration of dental tissues. However, no studies have been reported on its dentinogenic effects on human dental pulp cells (HDPCs). This study was designed to investigate the effects of magnesium (Mg²⁺) on cell attachment efficiency, proliferation, differentiation, and mineralization of HDPCs. HDPCs were cultured with 0.5 mM, 1 mM, 2 mM, 4 mM, and 8 mM concentrations of supplemental Mg²⁺ and 0 mM (control). Cell attachment was measured at 4, 8, 12, 16, and 20 hours. Cell proliferation rate was evaluated at 3, 7, 10, 14, and 21 days. Crystal violet staining was used to determine cell attachment and proliferation rate. Alkaline phosphatase (ALP) activity was assessed using the fluorometric assay at 7, 10, and 14 days. Mineralization of cultures was measured by Alizarin red staining. Statistical analysis was done using multiway analysis of variance (multiway ANOVA) with Wilks' lambda test. Higher cell attachment was shown with 0.5 mM and 1 mM at 16 hours compared to control (P < 0.0001). Cells with 0.5 mM and 1 mM supplemental Mg²⁺ showed significantly higher proliferation rates than control at 7, 10, 14, and 21 days (P < 0.0001). However, cell proliferation rates decreased significantly with 4 mM and 8 mM supplemental Mg²⁺ at 14 and 21 days (P < 0.0001). Significantly higher levels of ALP activity and mineralization were observed in 0.5 mM, 1 mM, and 2 mM supplemental Mg²⁺ at 10 and 14 days (P < 0.0001). However, 8 mM supplemental Mg²⁺ showed lower ALP activity compared to control at 14 days (P < 0.0001), while 4 mM and 8 mM supplemental Mg²⁺showed less mineralization compared to control (P < 0.0001). The study indicated that the optimal (0.5–2 mM) supplemental Mg²⁺ concentrations significantly upregulated HDPCs by enhancing cell attachment, proliferation rate, ALP activity, and mineralization. Magnesium-containing biomaterials could be considered for a future novel dental pulp-capping additive in regenerative endodontics.

Removal of accumulated hard tissue debris from mesial root of mandibular molars evaluated using micro-CT - a systematic review and network meta-analysis

Aim The aim of this systematic review and network meta-analysis was to identify the best irrigant activation technique (IAT) for the removal of accumulated hard tissue debris (AHTD) from the mesial root of mandibular molars evaluated using micro-CT studies.Methods The research question was based on the PICO format. Four electronic databases - PubMed, Scopus, Embase and Web of Science - were searched for articles up to June 2020. Selected articles were assessed for bias using the Joanna Briggs Institute Critical appraisal tool. The network meta-analysis using a fixed-effects model and SUCRA ranking were performed. The quality of the evidence was assessed using the CINeMA framework.Results Eleven studies were included for qualitative synthesis while seven were included for quantitative synthesis. The risk of bias of all included articles was low. The results based on SUCRA values revealed the IAT shock wave-enhanced emission photoacoustic streaming (100%) resulted in the greatest reduction of the volume of AHTD from mesial roots of mandibular molars. Ranking of the other IATs was as follows: photon-induced photoacoustic streaming (87%), laser-activated irrigation (79.3%), XP EndoFinisher (71.2%), ultrasonically activated irrigation (59.6%), apical negative pressure (42.3%), EasyClean (37.4%), EDDY (26.2%), EndoActivator (24.2%), self-adjusting file (11.6%) and needle irrigation (11.3%).Conclusion None of the IATs rendered the root canals completely free of AHTD. The laser-activated irrigation groups fared better than all other interventions in reducing AHTD from the mesial roots of mandibular molars. The confidence rating ranged from low to high for indirect evidence and moderate to high for mixed evidence. Results must be interpreted with caution due to the laboratory nature of the included studies.

4-Year Follow-up of Full Pulpotomy in Symptomatic Mature Permanent Teeth with Carious Pulp Exposure Using a Stainproof Calcium Silicate-based Material

INTRODUCTION

This study aimed to assess the pulpal and restorative outcome of full pulpotomy in symptomatic mature permanent teeth with carious pulp exposure over 4 years.

METHODS

Under local anesthesia, full pulpotomy was performed using the aseptic technique and a stainproof calcium silicate-based material (NeoMTA Plus; Avalon Biomed Inc, Bradenton, FL). The pain level was scored preoperatively and at 1 week posttreatment. Clinical and radiographic evaluation was performed at 6 months, 1, 2, and 4 years. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to analyze the data. Failed cases were classified as endodontic or restorative failure.

RESULTS

Full pulpotomy was completed in 109 teeth in 90 patients with an age range of 14-60 years (mean = 25 years). The study sample available for follow-up was 100 teeth in 86 patients with a recall rate above 90%. Preoperative pulp diagnosis was reversible pulpitis in 39 teeth and irreversible pulpitis in 61 teeth. The cumulative survival rates of pulpotomy were generally high (ie, 98%, 97.4%, 93%, and 83.8% at 6 months and 1, 2, and 4 years, respectively). The overall mean survival time of pulpotomy was 3.89 years (95% confidence interval, 3.84-3.95). The mean survival time was significantly higher for patients aged ≤25 years. However, in the multivariate analysis, the only significant predictor of pulpotomy failure was severe preoperative pain. Over the 4 years, 23 cases failed; only 10 of 23 failures were classified as endodontic failure, and the success of pulpotomy can be assumed to be 90%.

CONCLUSIONS

Full pulpotomy in cariously exposed pulp of mature permanent teeth sustained a high success rate over 4 years. The coronal seal is crucial for long-term survival.

Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The aim of this systematic review was to evaluate the existing randomized controlled trials (RCTs) on the safety and efficacy of vital pulp therapy (VPT) and to analyze the outcomes of VPT performed with a variety of pulp-capping materials and techniques.

METHODS

MEDLINE (PubMed), Embase, Cochrane Library, and gray literature were searched (January 2000-March 2021). Study selection and data extraction were performed in duplicate. Eligible RCTs were critically appraised for risk of bias and quality of evidence and were meta-analyzed to estimate the treatment effects.

RESULTS

Fourteen studies were included. The pooled success rate of VPT using contemporary capping materials such as mineral trioxide aggregate (MTA) or calcium silicate-based materials (CSMs) was 93.2% (95% confidence interval [CI], 91.6%-94.9%). Multiple subgroup analyses by different etiologies, procedure types, developmental stages of teeth, and preoperative diagnoses were performed. Analyses presented low certainty of evidence. No significant difference was noted between MTA and CSM at 12 months or a longer follow-up (risk ratio = 0.99; 95% CI, 0.95-1.03) with low certainty of evidence. Laser-assisted VPT failed to show significantly better outcomes than conventional VPT (risk ratio = 1.19; 95% CI, 0.99-1.49) with very low certainty of evidence.

CONCLUSIONS

When MTA or CSM was used as a capping material, VPT was 93% successful. The techniques, etiologies, developmental stages of teeth, and preoperative diagnosis had no significant influence on treatment outcomes. No major adverse effects (except discoloration associated with the use of MTA) were identified. The overall quality of evidence was low.

BiodentineTM Full Pulpotomy in Mature Permanent Teeth with Irreversible Pulpitis and Apical Periodontitis

Vital pulp therapy, including direct pulp capping and partial and full pulpotomy, is primarily indicated for immature or mature permanent teeth with reversible pulpitis. Mature permanent teeth with irreversible pulpitis are frequently treated with root canal therapy. This report presents two cases of full pulpotomy using Biodentine^TM in mature permanent teeth with irreversible pulpitis and acute apical periodontitis. The periapical radiograph illustrated a deep carious lesion extended to the pulp with apical radiolucency lesion or widened periodontal ligament space. Full pulpotomy with a tricalcium silicate-based cement was chosen as the definitive treatment. After decayed tissue excavation under a rubber dam, the exposed pulp tissue was amputated to the level of the canal orifice with a new sterile bur. Biodentine^TM was applied as the pulp capping agent after hemostasis was obtained and for temporary restoration. The clinical signs disappeared quickly after the treatment. After one month, the coronal part of the temporary restoration was removed, and a composite resin was placed over the capping agent as a final restoration. At two-year follow-ups, the teeth were asymptomatic. Radiographs showed healing of the periapical lesion and periodontal ligament. Biodentine^TM full pulpotomy of mature permanent teeth with irreversible pulpitis and apical periodontitis can be an alternative option to root canal therapy.

Influence of maintaining apical patency in post-endodontic pain

BACKGROUND

The concept of instrumentation beyond the apical foramen by small flexible file to prevent apical blockage is apical patency. However, this procedure might endow postoperative pain, thus to maintain apical patency or not is the matter of dilemma. Hence, the primary objective of this study was to compare postoperative pain between apical patency and non-patency groups and secondary objective was to evaluate the influence of number of visits, vitality of teeth, group of teeth and preoperative pain on post-operative pain.

METHODS

Preselected (n = 178) patients based on group of teeth and status of pulp were randomly divided into 2 groups, apical patency and non-patency which was further treated in either single or multiple visits. After exclusion, 160 patients were included. Each group (n = 80) was subdivided in single visit (n = 40) and multiple visits (n = 40), including vital (n = 20) and non-vital teeth (n = 20) and single-rooted (n = 10) and multiple-rooted teeth (n = 10). Apical patency was maintained with a size 10 K-file during conventional hand filing step-back shaping procedure. Intensity of pain was recorded before treatment and on days 1, 2, and 7 after treatment using Numerical Rating Scale (NRS-11). Statistical analysis was done using Mann-Whitney U test, Spearman correlation and Multiple linear regression analysis.

RESULTS

The primary outcome of this study showed statistically significant difference (p < 0.05) in postoperative pain scores between patency and non-patency groups with higher pain scores in patency group on 1st, 2nd and 7th day follow up. The secondary outcome showed postoperative pain in patency-maintained group was influenced by status of the pulp and preoperative pain only. Vital teeth of patency-maintained group treated in multiple visits showed statistically significant (p = 0.02) post-operative pain in day 1 follow up. Pre-operative pain showed positive correlation with postoperative pain with statistically significant difference.

CONCLUSIONS

Our study concluded that maintenance of apical patency increased postoperative pain. Evaluation of influence of number of visits, status of pulp, group of tooth and preoperative pain revealed status of pulp and preoperative pain as influencing factors for postoperative pain in patency group.

Patient satisfaction with root canal treatment and outcomes in the Swedish public dental health service. A prospective cohort study

AIM

To document satisfaction with root canal treatment procedures and outcomes among patients treated at Swedish public dental clinics.

METHOD

The original material comprised 243 patients who began root canal treatment (RCT) at 20 public dental clinics in the county of Västra Götaland, Sweden. One to three years later, 236 (97.1%) were posted a questionnaire of eight items, rating patient perceptions of RCT-completion, present pain intensity and satisfaction with the RCT. To evaluate the reliability of the original responses, the first 50 respondents were mailed a follow-up questionnaire. Both descriptive and analytical statistics were used to compare respondents and non-respondents and tooth groups.

RESULTS

One hundred and fifty-nine patients (67.4%) responded: 86 (54.1%) women and 73 (45.9%) men. The mean age 52.5 years, was higher than for non-respondents (P<0.001). A completed root filling was registered for the majority of the teeth (n = 112, 70.9%), but significantly fewer molars had been completed (n = 46, 59.7%, P = 0.02). Fifty percent (n = 59) of the patients reported current pain, mostly mild in intensity (n = 45, 38.1%). One hundred and twenty-three patients (80.9%) recalled experiencing pain during RCT. The highest satisfaction was registered for the item 'chewing ability' (mean = 1.6, SD = 1.9). The majority of patients (n = 114, 75.0%) stated that in retrospect they would still have chosen RCT. However, these patients belonged to the group which either registered the tooth as still present, or had not experienced much discomfort during or after RCT. Forty-four patients (88.0%) responded to the second questionnaire. The reliability of the responses was good. In summary, one to 3 years after beginning RCT at a public dental clinic, patient satisfaction was high, even though every fourth molar had been extracted or treatment had not been completed and half the patients reported persistent pain. The reliability of the patients' responses was considered to be good.

CONCLUSIONS

The results indicate a need for further clinical observational studies of RCTs undertaken in general dental practice, with special reference to patient-centred outcomes.

Conservative pulp therapy in the management of reversible and irreversible pulpitis

Conservative pulp therapy is an alternative treatment option to tooth removal and root canal treatment in the management of deep caries, traumatic pulp exposures and developmental anomalies. Pulp tissue preservation can extend the long-term survival of teeth through relatively simple restorative procedures. This article aims to update clinicians on the current state of research in materials, techniques and outcomes of vital pulp therapies and provide practical guidelines for their implementation into daily practice.

Success of pulpotomy in mature permanent teeth with irreversible pulpitis: A systematic review

The objective of the present systematic review is to evaluate the success of pulpotomy in mature permanent teeth presented with irreversible pulpitis. The following databases were searched: PubMed, Oral and Dentistry Database, Cochrane, and CINAHL plus. We included studies published in the English language only. However, narrative reviews and case reports/series were excluded. The first electronic and hand search yielded a total of 2851 articles. After going through extensive screening and eligibility process, only six articles were finally selected for the review. The follow-up period ranged from 1 to 10 years. Randomized controlled trial compared pulpotomy with the root canal treatment and reported comparable and even better success of the pulpotomy (78% success). All the other studies have also shown better clinical and radiographic success of pulpotomy (68%–100%). Pulpotomy can be considered an alternative option for mature permanent teeth with irreversible pulpitis.

Radiographic evaluation of immature traumatized incisors following different endodontic treatments

BACKGROUND/AIMS

Indirect pulp capping, pulpotomy, and apexification are three common endodontic treatments for immature traumatized incisors. They all affect tooth root development to some extent. The aim of this retrospective study was to compare the influence of these treatments on root development of immature permanent incisors following dental trauma.

MATERIALS AND METHODS

Twenty-one indirect pulp capping, 48 pulpotomy, and 58 apexification cases with a mean age of 8.4 ± 1.0 years and median follow up of 12 months were included. NIH ImageJ with TurboReg plug-in was used to correct angular differences between the pre-operative and recall periapical radiographs, and to calculate variations of root length, dentin wall thickness, and apical closure. Kruskal-Wallis ANOVA followed by pairwise comparisons was applied to compare the radiographic variations. The type of apical closure was assessed qualitatively and analyzed using Fisher's exact test.

RESULTS

The apexification group had a lower trend toward apical closure than the other two groups (P < .05). It also showed thinner dentin wall thickness compared with the pulpotomy group (P = .001). There was no significant difference between pulpotomy and indirect pulp capping in the trend to apical closure (P > .05) or dentin wall thickness (P = .775). There was no significant difference in the variation of root length among the three groups (P = .06). There was a moderate correlation between the treatment and the type of apical closure (Cramer's V Coefficient = .375). Pulpotomy tended to form a normal apical constriction rather than a calcific barrier while apexification showed the opposite inclination. Indirect pulp capping had no specific inclination toward any type of apical closure.

CONCLUSIONS

Apexification resulted in an abnormal root development mostly by affecting the dentin wall thickness and apical closure. Pulpotomy was beneficial for normal root development of immature traumatized teeth.

Combination effects of diode laser and resin-modified tricalcium silicate on direct pulp capping treatment of caries exposures in permanent teeth: a randomized clinical trial

OBJECTIVE

The purpose of this randomized clinical trial was to evaluate efficiency of diode 808-nm (Picasso-AMD, USA) laser using power 1.5 W, continuous wave (CW), fiber diameter of 400 μm, non-initiated and in contact mode, tip angle set at 90°, beam divergence 16°, 2 s per an area with 1-mm diameter, power density 190.98 W/cm², energy density 381.97 J/cm², vertical and horizontal scanning movement on the exposure site, and laser irradiation combined with a resin-based tricalcium silicate material (TheraCal LC, Bisco, USA) in direct pulp capping in caries exposures of permanent teeth over a period of 6 months.

MATERIAL AND METHODS

In this randomized clinical trial, a total of 20 anterior and posterior vital teeth without symptoms and radiographic changes of 14 patients between the age group of 15-35 years, of which randomly 10 teeth were considered, each for TheraCal LC, the exposed area was sealed with TheraCal paste and TheraCal combined with diode laser; the treated area was sealed with TheraCal paste after diode 808-nm laser irradiation. At the 1-, 3-, and 6-month recall examinations, the loss of vitality, spontaneous pain, reactions to thermal stimuli and percussion, and radiographic changes were considered failure. The samples were randomly divided using runs test. Measurements on the digitized radiograph were performed at the recalls. The data were analyzed by repeated measurements ANOVA using SPSS 25.

RESULTS

Analysis had indicated that at the end of follow-ups, a statistically significant increase in dentin thickness with both groups (p value < 0.001) was found. Clinically, diode laser group has shown better results (p value < 0.001); however, radiographically, no significant difference was observed between groups (p value = 0.56). In both groups, the highest thickness of dentin formed was at the first month; 0.40 mm ± 0.19 mm (p value < 0.001).

CONCLUSION

Diode laser 808 nm under proper parameters combined with TheraCal LC can be recommended for direct pulp therapy in caries exposure of permanent teeth.

CLINICAL TRIAL REGISTRATION

This research was approved by Esfahan Medical University, Dental School, Azad Branch (KHUISF)) Esfahan, Iran [IR.IAU.KHUISF.REC.1397.261].

Evaluation of the Efficacy of Erbium, Chromium-doped Yttrium, Scandium, Gallium, and Garnet Laser in Partial Pulpotomy in Permanent Immature Molars: A Randomized Controlled Trial

INTRODUCTION

The use of the erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser in vital pulp therapy contributes to the formation of dentin bridges and a sterile zone as well as the maintenance of the vitality of the pulp. However, no prior studies have used the Er,Cr:YSGG laser in partial pulpotomy of immature permanent teeth. The aim of this study was to compare the efficacy of partial pulpotomy treatment using mineral trioxide aggregate (MTA) alone and MTA with the Er,Cr:YSGG laser in permanent immature molars.

METHODS

A total of 90 caries-exposed permanent immature molar teeth were included and randomly divided into 2 groups: the MTA group (n = 45) and the laser + MTA group (n = 45). In the MTA group, MTA was applied to the exposed area on the pulp after bleeding control. In the same session, the tooth was restored with a composite resin. In the laser + MTA group, before MTA condensation, the Er,Cr:YSGG laser was applied to the exposure area. Patients were recalled at 1, 3, 6, and 12 months after treatment. The Mann-Whitney U and chi-Square tests were used for statistical analysis.

RESULTS

The success rate (95.5%) of the laser + MTA group was similar to that of the MTA group (88.8%). There was no significant difference between groups in terms of the frequency of at least 1 pathologic clinical or radiographic failure at 12 months (P > .05).

CONCLUSIONS

Partial pulpotomy treatment showed a high success rate in immature permanent molars; however, the use of the laser did not contribute to the success rate compared with MTA alone.

Effects of Contemporary Irrigant Activation Schemes and Subsequent Placement of an Interim Dressing on Bacterial Presence and Activity in Root Canals Associated with Asymptomatic Apical Periodontitis

New tools for activating endodontic irrigants have evolved, yet their impact on root canal disinfection, in comparison to the passive placing of an inter-visit medication, have not yet been fully elucidated. The use of DNA- and rRNA-based methods may cast some new light on this issue, as they allow a comparison to be made between microbial presence and activity. Therefore, the aim of this single-arm intervention trial is to evaluate the antibacterial effect of endodontic procedures using both molecular methods. Root canal samples were obtained from 20 patients with asymptomatic apical periodontitis after each treatment step: access cavity, chemo-mechanical preparation, adjunctive procedures (XP-endo Finisher file and passive ultrasonic irrigation), calcium hydroxide medication, and 2nd-visit root canal preparation. DNA and cDNA from the samples were subjected to quantitative polymerase chain reaction with universal primers for the bacterial 16S rRNA gene. Chemo-mechanical preparation promoted a drastic reduction in bacterial levels and activity, whereas the adjunctive procedures did not make a significant contribution to further disinfection. At the 2nd visit, bacteria were active after the use of calcium hydroxide medication; however, they were significantly reduced after a 2nd-visit preparation. Consequently, the lowest bacterial levels were found at the end of the treatment. This clinical trial, which used an rRNA and rDNA combined approach, confirmed previous studies showing that root canal preparation represents the main strategy for root canal disinfection.

Long-term Pulpal and Restorative Outcomes of Pulpotomy in Mature Permanent Teeth

INTRODUCTION

Pulpotomy in mature permanent cariously exposed teeth preserves the remaining pulp tissues, but long-term outcomes of the pulp and the restoration are unknown. This prospective study examined the immediate and long-term status of the pulp and the restored tooth and identified potential predictors of early and late failures in teeth that were asymptomatic or experiencing only mild symptoms at the time of treatment.

METHODS

Pulpotomy was performed using the aseptic technique and a tricalcium silicate cement under local anesthesia. Teeth were assessed for up to 5 years for pulpal and apical signs and symptoms, restorative marginal integrity, and periodontal health.

RESULTS

Fifty-two patients (61 teeth) with a median age of 40 years (range, 21-75 years) were included in this study; 17 (32.7%) men and 35 (67.3%) women were treated and reviewed. Overall pulp survival was 90.2% (95% confidence interval, 79.8%-96.3%); 6 teeth developed irreversible pulpitis or pulp necrosis when the restoration was intact. Preoperative pain was a potential predictor (P < .05) for early failure. Eleven late failures occurred between 2 and 4 years: 1 tooth with intact coronal restoration had pulp necrosis and asymptomatic apical periodontitis, 4 had recurrent caries resulting in asymptomatic apical periodontitis, 4 remained vital and only needed new restorations, 1 was unrestorable, and 1 was extracted for periodontal reasons. The type of definitive restoration was a potential predictor for late failure (P < .05).

CONCLUSIONS

Carious pulp exposures in asymptomatic mature permanent teeth can be predictably managed by pulpotomy using a tricalcium silicate cement. Short-term failures were few and managed by pulpectomy. Appropriate coronal restoration is critical to long-term success.

Incidence of postoperative flare-ups after single-visit and multiple-visit endodontic therapy in permanent teeth

AIM

Single- and multiple-visit root canal treatment has been the subject of long-standing debate in the endodontic community, so the purpose of this study was to determine the incidence of postoperative flare-up after single- and multiple-visit endodontic therapy in permanent teeth.

MATERIALS AND METHODS

A total of 65 children aged >10 years who underwent root canal treatment were randomly categorized equally into two treatment groups: the first group underwent single-visit treatment, and the other group underwent multiple-visit therapy. The visual analog scale was employed to evaluate pain preoperatively and postoperatively after obturation. Recall visits were carried out after 1 week, 1 and 3, 6 and 9 months. The Statistical Package for the Social Sciences version 15.0 was employed for statistical analysis.

RESULTS

Except at the baseline, at all the other time intervals, the mean pain score in the multiple-visit group was higher as compared to that of the single-visit group; statistically no significant difference was found.

CONCLUSION

The mean pain score in the single-visit group was lower as compared to that of the multiple-visit group; however, the difference between the two groups was statistically significant (P > 0.05).

Electrochemical Disinfection of Experimentally Infected Teeth by Boron-Doped Diamond Electrode Treatment

Disinfection and prevention of re-infection are the decisive treatment steps in endodontic therapy. In this study, boron-doped diamond (BDD) electrodes have been fabricated and used for disinfecting the root canals of extracted human teeth, which had been covered with bacterial biofilms formed by Bacillus subtilis and Staphylococcus epidermidis. The growth of B. subtilis could be successfully impaired, achieving a complete disinfection after 8.5 min treatment time with the success of disinfection depending on the insertion depth of the electrode in the root canal. S. epidermidis could completely be removed after 3.5 min treatment time. A clinically applicable electrode array led to complete disinfection after treatment times of 10 min for S. epidermidis and 25 min for B. subtilis. BDD electrode application allowed for the improved disinfection of root canals and dentin tubules based on a continuous production of reactive oxygen species and their enhanced penetration of dentin tubules most likely due the formation of a continuous stream of small gas bubbles. The treatment times that are required here will be shortened in clinical application, as mechanical shaping of the canal system would precede the disinfection process.

The effect of hyaluronic acid hydrogels on dental pulp stem cells behavior

Dental caries and trauma, particularly in childhood, are among the most prevalent teeth problems, which result in the creation of cavities and probably tooth loss. Thus, novel regenerative approaches with high efficiency and less toxicity are required. Stem cell therapy along with the implementation of scaffolds has provided excellent opportunities in the regeneration of teeth structure. Hyaluronic acid (HA) hydrogels have enticed great attention in the field of regenerative medicine. The unique chemical and structural properties of HA and its derivatives have enabled their application in tissue engineering. Several factors such as the location and type of the lesion, teeth age, the type of capping materials determine the success rate of pulp therapy. HA hydrogels have been considered as biocompatible and safe scaffold supports in human dental cell therapies.

Endodontic infection control routines among general dental practitioners in Sweden and Norway: a questionnaire survey

Objective: The purpose of this study was to investigate endodontic infection prevention and control routines among general dental practitioners in Sweden and Norway. Materials and methods: A questionnaire was sent by email to 1384 general dental practitioners employed in Sweden and Norway. The participants were asked questions concerning different aspects of infection prevention and control during endodontic treatment; use of rubber dam, sealing of rubber dam, antibacterial solutions, and use of hand disinfectant and gloves. Results: The response rate was 61.4% (n: 819). 96.9% reported routinely using rubber dam during endodontic treatment. 88.3% reported always, or sometimes, sealing the area between rubber dam and tooth. Most disinfected the endodontic operative field, but the antibacterial solutions used varied. 11.9% did not use gloves at all during treatment, and 10.5% did not use hand disinfectant during treatment. Conclusions: Most of the general dental practitioners took measures to establish and maintain aseptics during endodontic treatment, which infers an awareness of the importance of endodontic infection prevention and control. But the results were self-reported and there may be a gap between claimed and actual behaviour. Further studies using observation methodologies are needed to assess how infection control routines are performed in everyday clinical practice.

Present and future of tissue engineering scaffolds for dentin-pulp complex regeneration

More than two thirds of the global population suffers from tooth decay, which results in cavities with various levels of lesion severity. Clinical interventions to treat tooth decay range from simple coronal fillings to invasive root canal treatment. Pulp capping is the only available clinical option to maintain the pulp vitality in deep lesions, but irreversible pulp inflammation and reinfection are frequent outcomes for this treatment. When affected pulp involvement is beyond repair, the dentist has to perform endodontic therapy leaving the tooth non-vital and brittle. On-going research strategies have failed to overcome the limitations of existing pulp capping materials so that healthy and progressive regeneration of the injured tissues is attained. Preserving pulp vitality is crucial for tooth homeostasis and durability, and thus, there is a critical need for clinical interventions that enable regeneration of the dentin-pulp complex to rescue millions of teeth annually. The identification and development of appropriate biomaterials for dentin-pulp scaffolds are necessary to optimize clinical approaches to regenerate these hybrid dental tissues. Likewise, a deep understanding of the interactions between the micro-environment, growth factors, and progenitor cells will provide design basis for the most fitting scaffolds for this purpose. In this review, we first introduce the long-lasting clinical dental problem of rescuing diseased tooth vitality, the limitations of current clinical therapies and interventions to restore the damaged tissues, and the need for new strategies to fully revitalize the tooth. Then, we comprehensively report on the characteristics of the main materials of naturally-derived and synthetically-engineered polymers, ceramics, and composite scaffolds as well as their use in dentin-pulp complex regeneration strategies. Finally, we present a series of innovative smart polymeric biomaterials with potential to overcome dentin-pulp complex regeneration challenges.

Endodontic and Restorative Treatment Patterns of Pulpally Involved Immature Permanent Posterior Teeth

Objective

The study aims at investigating the treatment patterns for young permanent posterior teeth with pulp involvement.

Materials and Methods

A random sample of 1793 dental records of patients aged 6-18 years old who had received dental treatment was investigated. 663 permanent posterior treated teeth had pulp involvement. Demographic and treatment data were gathered from patients' records.

Results

Prevalence of young permanent teeth with pulp involvement was 36.9%. Treatments received significantly increased as patients' age increased (P=0.001). The first mandibular molar had the most pulp involvement among all teeth (43.89%). Temporary restoration was the most received restoration (59%). The most common pulpal diagnosis, leading to treatment, was irreversible pulpitis (43.04%). Only 19.8% of treated teeth received completed root canal treatment.

Conclusion

There is a high percentage of children and adolescents with immature permanent posterior teeth with pulp involvement. Similarly, a variety of treatment patterns is present, with a small percentage of completed root canal treatment.

Clinical Relevance

The study has identified the need to provide guidelines to provide high-quality root canal treatments for young permanent posterior teeth that have pulpal involvement. Only 21.8% of root canal treatments were completed, while 24% of teeth were extracted, and 59% of patients received temporary restorative treatments. This suggests that there might be several factors that might prevent completion of the dental treatment, such as patient preference, insurance coverage, or dentist capability. These factors and guidelines for patient care should be investigated and resolved.

The evaluation of MTA and Biodentine as a pulpotomy materials for carious exposures in primary teeth

OBJECTIVE

This study examined the effects of MTA and Biodentine on the clinical and radiographic success rates of pulpotomies performed on primary teeth with carious pulp exposures.

MATERIALS AND METHODS

This study was conducted with 44 mandibular primary molars requiring vital pulpotomy. Carious dentin surrounding the exposure site was used as the inclusion criteria for all teeth, which were randomly divided into two groups according to pulpotomy material [MTA group (n = 24), Biodentine group (n = 20)]. Treatment was followed up clinically and radiologically for 24 months. Pulp canal obliteration was not regarded as a failure.

RESULTS

Clinical and radiographic success rates at the end of 24 months were 100% for the MTA group and 89.4% for the Biodentine group. Success rates did not vary significantly between the groups (p = 0.646). Pulp canal obliteration was observed in two teeth (8.3%) in the MTA group at 6 months, but the teeth were found to be stabilized by 24 months.

CONCLUSION

The long-term clinical and radiographic success rates obtained in this study indicate that both MTA and Biodentine are appropriate options for pulpotomy treatment of primary teeth with carious exposure in patients whose teeth should be retained for long periods of time.

CLINICAL RELEVANCE

The etiology of exposure determines pulpal response, making it crucial to distinguish between mechanical and carious exposures. The carious exposure is presumed to be accompanied by severe inflammation, which makes the prognosis of treatment unpredictable. Biomaterials can be used especially in cases with carious pulp exposures.

Treatment Outcome Following Direct Pulp Capping Using Bioceramic Materials in Mature Permanent Teeth with Carious Exposure: A Pilot Retrospective Study

INTRODUCTION

The aim of this study was to investigate the sequelae of direct pulp capping (DPC) using mineral trioxide aggregate (MTA) and Biodentine in mature permanent teeth with carious exposure.

METHODS

Clinical records of 30 patients (15 each with MTA and Biodentine) treated with DPC technique from January 2015 to June 2015 were retrieved. Success rates (based on symptoms, sensibility tests, and radiographic analysis) and adverse events were analyzed.

RESULTS

The patients were reviewed at 1, 3, 6, 12, and 18 months after treatment. Four cases (2 each of MTA and Biodentine) were lost to follow-up. MTA and Biodentine groups showed success rates of 84.6% and 92.3%, respectively, with overall success rate of 88.5%. Radiographically visible dentin bridge formation was observed in 69.2% (9/13) and 61.5% (8/13) of cases done with MTA and Biodentine, respectively. The cases done with MTA showed coronal discoloration on review. Diffuse calcifications of the pulp chamber were observed in 1 (7.7%) case done with MTA and 3 (23.1%) cases done with Biodentine.

CONCLUSIONS

The advent of bioceramic materials with better biocompatibility and sealing properties can make the outcome of DPC technique in mature permanent teeth with carious exposure more predictable. The success rate observed in this study should be confirmed through randomized controlled trials with long follow-up periods. Effects of adverse events like coronal discoloration and calcifications of the pulp chamber also need to be evaluated.

Strength of recommendation for single-visit root canal treatment: grading the body of the evidence using a patient-centred approach

AIM

To identify, search for and critically interpret the results from clinical studies on single- versus multiple-visit root canal treatment in the light of an evidence-based paradigm. For that purpose, the quality of the available body of evidence was assessed using the SORT 'grade' - Strength of Recommendation Taxonomy.

METHODOLOGY

A protocol was followed including all aspects of the review methods: (i) search strategy, (ii) inclusion criteria for studies, (iii) screening methods, (iv) quality assessment, (v) data synthesis of the selected studies, and (vi) the assessment of quality of the body of evidence available by the means of the SORT 'grade'. An extensive search of recent biomedical literature was performed in PubMed (up to May, 2014), EMBASE (dating from 1980 to May 2014) and Cochrane databases with appropriate headings and keywords related to single- and multiple-visit root canal treatment. Selected studies were stratified according to their level of evidence using the SORT criteria: (i) quality - Level A high-quality evidence, Level B medium/low-quality evidence and Level C no evidence; (ii) degree of consistency - consistent, when most studies found a similar conclusion, or inconsistent, when there was considerable variation amongst study findings.

RESULTS

After the digital and manual searches, 246 studies were indentified. Two hundred and seven studies were eliminated by exclusion criteria, resulting in a yield of 39 articles that were selected for retrieval. Of the 39 articles, only 11 could be classified as Level 2 (B); the other 28 articles did not obey the criteria to be considered as real patient-oriented evidence; thus, they were classified as Level 3 (C). No studies were ranked as Level 1 because they did not obey the minimum standard to be considered as both good-quality research and patient-oriented evidence. Despite this, all of the selected Level B studies reported no significant differences between single- and multiple-visit treatments.

CONCLUSION

There is B-level (mid-level) evidence to confirm there is no difference between the two different treatments, based on research addressing clinical outcomes and using some consistent but limited-quality methods of scientific investigation. More studies focused on evaluating patient-centred outcomes are urgently required.

Predetermination of root canal lengths in molar teeth: A comparison between radiovisiography and two-dimensional and three-dimensional measurements using cone-beam computed tomography

Introduction:

Obtaining a correct working length is critical to the success of endodontic therapy. The aim of this clinical study was to compare the effect of working length determination using radiovisiography (RVG) and two-dimensional (2D) and three-dimensional (3D) measurements using cone-beam computed tomography (CBCT).

Materials and Methods:

Thirty mandibular teeth were taken and three groups of 10 each were made. Teeth with previous endodontic treatments, metal restorations, resorptions, incomplete apex formations, and multiple visible foramina were excluded. The root canal length was determined using RVG, CBCT measurement method 2D, and CBCT measurement method 3D. The difference between CBCT measurements, RVG, and the actual canal length were compared to evaluate the accuracy of each method.

Results:

No significant statistically difference was seen with 3D measurements and actual measurements. Measurements with RVG were better than CBCT 2D.

Conclusion:

Under experimental conditions, CBCT 3D measurements are accurate than RVG and CBCT 2D in the determination of root canal length.

The evaluation of endodontic flare-ups and their relationship to various risk factors

BACKGROUND

To evaluate the incidence of flare-ups and identify the risk factors including age, gender, tooth type, number of root canals, initial diagnosis, the type of irrigation regimen, treatment modality and the number of visits, in patients who received root canal treatment from January 2002 to January 2008.

METHODS

Records of 1819 teeth belonging to 1410 patients treated by 1 endodontics specialist during 6-year period were kept. Patient, tooth, and treatment characteristics were evaluated and the relationships between these characteristics and flare-ups were studied. Statistical analysis was carried out by using Pearson Chi-square test, Fisher's Exact test, and Binary Logistic regression analyses.

RESULTS

The incidence of flare-ups was 59 (3.2 %) out of 1819 teeth that received endodontic therapy. Pulpal necrosis without periapical pathosis was the most common indication for flare-up (6 %) (p < 0.01). Teeth undergoing multiple visits had a higher risk of developing flare-ups compared to those with single appointments (OR: 3.14, CI: 1.414-7.009, p < 0.01). There were also no statistically significant differences in the incidence of flare-ups regarding to age, gender, tooth type, number of root canals, treatment modality, and the irrigation solutions that used during the treatment.

CONCLUSIONS

The incidence of flare-up is minimal when teeth are treated in one visit. Absence of a periapical lesion in necrotic teeth is a significant risk factor for flare-ups.

Outcomes of direct pulp capping: interrogating an insurance database

AIM

To evaluate the effectiveness of direct pulp capping under general practice conditions. It was hypothesized that direct pulp capping is an effective procedure in the majority of cases and prevents the need for root canal treatment or extraction.

METHODOLOGY

Claims data were collected from the digital database of a major German national health insurance company. Only patients who had been insurance members for the entire 3 year period 2010 to 2012 were eligible. Kaplan-Meier survival analyses were conducted for all teeth with direct pulp capping. Success was defined as not undergoing root canal treatment. Survival was defined as not undergoing extraction. Differences between survival functions were tested with the log rank test.

RESULTS

A total of 148 312 teeth were included. The overall success rate was 71.6% at 3 years. The overall survival rate was 95.9% at 3 years. The success rates for single-rooted teeth (71.8%) and multirooted teeth (71.5%) were similar although significantly different (P < 0.001). Best 3-year success rates were found at low (79.7%; <18 years.) and very high age (81.8%; >85 years.).

CONCLUSIONS

After direct pulp capping, more than two-thirds of the affected teeth did not undergo root canal treatment within 3 years. Although this study has the typical limits of a claims data analysis, it can be concluded that direct pulp capping is an effective intervention to avoid root canal treatment and extraction in a general practice setting.

The effect of residual calcium hydroxide on the accuracy of a contemporary electronic apex locator

OBJECTIVE

The aim of this study was to evaluate the effect of residual calcium hydroxide [Ca(OH)2] on the accuracy of an electronic apex locator (EAL).

MATERIALS AND METHODS

Working lengths (WLs) of 56 extracted maxillary incisors were determined initially by two different methods. The first method used the 'APEX' reading of the EAL as a reference point, 0.5 mm was subtracted and recorded as WL0. The second method used the '0.5' reading and the score was recorded as WL0.5 without subtraction. The roots were prepared to WL0 and divided randomly into three experimental groups (n = 16) (1 mm in group A, 2 mm in group B and 4 mm in group C) and a control (n = 8). Specimens in all experimental groups were filled with Ca(OH)2 paste. Following its removal, WLs were re-determined with the same methods.

RESULTS

In group C, pre/post WLs were significantly different (p < 0.05). No significant difference was observed between the other experimental groups and the control group.

CONCLUSION

Accuracy of EAL decreased proportionally with the amount of paste remaining at the ±0.5-mm tolerance level. Ca(OH)2 paste remnants may cause incorrect EAL readings.