Endodontic Periapical Lesion: An Overview on the Etiology, Diagnosis and Current Treatment Modalities

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

A Comparison of Conventional Root Canal Sealers With Ones That Use Green Synthesized Nanoparticles for Antimicrobial Activity: Protocol for a Systematic Review

BACKGROUND

Root canal failure and secondary endodontic infection are frequent clinical scenarios in dentistry. The main microorganisms implicated in root canal therapy failure are persistent Enterococcus faecalis, Candida albicans, and Staphylococcus aureus. To combat the impact of disease resistance, scientists are concentrating on alternative antimicrobial root canal sealers. Nanomaterials are a recent development in endodontic materials that exhibit great antimicrobial properties, making them an ideal material choice for root canal sealers.

OBJECTIVE

This systematic review aims to compare the antimicrobial properties of conventional root canal sealers to those incorporating green synthesized nanoparticles between 2010 and 2024.

METHODS

A well-constructed protocol was established and registered with PROSPERO (CRD42021286373). Ethics approval was obtained from the Biomedical Research and Ethics Committee from the University of the Western Cape (UWC; BM22/1/4). PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) reporting guidelines were followed. The included criteria demonstrate the green synthesized nanoparticles studies where the nanoparticles (NPs) are incorporated in root canal sealers. MeSH (Medical Subject Headings) terms were used for the search strategy of the systematic electronic databases for articles published in English between 2010 and 2024. The selected databases included Scopus, PubMed, Web of Science, Science Direct, EBSCOhost, SpringerLink, and Wiley Online. A quality assessment tool for laboratory studies will be used to critically appraise the included studies. If applicable, statistical measures (mean, SD, etc) will be used for data analysis and presentation of the results.

RESULTS

The protocol is registered with PROSPERO. A preliminary search was conducted using a determined search strategy across 8 electronic databases, and the review is now complete.

CONCLUSIONS

It is anticipated that the results of this systematic review may reveal the increased interest and application for nanoparticle-enhanced root canal sealers. This will aid in the future development of root canal sealants and mitigate the risk of endodontic failure.

TRIAL REGISTRATION

PROSPERO CRD42021286373; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=286373.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51351.

A Comparative Analysis of the Quality of Root Canal Fillings of In Vivo Studies Conducted in Saudi Arabia and Worldwide: A Systematic Review

Aim

Root canal treatment (RCT) is a common procedure practiced daily by dentists worldwide. The current systematic review aimed to evaluate and compare clinical studies on the quality of root canal fillings (RCFs) carried out by dentists with different levels of experience conducted worldwide with those conducted specifically in Saudi Arabia (SA).

Materials and Methods

A full literature search was conducted in Clarivate Analytics' Web of Science, Elsevier's Scopus, Embase, CINHAL, and PubMed, without a restriction to studies published before January 2015. Also, a manual search was carried out by checking papers that may have been missed during the electronic search. The following keywords were used: [(quality of root canal filling(s)) OR (quality of root canal obturation)) and dental practitioners as (general dental practitioners; final year students; endodontist; specialist) AND (root canal obturation) OR (endodontic treatment)]. Parameters of the quality of RCFs, such as length, density, and taper, were assessed and counted.

Results

A total of 13 worldwide and nine SA studies were included in this review, published between 2015 and 2023. Molars were the most treated teeth, at 42.3% and 40.2% for the worldwide and SA studies, respectively. Cases treated by final year students had the highest percentage, at 60.0% for both study groups. The percentages of acceptable quality, with regard to the length, density, and taper of RCFs, were 70.9%, 77.6%, and 84.3%, and 73.2%, 64.6%, and 67.8% for the worldwide and SA studies, respectively.

Conclusion

The overall acceptable quality of RCFs was marginally higher in worldwide studies than in SA studies. Both prevalences can be considered as good, which indicates that the quality of RCFs is moving in the right direction.

Comparison between AH plus sealer and total fill bioceramic sealer performance in previously untreated and retreatment cases of maxillary incisors with large-sized periapical lesion: a randomized controlled trial

OBJECTIVE

This study aims to assess the efficacy of bioceramic (BC) sealer when applied using the single cone technique (SCT), in comparison to AH Plus sealer applied with the cold lateral condensation technique (LCT), concerning their impact on the healing of large-sized periapical lesions in both untreated and retreatment cases.

MATERIALS AND METHODS

A randomized controlled trial was conducted on 41 patients who had 60 permanent teeth in the maxillary incisors that were accompanied by large-sized periapical lesions. The included teeth were radiographed with cone beam computed tomography (CBCT) images and divided equally into two groups according to the endodontic treatment statute (30 untreated previous cases and 30 retreated cases). Subsequently, teeth received uniform preparation, irrigation, and dressing procedures. Then each group was divided equally according to the used sealer (15 teeth obturated using AH plus sealer with LCT and 15 teeth obturated using BC sealer with SCT). All cases were followed up after 6 and 12 months with CBCT images. Subsequently, the change in periapical lesion diameter (PLD) was observed as an indicator to determine the treatment outcome score. One-way ANOVA and Mann-Whitney U test were used to analyze the PLD changing and scoring the treatment outcome during the follow-up periods. The significance level was set at α = 0.05.

RESULTS

There were no statistically significant differences between untreated and retreatment cases neither using AH plus sealer with LCT nor BC sealer with SCT regarding changes in PLD in the follow-up periods. Moreover, there were no significant differences between groups regarding treatment outcome scores in the follow-up periods. All groups showed a high success rate.

CONCLUSIONS

Successful treatment was achieved for untreated or retreatment maxillary incisor cases accompanied by large-sized periapical lesions using either BC sealer with the SCT or AH Plus sealer with LCT with a similar high success rate up to 12 months follow-up period.

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.

A 980 nm Diode Laser as an Adjunctive Therapy on the Healing of Apical Periodontitis Following Endodontic Retreatment: A Randomized Controlled Clinical Trial Study

Introduction: Apical periodontitis is one of the common dental diseases. Microorganisms are the main reasons for these lesions; irrigations are used to remove them, but because of limited penetration, the rinsing agents may not always kill the microorganisms. Laser irradiation is effective in canal disinfection. The goal of this study was to compare the effect of calcium hydroxide (Ca(OH)2 ) and diode laser on the improvement of apical periodontitis following root canal retreatment (RCR). Methods: Twenty-four teeth of 19 patients with periapical lesions which needed RCR were divided into two groups (Ca(OH)2 and Ca(OH)2+laser irradiation [LI]). In the first session, after gutta-percha removal, cleaning, and shaping, Ca(OH)2 was used for 10 days. In the second session, in the Ca(OH)2+LI group, the irradiation utilizing a diode laser (using non-initiated 200-µm fiber, continuous wave (CW), power output of 1W) was done. The periapical radiographic healing was assessed before the retreatment and after 3-month and 6-month follow-ups by periapical index (PAI) Qrstavik. The quantitative data were analyzed (P<0.05). Results: The initial periapical lesion score was 3.75 and 3.88 in the Ca(OH)2 and Ca(OH)2+LI groups, respectively. In the Ca(OH)2 and Ca(OH)2+LI groups, 3 months after the RCR, the average periapical lesion score was 2.94 and 3.05, respectively. In the Ca(OH)2 and CA(OH)2+LI groups, 6 months after the RCR, the average periapical lesion score was 1.80 and 1.75, respectively. No significant differences were found at the 3 and 6 months between the experimental groups. Conclusion: The diode laser can reduce the periapical lesion, but there was no significant difference between CA(OH)2+LI and Ca(OH)2 at 3-month and 6-month follow-ups.

Management of a Persistent Radicular Cyst in the Maxillary Right Lateral Incisor: A Case Report

A 32-year-old male patient presented with a chief complaint of ongoing endodontic treatment and swelling in the hard palate, specifically in the rugae region. On examination, a soft, non-tender, non-fluctuant swelling was observed between teeth #11 and #12, accompanied by radiographic evidence of periapical radiolucency and perforation. Cone beam computed tomography (CBCT) scans confirmed a well-defined radiolucency in the affected region, indicative of a radicular cyst. Root canal treatment was completed with mineral trioxide aggregate (MTA) obturation during the second visit. An apicoectomy was performed to remove the cystic content, followed by the placement of bone graft material, a platelet-rich fibrin (PRF) membrane, and sutures to facilitate bone regeneration. This comprehensive approach aimed to resolve the periapical pathology and promote tissue healing around the affected tooth.

Comparative Evaluation of Three Access Cavity Preparation Techniques on Root Canal Instrumentation Using Micro-CT: An In Vitro Study

Background Access cavity preparation is a crucial step in nonsurgical root canal treatment. Recent advancements in access cavity designs focus on preserving maximum tooth structure while ensuring sufficient access to canal orifices for effective cleaning and shaping, resulting in minimally invasive procedures. However, there is limited information on the impact of three-dimensional (3D)-guided access cavity preparation in molars. A literature review found no prior studies comparing the effects of various access cavity preparation techniques on apical transportation, untouched surfaces, and debris formation within the canal. Objective The objective of this study is to compare and evaluate the effects of three different access cavity techniques on apical transportation, untouched surfaces, and debris formation within the root canal. Material and methods Thirty extracted permanent mandibular first molars were selected and randomly assigned to three groups for this study: Group I received 3D-printed static guided cavity preparation, Group II underwent conservative access cavity preparation, and Group III was subjected to traditional access cavity (TAC) preparation. The mesial canals in all samples were cleaned and shaped using TruNatomy files. Preoperative and postoperative micro-CT imaging was performed on each sample to assess the effects of the different access cavity preparation techniques on apical transportation, untouched surfaces, and debris formation within the root canal. Results The study found that Group I, which used 3D-printed static guided cavity preparation, exhibited significantly less apical transportation compared to Groups II and III, with mean differences of -0.1677 and -0.2079, respectively. Debris accumulation was similar across all groups, with mean values of 0.928 ± 0.824 for Group I, 0.751 ± 0.495 for Group II, and 0.938 ± 0.681 for Group III, indicating no significant impact of cavity preparation type on debris levels. For untouched canal surfaces, Group III (TAC preparation) had the fewest untouched surfaces, with mean differences of 3.0380 and 3.9020 compared to Groups II and I, respectively. Conclusions While TAC preparation reduces substantial tooth structure, it shows higher instrumentation efficacy and better cleaning of the root canal system. However, in complex cases where tooth structure preservation is crucial, guided access cavity preparation provides an effective balance between structural conservation and adequate canal access. This approach offers a tailored solution, optimizing treatment outcomes based on the specific clinical scenario.

Assessment of Debris Extrusion in Curved Canals: An In Vitro Analysis of Various Single-File Endodontic Instrumentation Systems

Objectives

Rotary single-file endodontic systems are commonly used for root canal treatment. However, very few studies have evaluated the apical extrusion of debris generated by these systems during canal preparation at normal body temperature in laboratory conditions. The aim of this study was to evaluate the amount of apically extruded debris caused by seven different single-file endodontic instrumentation systems at body temperature in mandibular molar teeth with curved root canals.

Methods

One hundred forty mandibular first permanent molars were randomly divided into seven groups (n = 20) to be prepared by one of the following systems at 35°C: Reciproc Blue (REC Blue), WaveOne Gold (WOG), One Reci (OR), Neoniti, HyFlex EDM (HEDM), One Curve (OC), or XP Shaper (XPS). Debris was collected into preweighted Eppendorf tubes. The weight of the extruded debris was recorded by subtracting the weight of the tooth-free apparatus from the post-procedure weight. Data were analyzed by one-way ANOVA and Tukey's tests (p  < 5%).

Results

REC Blue, WOG, and OR groups extruded significantly more debris from the apex than XPS, OC, and Neoniti groups (p  < 0.05). No significant difference was observed among the XPS, OC, Neoniti, and HEDM groups (p  > 0.05).

Conclusion

All the instruments were associated with debris extrusion. However, REC Blue, WOG, and OR extrude significantly more debris than other instruments. The amount of debris with different files was REC Blue > OR > WOG > HEDM > OC > Neoniti > XPS. XPS, Neoniti, and OC caused significantly less extrusion of debris than REC Blue, WOG, and OR.

[Repair of perirradicular tissues in non-surgical endodontic treatment. A review]

Introduction

Non-surgical endodontic treatment aims to prevent apical periodontitis, achieved with the disinfection of the root canal system. Additionally, there are pathologies where the toxic content of the canal goes to the periradicular tissues, causing osteolysis or lesions of the bone tissue that are radiographically observed as radiolucent images. When the endodontic treatment is successful, the repair of these lesions occurs over time.

Aim

To analyze the periradicular repair process of non-surgical endodontic treatment and the factors that affect it.

Materials and Methods

An electronic search was carried out using the search engines PUBMED, Scopus, Google Academic, and Scielo with the words "Non-Surgical Endodontic Treatment," "Periapical Tissues," "Biological Repair," "Apical Repair." Factors such as incomplete texts, PDF texts, and publication date of the article were considered, including data from the last five (05) years.

Results

The information reviewed comprised 236 articles analyzed with the inclusion and exclusion criteria, and only 42 articles met these criteria.

Conclusion

The success of endodontic treatment lies in the absence of clinical and radiographic signs and symptoms of infection; this is achieved with a good application of clinical protocols and procedures focused on the disinfection of the root canal system, from diagnosis, biomechanical preparation, and disinfection of the root canal system with irrigating substances and filling, including coronal rehabilitation from an aesthetic and/or prosthetic point of view.

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

BACKGROUND

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Non-surgical Management of a Large Periapical Lesion: A Case Study of the Successful Application of a Modified Triple Antibacterial Paste

Infection of the dental pulp involves mainly Gram-negative, anaerobic bacterial flora and due to this infection, the periapical area experiences an immunological response, which is termed a periapical lesion. This lesion may appear as a radiolucent (dark) area on X-rays, which indicates periapical inflammation and infection. Its prevalence depends on factors such as age, oral health maintenance, and dental care. Men are more likely to be affected by this infection than women. There are two modalities for the treatment of periapical lesions: surgical or non-surgical endodontic therapy. The modified triple antibiotic paste (TAP) comprising ciprofloxacin, metronidazole, and clindamycin in the ratio of 1:1:1 was first prepared expressly to treat the teeth with necrotic pulp and to support the protocol for revitalization and regrowth. The treatment was very successful in eliminating germs from the root canal system. It provides broad-spectrum antimicrobial activity against a wide range of bacteria commonly associated with endodontic infections. The modified TAP is usually inserted into the canal for a predetermined amount of time and then removed followed by the irrigation of root canal, which helps to eliminate the microorganisms from the root canal. The non-surgical treatment should always be the first choice over the surgical approach so as to avoid a more invasive procedure.

Application of personalized templates in minimally invasive management of coronal dens invaginatus: a report of two cases

BACKGROUND

Treating the coronal dens invaginatus (CDI) with pulp infection commonly involves the removal of invagination, which increases the risk of perforation and fracture, and compromises the tooth structure. Minimally invasive endodontic management of CDI is highly recommended. This report describes two cases of type II CDI with the application of personalized templates.

CASE PRESENTATION

Two cases of type II CDI, affecting the main root canal in a maxillary canine and a lateral incisor, were diagnosed. A guided endodontics (GE) approach was applied. Cone-beam computed tomography and intraoral scans were imported and aligned in a virtual planning software to design debridement routes and templates. The MICRO principle (which involves the aspects of Mechanical (M) debridement, Irrigation (I), Access cavities (C), Rectilinear routes (R), and Obstruction (O)) was proposed for designing optimal debridement routes for future applications. The templates were innovatively personalized and designed to preserve the tooth structure maximally while effectively debriding the root canal. Root canal treatment with supplementary disinfection was then performed. The follow-up of the two patients revealed favorable clinical and radiographic outcomes.

CONCLUSIONS

The GE approach could be a feasible method for preserving healthy dental structure while effectively debriding the root canal, thereby achieving successful and minimally invasive endodontic treatment for CDI.

The effects of NLRP3 inflammasome inhibition or knockout in experimental apical periodontitis induced in mice

OBJECTIVE

To evaluate the effects of NLRP3 inflammasome inhibition or knockout in experimental apical periodontitis (AP) induced in mice.

METHODS

The experimental AP was induced by pulpal exposure. To evaluate NLRP3-specific inhibitor medication (MCC950), WT mice received intraperitoneal injections, while the control received PBS (n = 10). In addition, to evaluate NLRP3 knockout, 35 wild-type (WT) and 35 NLRP3-/- mice were divided into a control group (without pulpal exposure, n = 5) and three experimental groups: after 2, 14 and 42 days after pulpal exposure (n = 10). Microscopic and molecular analyzes were carried out using a significance level of 5%.

RESULTS

Exposure to MCC950 did not affect the periapical lesion size after 14 days (P = 0.584). However, exposed mice had a lower expression of IL-1β, IL-18 and caspase-1 (P = 0.010, 0.016 and 0.002, respectively). Moreover, NLRP3-/- mice showed a smaller periapical lesion after 14 and 42 days (P = 0.023 and 0.031, respectively), as well as a lower expression of IL-1β after 42 days (P < 0.001), of IL-18 and caspase-1 after 14 (P < 0.001 and 0.035, respectively) and 42 days (P = 0.002 and 0.002, respectively). NLRP3-/- mice also showed a lower mRNA for Il-1β, Il-18 and Casp1 after 2 (P = 0.002, 0.036 and 0.001, respectively) and 14 days (P = 0.002, 0.002 and 0.001, respectively).

CONCLUSIONS

NLRP3 inflammasome inhibition or knockout can attenuate the inflammatory events that result in the periapical lesion (AP) formation after pulpal exposure in mice.

CLINICAL RELEVANCE

The NLRP3 inflammasome may be a therapeutic target for AP, and new approaches may verify the impact of its inhibition (through intracanal medications or filling materials) on the bone repair process and treatment success.

Survival of endodontically treated teeth in public dental service in Northern Finland: a practise-based register study

OBJECTIVE

The aim of this study was to explore the factors associated with the survival of root canal treated teeth in a practise-based study setting in a 5-year period.

MATERIAL AND METHODS

This retrospective study used data from the electronic patient registration system of the public dental services of the City of Oulu, Finland. The inclusion criteria for this study were patients aged ≥ 20 years who had root canal treatment (RCT) that was initiated in 2014. One RCT per patient was included in the study. A total of 713 patients met the inclusion criteria. The outcome variable for this study was the extraction of the RCT tooth during the 5-year period. Explanatory variables included age, diagnosis, tooth type (incisive, canine, premolar, molar), RCT technique (manual, motorized), time from RCT initiation to final restoration and type of final restoration (composite, glass ionomer, fixed dental prosthesis). To evaluate the association between the outcome variable and explanatory variables, Cox regression analyses were performed.

RESULTS

The overall survival rate was 91%. The middle-aged (40-59-years-old) and the oldest (60 and older) patients had a two-fold risk of extraction compared to younger (20-40-years-old) patients. Similarly, a short length of time from RCT initiation to final restoration (0-14 days) resulted in a nearly three times higher risk of extraction compared to a longer period (≥ 90 days).

CONCLUSIONS

The 5-year survival rate of RCTs seems high. Extractions were more common among patients over 40 years of age and if the RCT was completed shortly after its initiation.

The Effect of Lasers on the Healing of Periapical Lesion: A Systematic Review

Introduction: Endodontic treatment of teeth with periapical lesions presents more clinical difficulty. Various lasers in several methods are used in endodontics, and most of them are utilized as an adjunctive protocol in order to reduce the bacterial load of the root canal system. Improved disinfection plays a crucial role in enhanced and accelerated healing of periapical lesions. This review aims to summarize studies assessing the effect of lasers on periapical lesion healing. Methods: PubMed/MEDLINE, Scopus, Embase, and Web of Science (ISI) online databases were searched, with no publication year or status restriction, for relevant articles on April 2023. Clinical studies evaluating the effect of laser application on the periapical lesion of patients using radiographic assessment were considered eligible for inclusion. Results: Eight studies were included after carefully screening the obtained articles, first by their title and abstract and then by their full texts. Diode (4), Er, Cr: YSGG (3), and Nd: YAG (1) lasers were used with output powers that varied from 0.75 to 2 watts. Photodynamic therapy was employed in two studies, and in other studies, the root canal system was directly irradiated. Irradiation of the root canal system was adjunctive to standard preparation in all studies. The healing of the teeth treated with lasers was not inferior to those conventionally treated. In all of the included studies, laser application outperformed the standard cleaning and shaping protocol; however, this improved or faster healing was not statistically significant in most studies. Conclusion: Lasers might expedite and improve the healing process of periapical lesions. Since lasers enhance the quality of cleaning of the root canal system, it is hard to point out the exact mechanism of it. Further investigations are needed to realize the effectiveness of this treatment modality and to discover the underlying biological concepts.

[Effectiveness of curcumin as photodynamic therapy for endodontic procedures: a narrative review]

Introduction

Endodontic therapy is performed by biomechanical preparation and intracanal medication; however, residual bacteria can be compromised due to their ability to adhere to the root canal walls. Therefore, photodynamic therapy has gained popularity because of its good ability to prevent and eradicate microbial infections by using a light-activated dye. Objective: Analyze and to update the information on the effect of curcumin in photodynamic therapy in root canal treatment.

Material and Methods

A literature search was carried out in PubMed/MEDLINE, Scopus, Ebsco, Science Direct, and LILACS databases using the keywords "curcumin", "turmeric", "photodynamic", "photochemotherapy", "photoradiation", "photoactivated disinfection", "root canal disinfection", "root canal therapy", "endodontics" in both Spanish and English, from 2018 to 2023.

Results

Information from the last five years was collected with the aim of updating the study topic. 749 articles were examined using inclusion and exclusion criteria, of which only 50 met these criteria and were analyzed. Current studies show the effects of therapy on the contamination of the root canal biofilm with E. faecalis, demonstrating that photoactivated curcumin promotes the disruption of the biofilm and reduction of Colony-Forming Units.

Conclusions

Curcumin as a photosensitizer demonstrates a potential antibacterial effect significantly decreasing the viability of microbial cells and the vitality of biofilms.

Assessment of bone regeneration after maxillary radicular cyst enucleation with or without bone grafting materials: a retrospective cohort study

OBJECTIVE

The limitations of spontaneous bone healing underscore the necessity for exploring alternative strategies to enhance bone regeneration in maxillary radicular cyst cases. This retrospective study aimed to assess the impact of a bone substitute material (i.e., Bio-Oss) on bone volume regeneration following maxillary radicular cyst enucleation using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Seventy-three patients with maxillary radicular cysts were divided into two groups: one undergoing guided bone regeneration (GBR) with Bio-Oss and absorbable collagen membrane (n = 35), and the other receiving cyst excision alone (n = 38). Volumetric measurements using Amira software on CBCT scans evaluated bone regeneration, with cystic lesion shrinkage rates calculated. Intergroup comparisons utilized independent sample t-tests (P < 0.05), and linear regression analysis assessed the influence of preoperative cyst volume and group on bone healing.

RESULTS

Both groups showed similar success rates in bone formation at the 12-month follow-up, with no significant differences between them (mean (SD), control: 75.16 (19.17) vs. GBR: 82 (20.22), P > 0.05). Linear regression analysis revealed a negative correlation between preoperative cyst volume and bone regeneration in both groups (P < 0.05).

CONCLUSION

Bio-Oss may not significantly enhance bone augmentation in maxillary radicular cysts. In addition, preoperative cyst volume negatively affected the shrinkage rate of cystic lesions.

CLINICAL RELEVANCE

Clinicians should consider patient-specific factors such as anatomy and lesion size when determining the need for bone substitute materials. Future research could focus on optimizing treatment protocols and alternative regenerative strategies to improve patient outcomes in maxillary cyst cases.

MTA as modulator of periapical tissue healing in rat molar: A histological study

Background

Periapical surgery has been suggested as a treatment option for teeth with periapical lesions when those lesions continue despite receiving root canal therapy. Since sealing the apical region is the operation's primary goal, the choice of the root-end filling material affects how the surgery turns out. The retrofilling materials Zinc Oxide Eugenol (ZOE) and Mineral trioxide aggregate (MTA) are both known to have antibacterial characteristics. The purpose of this study is to determine how MTA affects as a Modulator of Periapical Tissue Healing through histological examination in Rat Molar.

Methods

A dental fissure bur measuring 0.7 mm is used to remove the buccal root apex from the buccal alveolar bone's surface, creating the cavity. One of the following is placed within each cavity: Group 1: MTA, Group 2: ZOE. For each material series, six samples were used. We classified the healing outcomes for each MTA and ZOE retrograde filling material into three groups based on histological analysis: the amount of newly generated bone, the number of fibroblasts, and the infiltration of neutrophils into the surgical site.

Results

On the 6th day of examination, fibroblasts were seen in the area around the wound. A significant inflammatory response, including neutrophil infiltration, was seen around the ZOE after retrograde filling. On the 16th day, the new alveolar bone structure showed a slight increase. After filling the MTA on the 6th day of examination, the immediate inflammatory response was insignificant. Neutrophils were observed to enter the region surrounding the retrofilled MTA, and a small number of osteoclasts were observed to be resorbing bone. Around the wound site, fibroblasts can also be detected. On the 16th day, unlike ZOE, a lot of new bone grows close to this material.

Conclusion

MTA has the ability to modulate periapical healing in rat molar.

Orthodontics and Endodontics Clinical Practice Correlation: A Narrative Review

Research on the connection between endodontic therapy and orthodontics is lacking. This overview of the literature synthesizes the findings from the fields of orthodontics and endodontics and explains how they are related. Beginning with the diagnosis, treating the patient at the appropriate time, moving endodontically treated teeth and traumatized teeth, resorbing roots by orthodontic mechanics, and managing traumatized teeth with orthodontic therapy. Multiple electronic databases were utilized including (PubMed, Scopus, Science Direct, and Web of Science) to perform manual literature searches. A total of 31 articles were reviewed and summarized in this paper in keywords like "Endodontically Treated Teeth and Orthodontic Treatment," "Endodontically Treated Tooth and Orthodontic Movement," "Orthodontic Treatment in RCT Teeth," "Root Canal Treatment with Orthodontic Movement," "Trauma with Orthodontic Movement," "Orthodontic and Endodontic." Orthodontic treatment of endodontically treated and traumatized teeth is a subject of controversy. The lack of research on the topic makes it a hard decision to make when to treat these teeth. Especially given that both orthodontic and endodontic treatments have multiple consequences on each other's outcomes. Thus, it is crucial for clinicians to understand how they integrate and have a guideline to refer to during decision-making. Successful orthodontic tooth movement could be carried out immediately after endodontic treatment. However, traumatized teeth need a follow-up period before initiating orthodontic movement, which ranges from three months to 12 months depending on the type of trauma and severity. Careful radiographic and clinical follow-up should be done during the healing period. Collaborative teamwork is important between orthodontists and endodontists for the success of treatment, and to achieve satisfactory outcomes.

Comparison of the Antibacterial Effect of AH26, Adseal and Beta RCS Root Canal Sealers against Enterococcus Faecalis, an in Vitro Study

Objectives: Antibacterial activity against endodontic pathogens is a desirable feature for root canal sealers. The objective of this study was to compare the antibacterial effect of three resin-based endodontic sealers (AH26, Adseal, and Beta RCS) against Enterococcus faecalis in vitro. Materials and Methods: The antibacterial properties of the sealers were assessed against E. faecalis using agar diffusion test (ADT) for fresh state (N=10) and direct contact test (DCT) for freshly-mixed and set states of the materials (N=10). In ADT, the diameter of the zones of inhibition was measured after 24h of contact. In DCT, the colony-forming units of the bacteria were counted after 30 minutes and 180 minutes of exposure. The results were analyzed with two-way ANOVA and independent sample t-test. P<0.05 was considered significant. Results: Regarding DCT results, all test materials indicated an antibacterial effect, both in freshly-mixed and set states. The highest antibacterial effect was related to Adseal, whereas the lowest was observed in Beta RCS. There was a significant difference between all study groups (different sealers, setting states, and contact times; P<0.001), except for freshly-mixed AH26 and Adseal at 180 minutes (P>0.05). According to ADT, AH26 and Adseal represented the widest and the smallest inhibition zones, respectively (P<0.001). Conclusion: Within the limitations of this in vitro study, AH26, Adseal, and Beta RCS showed antibacterial effects against E. faecalis in both freshly-mixed and set states. The antibacterial effect increased over time in all of the studied sealers.

Periapical Healing Outcome of Endodontic Re-Treatment Using Calcium Silicates Versus Resin-Based Sealers: A Systematic Review

Aim

This systematic review was conducted with the purpose of analyzing the effects of root-end sealers in endodontic re-treatment cases and comparing calcium-based sealers with sealers, which were resin-based.

Methodology

We conducted this review based on the principles of Cochrane systematic type of studies and also based on guidelines of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). An exhaustive search was conducted across PubMed, Medline, and Embase databases for the studies, which were based on root end sealers in cases of endodontic re-treatments. The data were then analyzed statistically with the help of SPSS 25.0.

Results

It was seen that when comparing pain levels in post-obturation cases with these sealers after 24 hours and 48 hours, not much of statistically noteworthy differences were evident. Mean difference (MD) values at 24 hours were -0.20 with confidence intervals between -0.44 and 0.07 and P value of 0.15, whereas in case of 48 hours, MD was -0.36, CI- 0.65, and P value was 0.03. However, the results were slightly better with calcium-based sealers.

Conclusion

Calcium silicate-based root end obturation sealers had similar performance when compared to resin-based sealers when we compared variables like pain intensity, etc.

Efficacy of a Novel Intracanal Medicament on Total Antioxidant Status in Patients With Apical Periodontitis: A Randomized Controlled Clinical Trial

Introduction Successful endodontic treatment relies upon the microbial debridement of the root canal system. This can be achieved to a great extent by using intracanal medicaments, which inhibit the microbes growing in the root canal. Evaluating the capacity of oxidants in the saliva is a crucial parameter for assessing the antioxidant capacity of any individual, which decreases in inflammatory conditions. An effective intracanal medicament can increase the total antioxidant capacity of saliva, which comes down because of inflammatory conditions. Aim To evaluate the effect of two intracanal medicaments on the antioxidant capacity of saliva. Materials and methods In a randomized prospective clinical trial, 42 patients with a mean age of 18-70 years were selected based on exclusion and inclusion criteria, and the baseline value of the total antioxidant capacity of saliva was recorded. The patients were categorized into two groups as per the block randomization method (Group I: calcium hydroxide (Maarc, New Delhi, India) intracanal medicament; Group II: Hekla lava (SBL Pvt. Ltd., Germany) intracanal medicament). Access opening, working length determination, and cleaning and shaping were conducted using hand K-files and ProTaper Gold rotary files. Intracanal medicaments were placed according to the groups assigned, and temporary restoration was placed. The patients were recalled after seven days. If the tooth was asymptomatic, obturation was completed, and a saliva sample was collected to assess the total antioxidant capacity. Results The total antioxidant capacity of saliva was increased after using intracanal medicaments and endodontic therapy, and there was a statistically significant difference before and after using both the medicaments (p=0.0005; i.e., calcium hydroxide and Hekla lava. When both medicaments were compared, there was no significant difference in the antioxidant capacity of saliva among medicaments (p=0.384). Conclusion The total antioxidant capacity of saliva was increased after using both the intracanal medicaments. Hence, Hekla lava can be potentially used as an alternative intracanal medicament.

Treatment of an apical cyst with platelet concentrate - a case report

Apical cysts are typically caused by dental pulp disease and are difficult to treat. In the majority of cases, surgical intervention is required. The rate of success after apical osteotomy varies between 60% and 91%. The introduction of platelet concentrates in treating chronic apical periodontitis is a promising direction for achieving quick and secure results. This article examines the healing of a sizable apical cyst after conservative surgical intervention and the application of platelet concentrate.

In vitro evaluation of three engineered multispecies endodontic biofilms on a dentinal disk substrate

The aim of this study was the development of a complex multispecies endodontic biofilm using Candida albicans, Proteus mirabilis and Pseudomonas aeruginosa on a biofilm of Enterococcus faecalis in a dentinal substrate design. The endodontic pathology is a biofilm-mediated infection, and the aim of root canal therapy is to reduce, as much as possible, the bacterial population. Thus, it is important to develop a laboratory endodontic biofilm to test the effect of new irrigation and obturation techniques on reduction of bacterial count. The culture of Enterococcus faecalis from ATCC 29212 began with aerobic cultivation on blood agar, followed by transfer to Brain Heart Infusion (BHI) broth with 5% sucrose. Incubation occurred in a shaker at 37 °C for 24 h, followed by an additional 24-h static phase. After 10 d, Proteus mirabilis, Pseudomonas aeruginosa, and Candida albicans were introduced sequentially in three distinct groups. Group 1: the order of addition was Candida albicans, Proteus mirabilis, and Pseudomonas aeruginosa; Group 2: the order was Pseudomonas aeruginosa, Candida albicans, and Proteus mirabilis; and Group 3: Proteus mirabilis, Pseudomonas aeruginosa, and Candida albicans. After 16 days, the biofilm was carefully extracted, transferred to sterile BHI, and dissected using a sterile needle technique. Subsequently, an optical density test, bacterial counts, and colony enumeration were performed on various agar plates. Group 2 in which Pseudomonas aeruginosa was added directly after Enterococcus faecalis followed by Candida albicans and Proteus mirabilis showed significantly greater total bacterial count than the other two groups.

Dental pathologies of endodontic origin and subsequent bacterial involvement - a literature review

Dental pathologies of endodontic origin are varied in nature, and include infectious and non-infectious causes. Through this review, we aim to provide a deeper understanding of the role of bacterial involvement and in the pathogenesis of endodontic pathologies, by reviewing the relevant literature on the most common bacterial species involved, and their capacity to organize as biofilms. Furthermore, we focus on the most important recent updates in the management of endodontic infections, from a multidisciplinary perspective.

Comparison of the Fracture Resistance of Root-Canal-Treated Premolars Obturated With Dissimilar Materials: An In Vitro Study

Introduction The utilization of endodontic sealers is of paramount importance in ensuring the sustained efficacy and resilience of endodontic treatment. The primary objective of the research was to appraise and contrast the fracture resistance (FR) of three distinct categories of endodontic sealing materials that are frequently employed in the context of endodontic therapy. Materials and methods This research used an in vitro experimental design. Sixty single-rooted human teeth indicated for extraction were utilized according to established protocols. These teeth were then arbitrarily divided into four piles, one for each of the four possible sealants. All specimens were put through a standardized thermal cycling procedure to simulate clinical conditions after the root canals were obturated. The subsequent step involved testing the FR of each group by utilizing a universal testing machine up until failure. Any statistically significant difference in FR among the three sealing materials was identified through appropriate statistical analysis. Results Group 1, which utilized a particular sealing material, exhibited the highest mean fracture resistance, measuring at an impressive 1198.33 ± 321.4 Newtons (N). A post hoc analysis was done to see the exact differences between each group and statistically significant differences between Groups 1 and 2 (p<0.05), Groups 1 and 4 (p<0.05), and Groups 3 and 4 (p<0.001) were observed. Conclusion The FR of Group 1 specimens were noticeably greater than those of Group 2 and Group 4 while the FR of Group 3 specimens was more than that of the Group 4 specimens. This study provides important insights into the fracture resistance of various endodontic sealing materials.

The role of systemic statins in the inception and healing of apical periodontitis: a systematic review

OBJECTIVES

Statins are a category of medications widely used to reduce plasma LDL-cholesterol levels, that also possess antibacterial, anti-inflammatory, and immunomodulatory action. The aim of this systematic review was to explore the effects of systemic statins therapy on the development and treatment of apical periodontitis (AP) on humans and animals.

MATERIAL AND METHODS

Three electronic databases (PubMed, Web of Science, and Scopus) and grey literature were searched from their inception until February, 20 2023 (PROSPERO CRD42021246231). For the quality assessment and risk of bias, different guidelines were used according to the typology of the studies considered (Animal Research Reporting of In Vivo Experiments, Newcastle-Ottawa Quality Assessment Form for Cohort Studies, Systematic Review Centre for Laboratory animal Experimentation Risk of Bias tool and Tool to assess risk of bias in cohort studies of CLARITY Group).

RESULTS

Seven hundred eleven records were screened, and six articles were included for this qualitative review. The eligible studies showed a moderate overall quality and risk of bias. Human patients in treatment with statins exhibited a higher healing rate of AP following root canal treatment. In experimental animal models, statins had a beneficial effect on the development of AP.

CONCLUSIONS

Despite the limited number of studies and considering that most of them are on animals, our findings suggest that systemically administered statins make a positive contribution to prevent the development and help healing of AP.

CLINICAL RELEVANCE

There is an increased evidence that a pharmacologic adjunct to endodontic treatment may be considered to enhance healing of AP. Among other medications, statins seem to have a positive impact on the disease.

[Effectiveness of an irrigant in the chronic periapical abscess management: a case report]

The endodontic environment has optimal conditions for the growth of microorganisms that can release by-products into the periapical region of the tooth and cause inflammatory lesions. Chemical disinfection using irritants solutions plays an clinical important role, as they are able to remove waste from contaminated organic and inorganic tissues, generating a residual antibacterial effect. The purpose of this study was to show the effectiveness of 2.5% and 5.25% sodium hypochlorite as an irrigating agent for the clinical management of a chronic periapical abscess in a tooth with apical resorption. Initially, 2.5% sodium hypochlorite was used, however, as it did not have an optimal abscess healing response after 3 days, it was decided to use a concentration of 5.25% to achieve a better bactericidal effect. After 5 days, the fistula healed, and endodontic treatment continued. One of the perspectives of this case report is to investigate more about the use of antibiotic therapy in conjunction with a good irrigation protocol.

Assessment of Digital Intraoral Periapical Radiograph for the Detection of Apical Root Resorption in Inflammatory Periapical Pathologies: A Radiovisiography Study

Introduction Resorption often takes the form of external inflammatory root resorption. Apical periodontitis or an apical cyst is the most typical cause of external inflammatory root resorption. Failure of endodontic treatment can occur if severe apical root resorption occurs.This is due to the difficulty of reaching these sites.Apical root resorption is usually discovered during routine radiographs and is usually in its later stages. If the lesion is advanced, extraction is the only viable solution. An accurate diagnosis of incipient root resorption is essential. This research is designed to analyze the effectiveness of digital intraoral periapical radiographs in assessing apical root resorption (ARR) related to periapical pathologies. Material and methods This cross-sectional radiographic observational research was conducted in a dental college and hospital in central India. Radiovisiography (RVG) images of 190 patients' teeth with inflammatory periapical pathologies were evaluated to determine the presence or absence of resorption in the apical area of the root. After the radiographic assessment of the apical root resorption, the extraction of the affected teeth was done under all aseptic conditions. The periapical tissue was sent for histological analysis and the extracted tooth sample was examined for the presence or absence of apical root resorption. Results In comparison to apical periodontitis, the proportion of severe root resorption patients was significantly higher in abscess and periapical granuloma. Using Pearson's Chi-square test, the difference in patient proportions according to the kind of resorption in the three radiological diagnosis groups was statistically significant with a p-value of 0.0058. Conclusion It was concluded that on radiographic examination, digital intraoral periapical radiographs were found to be accurate in determining periapical apical pathologies and apical root resorption.

Evaluation of 3D MRI for early detection of bone edema associated with apical periodontitis

OBJECTIVES

To detect and evaluate early signs of apical periodontitis using MRI based on a 3D short-tau-inversion-recovery (STIR) sequence compared to conventional panoramic radiography (OPT) and periapical radiographs in patients with apical periodontitis.

MATERIALS AND METHODS

Patients with clinical evidence of periodontal disease were enrolled prospectively and received OPT as well as MRI of the viscerocranium including a 3D-STIR sequence. The MRI sequences were assessed for the occurrence and extent of bone changes associated with apical periodontitis including bone edema, periradicular cysts, and dental granulomas. OPTs and intraoral periapical radiographs, if available, were assessed for corresponding periapical radiolucencies using the periapical index (PAI).

RESULTS

In total, 232 teeth of 37 patients (mean age 62±13.9 years, 18 women) were assessed. In 69 cases reactive bone edema was detected on MRI with corresponding radiolucency according to OPT. In 105 cases edema was detected without corresponding radiolucency on OPT. The overall extent of edema measured on MRI was significantly larger compared to the radiolucency on OPT (mean: STIR 2.4±1.4 mm, dental radiograph 1.3±1.2 mm, OPT 0.8±1.1 mm, P=0.01). The overall PAI score was significantly higher on MRI compared to OPT (mean PAI: STIR 1.9±0.7, dental radiograph 1.3±0.5, OPT 1.2±0.7, P=0.02).

CONCLUSION

Early detection and assessment of bone changes of apical periodontitis using MRI was feasible while the extent of bone edema measured on MRI exceeded the radiolucencies measured on OPT.

CLINICAL RELEVANCE

In clinical routine, dental MRI might be useful for early detection and assessment of apical periodontitis before irreversible bone loss is detected on conventional panoramic and intraoral periapical radiographs.

Reduction of NrF2 as coadjuvant during the development of persistent periapical lesions

BACKGROUND

Persistent periapical lesions (PPL) are the result of pulpar necrosis induced by bacterial infection resulting in bone degradation and culminating with the loss of dental piece. Pathological changes in the peripapice are associated with the presence of free radicals. The transcription factor Nrf2 is the main regulator of the endogenous antioxidant response against oxidative stress and has been implicated in the regulation of osteoclastogenesis.The aim is to determine the oxidative condition in samples from patients with Persistent Periapical Injuries as a detonating factor of tissue damage.

MATERIAL AND METHODS

An observational, descriptive, cross-sectional study was carried out in samples with PPL (cases) and samples by removal of third molars (controls) obtained in the clinic of the specialty in endodontics, University of Guadalajara. Samples were submitted to histological staining with Hematoxylin-Eosin, lipoperoxide analysis, Superoxide Dismutase (SOD), Glutathione-Peroxidase (GPx) and Catalase (CAT) activities were determined by immunoenzymatic assays and NrF2 by Western Blot analysis.

RESULTS

Samples from PPL patients histologically showed an increased presence of lymphocytes, plasma cells, and eosinophils, as well as a decrease in extracellular matrix proteins and fibroblast cells. There was a rise in lipid peroxidation, GPx and SOD activities, but an important decline (36%) in Catalase activity was observed (p<0.005); finally, NrF2-protein was diminished at 10.41%. All comparisons were between cases vs controls.

CONCLUSIONS

The alterations in antioxidants endogenous NrF2-controlled are related to osseous destruction in patients with PPL.

Conservative endodontic microsurgery to protect critical anatomical structures-selective curettage: a case series

BACKGROUND

Endodontic microsurgery has yielded highly successful outcomes in preserving teeth with persistent or recurrent cases of periapical periodontitis that could not be successfully treated by nonsurgical endodontic approaches. To avoid complications in conditions in which periapical lesions invade anatomical structures such as the nasopalatine nerve tube and mandibular canal, selective curettage has been proposed as an alternative choice of complete curettage in surgery.

CASE PRESENTATION

The 8 cases reported herein had undergone root canal treatment and/or retreatment but still presented with symptoms, such as recurring sinus tracts and persistent dull pain. The radiographic examination indicated a large area of radiolucency that was associated with the tooth and had invaded adjacent critical anatomical structures. The patients opted for selective curettage via endodontic microsurgery, and the lesions were histologically confirmed as periapical cysts or granulomas. The follow-up results for one year or more indicated that the affected teeth were clinically asymptomatic and exhibited complete or incomplete healing radiographically.

CONCLUSION

This case series provides clinical evidence for the feasibility of selective curettage in endodontic microsurgery, which can avoid complications caused by damage to the adjacent critical anatomical structures.

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

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

A Systematic Review on Comparison of Periapical Healing and Post-Operative Pain between Bioceramic and Epoxy Resin Based Sealers

To compare the incidence of postoperative discomfort and periapical healing in endodontically treated teeth following the use of resin-based or bioceramic sealers. In vivo, clinical trials were included in the study. The selection criteria, data extraction, and analysis were performed to evaluate the quality and publication bias of the selected studies. The primary outcome measure was the comparison of postoperative discomfort between the two sealer types. Seven studies were included in the systematic review, with a modest level of evidence found in the quality assessment. There are no significant differences in the postoperative discomfort levels between resin-based and bioceramic sealers. However, the overall quality of the clinical trials was moderate, highlighting the need for further well-designed clinical trials with appropriate measures of randomization, allocation concealment, and blinding to establish a definitive conclusion on the incidence of Postoperative discomfort associated with the use of these sealers.

Resolution of a periapical lesion in an autoimmune pancreatitis patient treated with long-term low-dose glucocorticoids: a case report

BACKGROUND

Patients diagnosed with an autoimmune disease are often systemically medicated with glucocorticoids. Autoimmune pancreatitis (AIP) Type 1 is considered a rare autoimmune disease, which is very well responsive to glucocorticoids and hence can be treated optionally on a long-term basis using low dose of the drug. Apical lesions of root canal-treated teeth can be solved by retreatment of the preexisting root canal obturation or via surgical approaches.

CASE PRESENTATION

This case report relates to a 76-year-old male patient, whose symptomatic acute apical periodontitis was treated nonsurgically by root canal treatment. However, overtime both roots of tooth 46 were associated with asymptomatic apical lesions. Despite progression of the lesions, due to a painless situation, the patient refrained from proceeding with any further treatment options after explaining the pathological pathway with all its consequences. A few years later the patient was prescribed 2.5 mg glucocorticoid prednisone daily for long-term therapy due to an AIP Type 1. Six years later under strict glucocorticoid therapy the apical lesions healed nearly completely and the patient remained free of symptoms without any further interventions.

CONCLUSIONS

These observations suggest that prospective clinical studies are required to further elucidate the potential healing effect of systemic long-term low-dose glucocorticoid medication on lesions of endodontic origin.

Application of apical negative pressure irrigation in the nonsurgical treatment of radicular cysts: A case report

BACKGROUND

Radicular cysts are one of the most common odontogenic cystic lesions found in the jaw. Nonsurgical treatment of large radicular cysts is a topic of ongoing debate, and there is still no clear consensus on the most effective therapies. The apical negative pressure irrigation system aspirates the cystic fluid and releases the static pressure in the radicular cyst, representing a minimally invasive approach for decompression. In this case, the radicular cyst was in close proximity to the mandibular nerve canal. We used nonsurgical endodontic treatment with a homemade apical negative pressure irrigation system and the prognosis was good.

CASE SUMMARY

A 27-year-old male presented to our Department of General Dentistry with complaints of pain in the mandibular right molar when chewing. The patient had no history of drug allergies or systemic disease. A multidisciplinary management approach was designed and included root canal retreatment with a homemade apical negative pressure irrigation system, deep margin elevation and prosthodontic treatment. According to a 1-year follow-up period, the patient showed a favorable outcome.

CONCLUSION

This report reveals that nonsurgical treatment with an apical negative pressure irrigation system may provide new insights into the treatment of radicular cysts.

Correlation between bacterial type/bacterial quantity and bone loss detected by cone beam computed tomography (CBCT) in primary endodontic infections

Periapical lesions (PL) of endodontic origin are one of the most common pathological conditions that affect peri-radicular tissues. The main ob-jective of this study was to evaluate the amount and species of microorganisms isolated from necrotic pulps, establish a correlation between these and the size of periapical lesions, and how the amount and species of microorganisms decreased with non-surgical root canal treatment. Twenty-seven patients with a clinical diag-nosis of dental pulp necrosis and chronic periapical lesions were selected; a Cone Beam Computed Tomography (CBCT) and microbial samples of the root canal system were taken previous to a disinfection protocol, a post-instrumentation/disinfection protocol, and a post-medication placement. Samples were processed for colony-forming unit (CFU) counting, Gram staining technique, and bacterial identification by the API-20 Strep/API-20A system. The API system identified 21 species of microorganisms in the pre-instrumentation samples, 11 species in the post-instrumentation samples, and 11 in the post-medication samples. There was a correlation coefficient of 0.598% between the initial size of the lesion and the number of bacteria, with a coefficient of determination up to 35.7%, a correla-tion coefficient of 0.486% and a determination coefficient of 23.6% between the size of the periapical lesion and the number of CFUs. This study contributes to the knowledge of the amount and species of microorganisms isolated and identi-fied from necrotic pulps, establishes a correlation between the amount and spe-cies of microorganisms and the size of the periapical lesions, and shows how the decrease of microorganisms contributes to the healing of PL, corroborating the importance of an adequate disinfection protocol.

Comparative evaluation of antifungal efficacy of conventional endodontic irrigants and chitosan nanoparticles

Aim

The purpose of this study was to evaluate the efficacy of 3% sodium hypochlorite (NaOCl), 2% chlorhexidine (CHX), and chitosan nanoparticles against Candida albicans using the agar disc-diffusion test.

Materials and Methods

Strain of C. albicans was cultivated in Sabouraud Dextrose Agar. Chitosan nanoparticles were synthesized using an ionic gelation method. Four groups were made according to the irrigants used. Group 1: 3% NaOCl, Group 2: 2% CHX, Group 3: chitosan nanoparticles, and Group 4: saline as control. Discs were added with the different irrigants and placed in a dish containing C. albicans. The plates were incubated at 37°C for 24h. The zone of inhibition was measured in millimeter.

Results

Statistical analysis was performed using the test of one-way variance (ANOVA) and post hoc Tukey. Group 1 showed significantly higher zone of inhibition compared to Groups 2 and 3 (P < 0.05). There were no significant differences between the zones of inhibition of Groups 2 and 3 (P < 0.05).

Conclusion

Chitosan nanoparticles and 2% CHX have similar efficacy against C. albicans, whereas 3% NaOCl was significantly better than both chitosan nanoparticles and CHX.

Proinflammatory Cytokine Expression in Apical Periodontitis from Diabetic Patients

Diabetes mellitus has been regarded as a condition capable of influencing the evolution of periapical lesions. Therefore, this study evaluated the immunoexpression of IL-1β, TNF-α, and IL-17 in apical periodontitis from type 2 diabetic patients through immunohistochemistry. Twenty-six periapical lesions were selected, and the images obtained through immunohistochemistry reactions were analyzed. The statistical significance was set at p < 0.05. IL-1β expression was considered focal (54%), weak to moderate (38%), and strong (8%) in diabetics, and focal (46%), weak to moderate (31%), and strong (23%), in controls. TNF-α was focal (85%) and weak to moderate (15%) in diabetics, and focal (92%) and weak to moderate (8%), in controls. IL-17 was focal (8%), weak to moderate (46%), and strong (46%) in diabetics, and focal (62%), weak to moderate (8%), and strong (30%), in controls. The quantitative analysis revealed greater expression of IL-17, with a significant difference between IL-17 × IL-1β × TNF-α(p=0.0009) in the diabetic group. The cytokines IL-1β and TNF-α did not express statistical differences between the tested groups. The IL-17 showed higher immunoexpression in the diabetic group (p=0.047), which may suggest higher bone resorption activity in chronic apical periodontitis in this group of patients.

In vitro evaluation of the sealing ability of combined use of iRoot BP Plus and iRoot SP for root-end filling

OBJECTIVES

The aim of this in vitro study was to evaluate the sealing ability of combined application of iRoot BP Plus Root Repair Material (BP-RRM) and iRoot SP Injectable Root Canal Sealer (SP-RCS) for root-end filling.

MATERIAL AND METHODS

A total of 120 extracted human teeth were used in this study and were randomly divided into four groups. The BP-RRM+SP-RCS group included teeth retro-filled with combined use of BP-RRM and SP-RCS (n=45), and the BP-RRM group included teeth retro-filled by BP-RRM alone (n=45). Teeth without root-end preparation and filling were equally divided into positive control (n=15) and negative control (n=15). The apical sealing ability was evaluated by micro-CT analysis, dye penetrant examination, bacterial leakage test, and glucose leakage test.

RESULTS

Micro-CT analysis showed that the total void fraction of BP-RRM+SP-RCS group was significantly lower than that of BP-RRM group, particularly at the coronal 1/3 segment of the retro-filled roots. Consistently, the maximum linear depth of dye leakage in BP-RRM+SP-RCS group was less than that of BP-RRM group. Bacterial leakage test showed that the microbial leakage in BP-RRM+SP-RCS group was significantly less than that in BP-RRM group. However, no significant difference in glucose leakage between BP-RRM+SP-RCS group and BP-RRM group was observed.

CONCLUSION

Combined use of BP-RRM and SP-RCS for root-end filling promotes apical sealing in vitro.

CLINICAL RELEVANCE

Combined use of BP-RRM and SP-RCS for root-end filling exhibited better apical sealing as compared to BP-RRM alone in vitro, and this may help reducing technical sensitivity and promoting clinical efficiency during endodontic microsurgery.

Root Canal Configuration and Its Relationship with Endodontic Technical Errors and Periapical Status in Premolar Teeth of a Saudi Sub-Population: A Cross-Sectional Observational CBCT Study

Endodontic technical errors are the foremost cause of treatment failure. A thorough understanding of root canal configuration (RCC) is essential to prevent these iatrogenic errors. This study used CBCT images to determine the association between root canal configuration, endodontic technical errors, and periapical status. CBCT images of 101 patients, including total of 212 obturated premolars (256 canals) were assessed. RCCs were classified according to the Vertucci system. The presence of endodontic errors and periapical lesions associated with each RCC was noted. Presence or absence of coronal restoration and its association with periapical radiolucency was recorded. The most frequent RCC was Type I (199 cases; 77.73%), followed by Type II (26 cases; 10.15%), Type IV (22 cases; 8.59%), Type V (4 cases; 1.56%), Type III (4 cases; 1.56%), and Type VI (1 case; 0.39%). Under-filling and non-homogeneous filling were the most common technical errors. Prevalence of periapical radiolucency was 81% in the presence of technical errors. The absence of coronal restoration caused apical lesions in 93% of cases. The frequency of endodontic technical errors increased as the root canal configurations became more complex. Periapical lesions occurred more often in teeth with endodontic errors and/or absent coronal restoration.

Impact of photodynamic therapy on the marginal adaptation of Biodentine used as root-end filling material

BACKGROUND

The marginal adaptation of root-end filling materials and the effective antibacterial control in a surgical site are crucial for the successful outcome of endodontic surgery.

OBJECTIVE

This study aimed to evaluate the effect of retrograde application of photodynamic therapy on the marginal adaptation of Biodentine used as a root-end filling material.

METHODS

Twenty single-rooted anterior teeth were selected, instrumented and obturated with gutta-percha and AH Plus. The apical 3 mm of the roots were resected and root-end cavities were prepared with an ultrasonic retro-tip. The teeth were randomly divided into two groups (n = 10). In the first group, photodynamic therapy (PDT) was applied in the retrograde cavity prior to the root-end filling. In the second group retro cavity was filled without PDT. All specimens were obturated with Biodentine and afterwards sectioned longitudinally. The gap width at the material-dentin interface was measured using a scanning electron microscope. The results were statistically analyzed.

RESULTS

The produced gap width by Biodentine/PDT was 3.85 μm versus 2.68 μm in the Biodentine control group with significant differences in-between.

CONCLUSION

Under the conditions of this study, PDT has a negative effect on the marginal adaptation of Biodentine used as root-end filling material.

Successful Management of Peri-Implant Infection from the Endodontic Lesion of Adjacent Natural Tooth

Recently, dental implants have had the most important role in oral rehabilitation. Peri-implantitis is considered a common complication of dental implants. Adjacent natural teeth with untreated endodontic pathology may be a potential risk for implant placement. Retrograde/periapical peri-implantitis (RPI), the inverting of the progress direction of peri-implantitis. Radiographically, it is characterized by signs of periapical bone loss and normal coronal osteointegration of the implant; and its prevalence is closely associated with endodontic lesions of adjacent teeth. Another novel separate disease entity is known as the endodontic peri-implant defects (endo-implant defects), manifesting as the peri-implant marginal bone loss due to endodontic pathology of adjacent teeth, to which endodontists and implantologists are supposed to attach great importance. This current study presented two cases of different types of peri-implant infection in which conducting proper intervention to the endodontic lesions of adjacent teeth resulted in full radiographic and clinical resolution of peri-implant defects.

An updated review on the link between oral infections and atherosclerotic cardiovascular disease with focus on phenomics

Atherosclerotic cardiovascular diseases (ACVD) and oral infections such as periodontal disease, dental caries, and apical periodontitis are diseases that affect a great portion of the worldwide population. Both are complex in nature and several studies show that they share etiological factors but a causal relationship between them has not been yet established due to the lack of well-designed clinical trials. Many studies in the recent years show convincing evidence of different mechanisms that might be involved in this association including chronic inflammation and immune response. However, some of these mechanisms are controversial because of confounding factors. It has been suggested that maladaptive inflammatory reactivity, determined in part by single nucleotide polymorphisms (SNPs) in pathway genes, could influence the association between oral infections, and cardiovascular diseases as pleiotropic genes. That is, these conditions could be outcomes of similar inflammatory pathways. Phenomics, the study of the changes in phenotypes or traits considering environmental variables and genetics is efficient in assessing and determining pleiotropic genes. Future research should focus on analyzing a combination of oral inflammatory conditions instead of focusing on one inflammatory phenotype alone and consider pleiotropy as a mechanistic contributor for these associations. Further, prospective observational studies seeking to follow the development of oral disease and subclinical ACVD will foster the understanding of the impact of oral health on general systemic health. Lastly, to demonstrate that oral infections would increase risk for subclinical ACVD development, clinical trials proposing to treat those infections considering genetic background and all other confounders are needed.

Plasma Rich in Growth Factors in the Treatment of Endodontic Periapical Lesions in Adult Patients: 3-Dimensional Analysis Using Cone-Beam Computed Tomography on the Outcomes of Non-Surgical Endodontic Treatment Using A-PRF+ and Calcium Hydroxide: A Retrospective Cohort Study

The study presents results of periapical lesion healing after one-visit root canal treatment (RCT) with Advanced Platelet Rich Fibrin plus (A-PRF+) application compared to a two-visit RCT with an inter-appointment calcium hydroxide filling. The comparison was made based on CBCT-Periapical Index (PAI) lesion volume changes and the occurrence of post endodontic pain. The results of 3D radiographic healing assessments based on volume reduction criteria were different from the CBCT-PAI. Based on volume changes, the healing assessment criteria-9 cases from the Study Group and six cases in the Control Group were defined as healed. Based on the CBCT-PAI healing assessment criteria, 8 cases from the Study Group and 9 cases from the Control Group were categorized as healed. The volumes of apical radiolucency were, on average, reduced by 85.93% in the Study Group and by 72.31% in the Control Group. Post-endodontic pain occurred more frequently in the Control than in the Study Group. The highest score of pain in the Study Group was five (moderate pain, n = 1), while in the Control Group, the highest score was eight (severe pain, n = 2). In the 6-month follow-up, CBCT scans showed a better healing tendency for patients in the Study Group.

A Multi-Criteria Approach for Comparison of Ginger Extract and Conventional Irrigants in Root Canal Treatment

Background

Considering the importance of irrigation in dental root canal treatment, there is an urgent need to find a risk-free bioactive and antibacterial endodontic solution. Enterococcus faecalis, an anaerobic gram-positive coccus, has been identified as the main reason for endodontic infections. Several studies have been conducted on E. faecalis and periapical infection. Nowadays, plants used in traditional medicine play a role that is widely appreciated by researchers. One of these herbs is ginger which shows an acceptable antimicrobial effect on E. faecalis. Due to the highly crucial role that irrigation plays in the success of endodontic treatment, a comprehensive survey based on several criteria, namely, scientific, technical, and empirical, is required to address the goal of determining the best endodontic solution.

Methodology

The most important criteria are antibacterial activity, risks and hazards, cost, and availability. In this study, the analytical network process (ANP), which is a multi-criteria decision-making method, was applied to determine the best endodontic irrigant.

Results

Several alternatives were investigated using the ANP. In this study, 5.25% sodium hypochlorite (NaOCl) and 2% chlorhexidine were at the top of the list. According to the sensitivity analysis, 10% ethanolic ginger extract showed comparable results to 2.5% NaOCl.

Conclusions

To carefully prioritize endodontic irrigants a wide range of standards and criteria should be considered. Considering the low risk, great wettability, and active compounds of ginger extract, it can be a promising viable risk-free solution for root canal treatments.

Evaluation of Root Canal Configuration of Maxillary and Mandibular First Molar by CBCT: A Retrospective Cross-Sectional Study

Adequate knowledge of root canal morphology along with its probable variations is imperative to acquire successful endodontic treatment. This retrospective cross-sectional study aimed to investigate the root canal configuration of maxillary and mandibular first molar using Cone-Beam Computed Tomography (CBCT) among patients in Al-Ahsa region, Saudi Arabia. A total of 377 samples were included, out of which 123 CBCT (I-CAT Vision QTM) scans with intact all first permanent molars were selected in this study and scanned in sagittal, axial, and coronal views by using BlueSkyPlan software. The number of canals in each root and their configuration according to the Vertucci classification system was evaluated. Statistical analysis was analyzed using SPSS version 21 (IBM). Chi-square test was applied to evaluate the association of root canal morphology and mandibular and maxillary first molars with respect to gender. Out of 123 CBCT scans, 59 (48.0%) were males and 64 (52.0%) were females; the mean age was 26.95 ± 10.65 years. The mesiobuccal root of bilateral maxillary first molar had Type-I (87.0%) of Vertucci classification followed by Type-IV (9.8%). Additionally, all mesiobuccal roots (100%) of the left mandibular first molar had Type-I of Vertucci’s classification. A significant association has been observed between gender and a number of canals in bilateral maxillary first molars. Females showed a significantly higher prevalence of three-root canal configuration in maxillary first molars of both sides compared four canals found most commonly in males (p = 0.004). This study concluded that the majority of maxillary and mandibular permanent first molars had three roots and three canals with Type-I Vertucci’s classification in patients belonging to the Al-Ahsa region of the Saudi Arabia. It was also proved that gender is significantly associated with the number of canals in a bilateral maxillary molar.