Effect of root immaturity and depth of intrusion on spontaneous re-eruption and healing complications: A retrospective analysis

BACKGROUND/AIMS

Dental trauma resulting in tooth intrusion is a severe injury of permanent dentition, with a prevalence of 0.5%-1.9% among traumatic dental injuries. Currently, treatment guidelines for intruded permanent teeth depend on root development and the degree of intrusion. However, the categorization of tooth maturity as mature or immature simplifies a complex continuum of root development stages. This study aims to investigate the impact of various stages of root development on the success of spontaneous re-eruption (SRE) of intruded teeth.

MATERIALS AND METHODS

This retrospective study analysed data from 80 children (125 teeth) aged 6-12 years who experienced dental intrusion between 2018 and 2022. Root maturation was classified based on Cvek's classification, eight were categorized as stage 1, 29 as stage 2, 44 as stage 3, 25 as stage 4, and 19 as stage 5. Intruded teeth with immature roots (Cvek's class 1-4) underwent SRE, while mature teeth (Cvek's class 5) were treated with SRE, orthodontic repositioning, or surgical repositioning based on the degree of intrusion. Primary outcome measures were successful re-eruption and secondary outcomes included observed complications during follow-up.

RESULTS

Regression analysis revealed that the patient's age, degree of root maturation, and degree of intrusion significantly affected spontaneous re-eruption (p < .05). SRE was more successful in teeth with Cvek's stages 1 and 2 compared to stages 3 and 4. Complications were associated with the treatment method, degree of root immaturity, and degree of intrusion.

CONCLUSION

The study demonstrates that as root maturation progresses, the likelihood of re-eruption decreases, and the risk of pulp necrosis and infection increases. Therefore, teeth in later stages of immaturity (Cvek stage 4) should be repositioned orthodontically or surgically without waiting for spontaneous re-eruption.

Regenerative Endodontic Procedures in Immature Teeth Affected by Regional Odontodysplasia

INTRODUCTION

Regional odontodysplasia (ROD) is a rare developmental disorder characterized by hypo-mineralization and hypoplasia of enamel and dentin. Symptoms include poorly developed tooth buds, delayed eruption of permanent teeth in affected quadrants, and ghost teeth. The affected teeth often become necrotic due to abnormal enamel and dentin development, making them susceptible to caries and infection. The aim of this case report is to describe the treatment of ROD through pulp revascularization.

CASE REPORT

A 13-year-old girl was referred for endodontic treatment. The mandibular left incisors and first premolar, which were affected by regional odontodysplasia, lost their vitality because of the impaired structure of the enamel. Due to the teeth's early developmental stage, a regenerative endodontic treatment was attempted. All 3 teeth were treated using the same protocol following the AAE guidelines. After 4 weeks, treatment of the premolar was completed, whereas the incisor teeth remained symptomatic and were and therefore, intracanal dressing with calcium hydroxide was repeated and left in place for 5 months. Finally, the regenerative procedure was completed, and the crowns were restored. The patient was scheduled for follow-up examinations after 6 months, and then yearly for the next 3 years. After 1 year, the periapical lesion around the central incisor and premolar had resolved, the lesion around the apex of the lateral incisor was healing, and the roots had continued to develop. After 3 years, complete healing and pulp canal obliteration were observed in the central incisor and in the premolar. However, the root of the lateral incisor tooth was split, and it was recommended to extract this tooth.

CONCLUSION

The positive outcomes of regenerative endodontics in the central incisor and premolar suggest that revascularization of the pulp may be optional for the treatment of immature necrotic teeth affected by developmental disorders, such as ROD, amelogenesis imperfecta, or dentinogenesis imperfecta.

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

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

The consequences of orthodontic extrusion on previously intruded permanent incisors-A retrospective study

AIM

The aim of this study is to compare the adverse effects that occur after orthodontic extrusion of teeth that have been traumatically intruded with those of similar teeth that have not experienced any trauma.

BACKGROUND

The outcome of incisors intrusion can be affected by the patient's age, extent of injury, root development, and malocclusion. Orthodontic extrusion is a potential solution, but it may also cause complications.

MATERIALS AND METHODS

A retrospective study of the effects of extrusion of traumatically intruded teeth was carried out. The study group included 21 teeth in 14 patients. The control group included 32 teeth in 10 patients that underwent orthodontic extrusion with no history of trauma. Patients' age, gender, and stage of root development were recorded. The severity of the intrusion was classified as mild (<3 mm), moderate (3-6 mm), and severe (≥7 mm). A comparison of signs of pulp necrosis and root resorptions between the groups was made.

RESULTS

The central incisor is the tooth that is most injured in 80.9% of cases. A majority of these incidents involve severe intrusion, which was found in 42.9% of cases. 90% of the traumatized teeth had already lost their vitality prior to orthodontic treatment. Various forms of root resorption were observed in the study group. In the control group, 31.2% of teeth showed signs of external root resorption, but no endodontic intervention was carried out during the follow-up period, as these teeth remained vital.

CONCLUSIONS

Following intrusion, there is a high risk for root resorption and pulp necrosis. Orthodontic repositioning should be carried out with caution and mild force to prevent complications. Long-term follow-ups are required to ensure the best possible outcome.

Use of Endodontic Procedures in Young Permanent Teeth

Background

Regenerative endodontic procedures (REPs) have emerged as a promising treatment option for young permanent teeth with pulp necrosis, offering the potential for tissue repair and preservation.

Materials and Methods

A retrospective analysis was conducted on a cohort of 30 patients aged 8 to 16 years with pulp necrosis in young permanent teeth. The patients underwent REPs, including disinfection, triple antibiotic paste application, and a coronal barrier. Clinical and radiographic data were collected at baseline and follow-up appointments at 6, 12, and 24 months. Radiographs were analyzed for root lengthening, apical closure, and resolution of periapical lesions.

Results

The mean increase in root length after 24 months was 3.42 mm (SD ± 1.12 mm), and 90% of cases demonstrated complete apical closure. The overall success rate, defined as the absence of clinical symptoms and radiographic evidence of pathology, was 80.

Conclusion

REPs show promising outcomes in young permanent teeth with pulp necrosis, promoting root development, and apical closure.

Genome-wide Association Study Identifies Novel Risk Loci for Apical Periodontitis

INTRODUCTION

Apical periodontitis (AP) is a common consequence of root canal infection leading to periapical bone resorption. Microbial and host genetic factors and their interactions have been shown to play a role in AP development and progression. Variations in a few genes have been reported in association with AP; however, the lack of genome-wide studies has hindered progress in understanding the molecular mechanisms involved. Here, we report the first genome-wide association study of AP in a large and well-characterized population.

METHODS

Male and female adults (n = 932) presenting with deep caries and AP (cases), or deep caries without AP (controls) were included. Genotyping was performed using the Illumina Expanded Multi-Ethnic Genotyping Array (MEGA). Single-variant association testing was performed adjusting for sex and 5 principal components. Subphenotype association testing, analyses of genetically regulated gene expression, polygenic risk score, and phenome-wide association (PheWAS) analyses were also conducted.

RESULTS

Eight loci reached near genome-wide significant association with AP (P < 5 × 10-6); gene-focused analyses replicated 3 previously reported associations (P < 8.9 × 10-5). Sex-specific and subphenotype-specific analyses revealed additional significant associations with variants genome-wide. Functionally oriented gene-based analyses revealed 8 genes significantly associated with AP (P < 5 × 10-5), and PheWAS analysis revealed 33 phecodes associated with AP risk score (P < 3.08 × 10-5).

CONCLUSIONS

This study identified novel genes/loci contributing to AP and specific contributions to AP risk in men and women. Importantly, we identified additional systemic conditions significantly associated with AP risk. Our findings provide strong evidence for host-mediated effects on AP susceptibility.

The risk of healing complications in primary teeth with root fractures: A retrospective cohort study

BACKGROUND/AIM

Primary teeth are frequently affected by traumatic dental injuries. Root fractures are rare and have a reported incidence of 2% in the primary dentition. Hence, there is limited evidence on this topic. This study aims to evaluate the risk of healing complications in primary teeth with root fracture and to identify possible sequelae in the permanent dentition following root fracture in the primary dentition.

MATERIALS AND METHODS

A retrospective analysis of a cohort of 53 patients with 74 root fractured primary teeth. The standard follow-up program included clinical and radiographic examination after 4 weeks, 8 weeks, 6 months, and 1 year after the trauma and when the patient was 6 years of age. The following complications were registered: pulp necrosis (PN), pulp canal obliteration (PCO), ankylosis with replacement root resorption (ARR), infection-related root resorption (IRR), premature tooth loss (PTL), and repair-related resorption (RRR).

STATISTICS

The Kaplan-Meier and Aalen-Johansen estimators were employed. The level of significance was 5%.

RESULTS

A total of 74 teeth were included. 42 teeth were extracted at the initial examination. Risks estimated after 3 years: PTL 45.9% [95% CI: 28.8-63.0], PCO 12.9% [95% CI: 2.3-23.4], PN 14.9% [95% CI: 3.9-25.9], RRR 2.6% [95% CI: 0.0-7.5]. No teeth showed ARR or IRR. All complications were diagnosed within the first year. Most common sequelae in the permanent dentition was demarcated opacities, with an estimated risk of 20% [95% CI: 8.2-41.3].

CONCLUSIONS

There is a low risk of healing complications following a root fracture in the primary dentition. Root fractures often result in early extraction of the coronal fragment. The remaining apical fragment will undergo a physiological resorption. Aside from opacities, there is a low risk of sequelae in the permanent dentition.

Effectiveness of revitalization in treating apical periodontitis: A systematic review and meta-analysis

BACKGROUND

Revitalization procedures primarily aim to eliminate clinical symptoms and heal periapical lesions.

OBJECTIVES

The objective of the study was to elucidate the effectiveness of revitalization in treating apical periodontitis in necrotic mature and immature permanent teeth based on the following PICO question: In patients with permanent immature or mature teeth and pulp necrosis with or without signs of apical periodontitis (P) what is the effectiveness of revitalization (I) in comparison with calcium hydroxide apexification, apical plug and root canal treatment (C) in terms of tooth survival, pain, tenderness, swelling, need for medication (analgesics and antibiotics), radiographic evidence of reduction of apical lesion size, radiographic evidence of normal periodontal ligament space, radiographic evidence of increased root thickness and length (not for mature teeth), tooth function (fracture and restoration longevity), need for further intervention, adverse effects (including exacerbation, restoration integrity, allergy and discolouration), oral health-related quality of life (OHRQoL), presence of sinus tract and response to sensibility testing (O). (T) = Defined as a minimum of 1 year and maximum of as long as possible for all outcome measures, except 'pain, tenderness, swelling, need for medication (analgesics)', which is a minimum of 7 days and maximum of 3 months and OHRQoL which is minimum of 6 months and a maximum of as long as possible.

METHODS

Three databases (PubMed, Embase and Cochrane Library) were searched for human, experimental and observational studies in English, complemented with hand search, until 31/10/2021. Studies recruiting teeth with pulp necrosis (with/without apical periodontitis), with minimum 10 teeth/arm at the end of the study and with a follow-up of at least 1 year, were included. Records without an abstract and a full text were excluded. The qualitative analysis of the included (non-) randomized controlled clinical trials was performed with the Revised Cochrane risk-of-bias tools (RoB 2 and ROBINS-I). Meta-analysis for survival and success (including a subgroup analysis for mature/immature permanent teeth) was performed using the Mantel-Haenszel method. The certainty of evidence was assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation).

RESULTS

From the 365 identified records, five met the inclusion criteria. The 12 months survival rate was 100% for all (im)mature permanent teeth in all groups (3 studies). The success rate at 12 months was 100% for immature permanent teeth for I and C (1 study), however, reduced to 92% and 80% for mature teeth in I and C respectively (1 study, p > .05). The risk of bias for the most critical outcome (survival) was high for two studies and low for one. For the critical outcome success, all assessed studies were highly biased. Meta-analyses provided pooled relative risk with no statistically significant difference between I and C for both survival (RR = 1.00, 95%CI = 0.96-1.04, p = 1.00) and success (RR = 1.06; 95%CI = 0.83-1.35, p = .66). The evidence level for survival was kept 'low' and for success was downgraded to 'very low' due to inconsistency and imprecision.

DISCUSSION

The survival and success rates were favourable in all included studies and for all groups; however, these outcomes are not reliable due to the low certainty level. Clinically, the most reported adverse event was tooth discolouration, hence the application of bismuth oxide containing calcium silicate cements should be avoided in revitalization. Radiographically, caution is needed when assessing periapical bone healing and further root development with periapical radiographs, due to multifactorial inaccuracies of this imaging technique. Methodological and assessment concerns need to be addressed in future clinical trials. Long-term results are necessary for studies reporting revitalization of mature permanent teeth, as they seem to be experimental so far.

CONCLUSIONS

No robust evidence was discovered to support that revitalization is effective to treat apical periodontitis in (im)mature permanent teeth. The success and survival rates of revitalized and fully pulpectomized (im)mature permanent teeth did not differ significantly.

REGISTRATION

Prospero: CRD42021262466.

An Ex-Vivo Model for Investigating Bacterial Extrusion from Infected Root Canals during Masticatory Function

INTRODUCTION

The extrusion of bacteria from infected root canals may lead to increase in symptoms, expansion of periapical lesions, and contribution to systemic diseases. The aim of this study is to investigate a potential proof-of-concept model to study the extent to which bacteria can escape from infected root canals under dynamic loading (simulated chewing).

METHODS

The study was completed in 2 experiments performed at 2 institutions. Biofilms of Streptococcus intermedius in the first experiment and S. intermedius and Actinomyces naeslundii were allowed to grow in root canals of single-rooted extracted teeth for 3 weeks. The roots of the teeth were suspended in a small chamber containing dental transport medium and were mounted on a lower sample holder of a chewing simulator. In the experimental group, simulated chewing cycles equivalent to 1 year of function were conducted, and then bacterial migration was quantified and compared with stationary teeth.

RESULTS

All experimental samples of the loading group revealed bacterial penetration in both experiments. Several of the unloaded samples revealed no bacterial penetration. In the first experiment, a significantly higher number of bacteria were able to escape into the periapex of the loaded group compared with the unloaded group (P = .017). In the second experiment, there was no significant difference between the 2 bacterial species used in the amount of extruded bacteria; however, there was a highly significant effect for occlusal loading (P = .0001).

CONCLUSIONS

The potential for occlusal forces to enhance bacterial extrusion from infected root canals should be further explored.

External Inflammatory Root Resorption in Traumatized Immature Incisors: MTA Plug or Revitalization? A Case Series

INTRODUCTION

External inflammatory root resorption (EIRR) in immature permanent teeth is a common complication after severe dental trauma. The management of this condition requires thorough disinfection of the root canal in order to arrest the resorptive process. However, current guidelines regarding the recommended treatment of EIRR following traumatic dental injuries vary, mainly in regard to the type of intracanal medication and its retention time in the root canal system. The objective of this case series was to present both the apical barrier technique (MTA plug) and revitalization procedures as valid treatment options in immature teeth with EIRR.

METHODS

Four cases of post-traumatic immature teeth diagnosed with pulp necrosis and EIRR, with or without apical periodontitis, were treated either by an MTA plug (two teeth) or revitalization (two teeth). Cases were followed between 12 and 24 months.

RESULTS

Both treatment methods were efficient in arresting EIRR and enabled bone healing. After revitalization, partial root maturation was observed.

CONCLUSION

Whereas the key to achieve periodontal healing in cases of EIRR is thorough disinfection of the root canal, both a subsequent MTA plug as well as revitalization may represent adequate treatment methods. An additional benefit lies in the potential of revitalization to promote further root maturation through hard tissue apposition.

Lesion sterilization and tissue repair with chloramphenicol, tetracyline, zinc oxide/eugenol paste versus conventional pulpectomy: A 36-month randomized controlled trial

BACKGROUND

Endodontic treatment of primary molars represents one of the challenges in pediatric dentistry. There is a lack of consensus in the literature about the endodontic techniques and filling paste for primary teeth with pulp necrosis.

AIM

To compare the effectiveness of the LSTR technique (lesion sterilization and tissue repair) with CTZ paste (chloramphenicol, tetracycline, zinc oxide and eugenol) and pulpectomy with ZOE paste (zinc oxide and eugenol) in the treatment of primary molars with pulp necrosis.

DESIGN

Eighty-eight primary molars with pulp necrosis from 70 children between the ages of 3 and 8 years were included. The teeth were randomized to the LSTR with CTZ paste group or pulpectomy with ZOE paste group. Clinical and radiographic evaluations were performed at 18, 24, 30 and 36 months.

RESULTS

At 36 months, clinical success was 86.4% in LSTR with CTZ paste and 90.9% in pulpectomy with ZOE paste (p = .45). Radiographic success was 43.2% in both groups (p = 1.00). The overall success was 40.9% in LSTR with CTZ paste and 43.2% in pulpectomy with ZOE paste (p = 1.00).

CONCLUSION

After 36 months of evaluation, the effectiveness of the LSTR technique with CTZ paste and pulpectomy with ZOE paste was similar for the treatment of primary molars with pulp necrosis.

Indications for root canal treatment following traumatic dental injuries to permanent teeth

The dental pulp may respond favourably or unfavourably to traumatic dental injuries. The most serious unfavourable responses are pulp necrosis and infection of the root canal system. These cause apical periodontitis and/or external inflammatory resorption of the tooth. The following injuries require root canal treatment as part of their emergency management-(A) complicated crown fractures (but some may be suitable for conservative pulp treatments, such as pulp capping, partial pulpotomy or pulpotomy), (B) complicated crown-root fractures, (C) supra-crestal coronal third root fractures and (D) injuries where pulp necrosis is predictable or highly likely to occur AND where there has been damage to the root surface and/or periodontal ligament with the aim of preventing external inflammatory resorption. This latter group of injuries are avulsion, intrusion, lateral luxation with a crown fracture, extrusion with a crown fracture (all in fully developed teeth) plus avulsion with a crown fracture and intrusion with a crown fracture (both in incompletely developed teeth). All other injuries should not have root canal treatment commenced as part of the emergency management, but they must be reviewed regularly to monitor the pulp for any adverse changes to its status, particularly pulp necrosis and infection of the root canal system.

Genome-wide association study identifies novel risk loci for apical periodontitis

Apical periodontitis (AP) is a common consequence of root canal infection leading to periapical bone resorption. Microbial and host genetic factors, and their interactions, have been shown to play a role in AP development and progression. Variations in a few genes have been reported in association with AP, however, the lack of genome-wide studies has hindered progress in understanding the mechanisms involved in AP. Here, we report the first genome-wide association study of AP in a well-characterized population. Male and female adults (n=932) presenting with deep caries with AP (cases) or without AP (controls) were included. Genotyping was performed using the Illumina Expanded Multi-Ethnic Genotyping Array. Single-variant association testing was performed adjusting for sex and five principal components. Subphenotype association testing, analyses of genetically regulated gene expression, polygenic risk score and phenome-wide association (PheWAS) analyses were also performed. Eight loci reached near-genome-wide significant association with AP (p < 5 x 10-6); gene-focused analyses replicated three previously reported associations (p < 8.9 x 10-5). Sex-specific and subphenotype analyses revealed additional significant associations with variants genome-wide. Functionally oriented gene-based analyses revealed eight genes significantly associated with AP (p < 5 x 10-5), and PheWAS analysis revealed 33 phecodes associated with AP risk score (p < 3.08 x 10-5). This study identified novel genes/loci contributing to AP and revealed specific contributions to AP risk in males and females. Importantly, we identified additional systemic conditions significantly associated with AP risk. Our findings provide strong evidence for host-mediated effects on AP susceptibility.

Surgical Management of Radicular Cyst With the Application of a Natural Platelet Concentrate: A Case Report

Traumatic dental injuries usually involve the dentoalveolar region, and they readily affect the teeth and their surrounding soft and hard tissues. The common sequelae of traumatic dental injuries lead to pulpal necrosis and apical periodontitis along with cystic changes. The current case report describes the surgical management of a radicular cyst in the periapical region of maxillary incisors and highlights the efficacy of natural platelet concentrate [platelet-rich fibrin (PRF)] used for postoperative healing. A 38-year-old male patient presented to the department with pain and mild swelling in the upper front tooth region. On radiographic examination, a radiolucent periapical lesion was evident in relation to the right maxillary central and lateral incisor. In the maxillary anterior region, root canal therapy was performed, followed by periapical surgery and retrograde filling with mineral trioxide aggregate (MTA), and PRF was placed in the surgical site to initiate the healing at a faster rate. The patient was recalled for follow-ups after 12 weeks, 24 weeks, and 36 weeks; he was found to be asymptomatic, and significant periapical healing was observed in the radiograph with almost adequate bone formation.

Tissue Characteristics in Endodontic Regeneration: A Systematic Review

The regenerative endodontic procedure (REP) represents a treatment option for immature necrotic teeth with a periapical lesion. Currently, this therapy has a wide field of pre-clinical and clinical applications, but no standardization exists regarding successful criteria. Thus, by analysis of animal and human studies, the aim of this systematic review was to highlight the main characteristics of the tissue generated by REP. A customized search of PubMed, EMBASE, Scopus, and Web of Science databases from January 2000 to January 2022 was conducted. Seventy-five human and forty-nine animal studies were selected. In humans, the evaluation criteria were clinical 2D and 3D radiographic examinations. Most of the studies identified a successful REP with an asymptomatic tooth, apical lesion healing, and increased root thickness and length. In animals, histological and radiological criteria were considered. Newly formed tissues in the canals were fibrous, cementum, or bone-like tissues along the dentine walls depending on the area of the root. REP assured tooth development and viability. However, further studies are needed to identify procedures to successfully reproduce the physiological structure and function of the dentin–pulp complex.

Endodontic pulp revitalization in traumatized necrotic immature permanent incisors: Early failures and long-term outcomes - a longitudinal cohort study

Aim

This prospective cohort study evaluates clinical and radiographical outcomes of endodontic pulp revitalization (PR) of traumatized necrotic incisors.

Methodology

Pulp revitalization was performed in 75 traumatized necrotic immature incisors from 71 patients. The radiographic outcome measures were continued root formation (width and length), root resorption, apex closure, periapical index, and root development stage. The clinical outcome measures were percussion pain, palpation pain, pathological tooth mobility, swelling, sinus tract, ankylosis, crown discolouration, response to pulp sensitivity test, and subjective pain. Treatment outcomes were categorized as a success based on the absence of clinical symptoms and when radiographic evidence was present for apical healing and continued root development. The performed statistical tests were repeated measures anova, pairwise comparisons of interactions (t‐test), McNemar's test, and linear regression model.

Results

In 45 of 75 teeth (60%), PR was successful with the resolution of clinical and radiographic signs and continued root development. PR failed due to the absence of bleeding (n = 19) and persistent infection (n = 11). PR showed statistically significant increases in root length (11%), and dentinal wall thickness (30%), root maturation (pre‐operative 3.38 [CI 1.88; 4.88]; post‐operative 4.04, [CI 2.56; 5.52]) apical closure (71.4%), healing of pre‐operative apical periodontitis (100%), and healing of pre‐operative inflammatory root resorptions (100%). Three predictive variables for continued root maturation were identified – root development stage at entry (p = .0001, β 0.649), [CI 0.431; 0.867], trauma to the soft tissues (p = .026, β −0.012), [CI −0.0225; −0.015], and pre‐operative dentinal wall thickness (p = .009, β −0.001); [CI −0.001; 0.0001].

Conclusions

Our findings indicate that PR provides satisfactory clinical and radiographical outcomes in traumatized necrotic incisors. The failed cases were related to lack of bleeding and persistent infections, indicating that new techniques are needed to improve the predictability of PR.

Altered Prevalence of Pulp Diagnoses in Diabetes Mellitus Patients: A Retrospective Study

INTRODUCTION

Diabetes mellitus (DM) is a complex multisystemic disorder that affects an estimated 21 million Americans. No studies have evaluated the association of DM with the prevalence of each pulpal diagnosis. The objective of this study was to compare the prevalence of each pulp diagnosis including symptomatic irreversible pulpitis (SIP), asymptomatic irreversible pulpitis, reversible pulpitis, normal pulp, and pulp necrosis (PN) in DM patients against a nondiabetic control group.

METHODS

A retrospective chart review was approved by Rutgers University Institutional Review Board. The prevalence of the diagnoses SIP, asymptomatic irreversible pulpitis, reversible pulpitis, normal pulp, and PN was calculated from AxiUm (Exan software, Las Vegas, NV) electronic health records at Rutgers School of Dental Medicine. The chi-square test was used to see the relationship between the 2 categoric variables. Second, binary logistic regression analyses were performed for each group.

RESULTS

A total of 2979 teeth were diagnosed with a pulp condition between April 2013 and November 2018. The total tooth number of DM patients was 682, whereas the tooth number of nondiabetic patients was 2297. In the subgroup of patients younger than 40 years old, SIP was notably more prevalent in DM patients. In addition, the prevalence of PN in elderly DM patients (60-69 years old) was significantly higher than in the control group.

CONCLUSIONS

The prevalence of SIP in DM patients was significantly higher compared with the control group (<40 years old), suggesting the possibility that DM could hypersensitize the subgroup of patients younger than 40 years old to pulpitis pain.

Bacterial Invasion of Pulp Blood Vessels in Teeth with Symptomatic Irreversible Pulpitis

INTRODUCTION

This study described the degenerative changes and infection patterns of the pulp tissue associated with symptomatic irreversible pulpitis.

METHODS

The material consisted of 32 extracted teeth with untreated deep caries that were clinically and histologically diagnosed with irreversible pulpitis and were part of the histopathologic collection of 1 of the authors. The controls consisted of intact teeth with normal uninflamed pulps and teeth with reversible pulpitis. Teeth were processed for histopathologic and histobacteriologic analyses.

RESULTS

All teeth with irreversible pulpitis showed areas of severe acute inflammation, necrosis, microabscesses, and bacterial infection in the pulp chamber. These areas were surrounded by a chronic inflammatory infiltrate, and, at the distance, the pulp tissue was often uninflamed. Bacteria were also observed in the areas surrounding the necrotic foci, both as scattered cells through the extravascular space and at varying numbers within the blood vessel lumen. The number of bacteria and the density of the intravascular bacterial aggregations varied considerably. In one third of the cases, bacteria occurred in the lumen of venules in areas at a considerable distance from the necrotic focus in the coronal third of the root. No intravascular bacteria were noted in the middle and apical segments of the canal. No bacteria were found in the pulps of any of the control specimens.

CONCLUSIONS

Bacterial invasion and colonization of necrotic areas were observed in the pulp of all teeth with caries exposure and symptomatic irreversible pulpitis. Bacterial penetration of blood vessels occurred in all cases, suggesting that this may be an important mechanism of spread of bacterial infection through the pulp tissue in an endodontic infection.

Treatment Outcomes of Permanent Immature Teeth with Crown Fracture: A Retrospective Cohort Study

INTRODUCTION

Crown fractures are a common type of traumatic dental injury. Various factors may affect the outcome of crown fractures. This study aimed to evaluate the treatment outcomes of immature teeth with a crown fracture.

METHODS

This retrospective cohort study included patients who presented to a dental trauma center from 2008-2018 with a history of a crown fracture of immature teeth and at least 6 months of follow-up. Outcomes of primary endodontic or restorative interventions as well as reinterventions were evaluated. Kaplan-Meier curves were used to compare the unadjusted differences in survival time. Logistic and Cox regression analyses were performed to identify potential predictors for complication and survival time, respectively.

RESULTS

The success rates of the primary interventions for 99 teeth (72 patients) after a median follow-up of 22 months were as follows: cervical pulpotomy (90.4%), partial pulpotomy (85.2%), mineral trioxide aggregate apical barrier (80.0%), root canal treatment (66.6%), and only restoration (47.2%). Teeth that received vital pulp therapy were less prone to complications (adjusted hazard ratio = 0.21; 95% confidence interval, 0.09-0.53; P < .05), whereas those with concomitant luxation injuries were more susceptible to complications (adjusted odds ratio = 2.90; 95% confidence interval, 1.01-8.29; P < .05).

CONCLUSIONS

Crown fractures had a relatively high favorable prognosis. Vital pulp therapy (partial or cervical pulpotomy) had the highest success rate, whereas cases that received only restoration had the lowest success rate. Teeth with concomitant luxation injuries had more odds and hazards of complications.

Photographic assessment of simulated dental luxation injuries

BACKGROUND/AIM

Dental photographs are a valid means for documentation of dental luxation injuries. The aim of the study was to evaluate the utility of two photographs from different perspectives in the assessment of dental luxation injuries compared to one perspective only.

MATERIALS AND METHODS

Photographs of simulated dental luxation injuries were shown to experts in dental traumatology and other dentists who had to estimate the displacement in the vertical and horizontal dimensions. The overall error of estimation as a result of both vertical displacement and horizontal displacement was calculated and statistically analyzed.

RESULTS

The mean overall error of estimation was 0.43 mm and 0.75 mm for experts and dentists, respectively. If two (frontal and occlusal) perspectives were available, the overall error was lower than when only one perspective was available (p < .001). Experts had a lower overall error compared to dentists (p < .015).

CONCLUSION

Two photographs from two perspectives allowed better interpretation of dental luxation injuries.

Use of Orthodontic Methods in the Treatment of Dental Luxations: A Scoping Review

(1) Background: Treating dental luxation injuries is challenging for the clinician. Dental luxations account for 18-33% of injuries to permanent teeth and can be addressed using different therapeutic approaches. The present work was conducted with two aims: (i) to evaluate, through a scoping review, current knowledge of the orthodontic methods (repositioning and stabilization splinting) that can be used at the time of the trauma, and (ii) to investigate the frequency and type of pulp consequences arising after these traumatic injuries. (2) Methods: The literature search was conducted in the period June 2020-December 2020 using the PubMed/MEDLINE, SCOPUS and Web of Science databases. The research questions were formulated according to the PICO (Population, Intervention, Comparison, Outcomes) method and considered the following aspects: type of luxation injury and stage of root development; use of orthodontic repositioning and splinting techniques; frequency and type of pulp consequences; and compliance of treatments with international guidelines. (3) Results: The initial screening of the databases, using the selected search keywords, yielded a total of 587 articles, just 8 fully met the inclusion criteria. Closer analysis of these 8 publications revealed that they would not produce clear meta-analytical data. This made it necessary to limit the data collected to the following six items: number and type of injuries, initial therapeutic intervention, duration of follow-up, number, and type of different pulp consequences. (4) Conclusions: While orthodontic techniques are commonly used to treat dental intrusions, in the case of extrusive and lateral luxation injuries, they are less frequently used and the orthodontic approach is generally confined to the stabilization phase. Among the various possible pulp consequences, many authors consider only pulp canal obliteration (PCO) and pulp necrosis (PN), often tending to overlook physiological healing (pulp survival) and the possible development of PN after PCO. There is therefore a clear need for new, high-quality clinical studies of this topic based on systematic and standardized data collection.

Extrusive Luxation Injuries in Young Patients: A Retrospective Study with 5-Year Follow-Up

(1) Background: The purpose of this study was to analyze the influence of the chosen diagnostic and therapeutic approach (repositioning and splinting methods) on the risk, frequency and timing of the onset of pulp canal obliteration and pulp necrosis following extrusive luxation in young patients with permanent dentition. (2) Methods: From an initial sample of 50 subjects affected by extrusive luxation, were selected the clinical data of 13 patients presenting extrusive luxation but no other type of injury to the dental hard tissue. All teeth were examined according to a standardized protocol. Follow-up examinations were performed at regular intervals for 5 years. Statistical associations between pulp consequences and several covariates were assessed using the Mann-Whitney test and Fisher's exact test. (3) Results: Among the 13 studied teeth, only 1 healed completely, whereas 9 showed pulp obliteration and 3 developed pulp necrosis. No tooth with obliteration developed pulp necrosis. The average time to treatment was 11.9 h. The treatment approaches used were manual repositioning, orthodontic repositioning and stabilization splinting. "Time to treatment" was the only covariate that showed a weak statistical association with the onset of pulp consequences. (4) Conclusions: There is still uncertainty over the most appropriate therapeutic approach to adopt in young patients with extrusive luxation injuries, particularly for repositioning of the injured tooth. Extruded teeth should be treated as soon as possible after the traumatic event. This study highlighted the value of orthodontic repositioning of the extruded tooth, which does not seem to aggravate the conditions of the dental pulp. In addition, the study confirmed that prophylactic endodontic treatment is not appropriate for immature teeth affected by extrusive luxation injuries, given the extreme rarity of pulp necrosis in teeth already affected by pulp obliteration.

Traumatic dental injuries and pulp sequelae in an adolescent population

BACKGROUND/AIMS

Traumatic dental injuries (TDI) occur frequently and may result in pulp sequelae. This includes pulp necrosis with infection, pulp canal obliteration and root resorption. The aim of this study was to assess the prevalence and risk factors of pulp sequelae after TDI among Norwegian adolescents.

MATERIAL AND METHODS

A retrospective longitudinal study, including historical clinical data, was conducted with 16-year-old pupils in western Norway. All first-grade pupils, born in 1997 (n = 5184), attending public high schools, were invited to participate and to respond to an electronically administered closed-ended questionnaire (response rate 39.6%, n = 2055). Consent was given to access the dental records in the Public Dental Health Service in Hordaland, where information regarding TDI (diagnosis and treatment) and radiographs were interpreted. Only TDIs to anterior teeth were recorded (canine to canine in the maxilla and mandible). Outcome variables of TDI were registered and analysed using logistic regression, Kaplan-Meier survival estimates and log-rank test.

RESULTS

The prevalence of TDI in the sample population was 16.4% (338 pupils), with a total of 637 teeth involved. The number of included teeth for analysis was 571 (90.5%). The prevalence of pulp necrosis with infection was 7.5%. Moderate and severe TDI was associated with a higher frequency of pulp necrosis with infection. Pulp canal obliteration and root resorption were found in 2.8% and 2.3% of teeth with TDI, respectively. Dental hard tissue injuries were more prone to the development of pulp necrosis than luxation injuries and combination injuries. The relationship between root development stage and development of pulp necrosis with infection was not statistically significant.

CONCLUSIONS

Occurrence of different pulp sequelae among teeth affected with TDI was low. Moderate and severe TDI were more at risk of developing pulpal complications and hard tissue injuries were at higher risk of developing pulp necrosis with infection.

[Comparative analysis of calcium hydroxide apexification and regenerative endodontic procedure for root dentine growth stimulation in immature incisors with pulp necrosis]

THE AIM OF THE STUDY

Was to compare the efficacy of Ca(OH)₂ apexification and regenerative endodontic procedure (REP) in immature teeth with pulp necrosis. The pilot study included 12 children aged 89 to 126 months having pulp necrosis in immature incisors. Dental trauma was the etiology for pulp necrosis in all cases and initial X-rays showed periapical translucency lesions (PTL). The patients were randomly divided in 2 groups with either Ca(OH)₂ apexification (group 1, n=6) or REP (group 2, n=6). The root length and the growth of root wall thickness, as well as root to crown ratio and dentinal wall to root canal space ratio was assessed radiologically in 6, 12 and 24 months. The root length increase was detected in 83% of all cases, but the pattern of root dentine growth in the groups was different. Dentin thickness in REP group was more prominent in the apical third and was observed in 100% of cases while in group 1 dentin thickness increased mainly in the coronal and middle third of the root, dentin thickness increased only in 33% of all cases in the apexification group. PTL were successfully eliminated in both groups.

CONCLUSION

Results and complications of both methods allow limiting indications for their usage. Ca(OH)₂ apexification is more reliable in cases of pulp necrosis in teeth with III and IV stages of root formation when an estimated time for apexification is 3 to 6 months, under condition of good patient cooperation and possibility for good marginal fit of the restoration. REP is indicated in cases with I, II and III stages of root formation, as well as initial root resorption signs regardless of root formation stage.

New Insights into the Microbial Profiles of Infected Root Canals in Traumatized Teeth

Traumatic dental injuries in young individuals are often exposed to the invasion of oral microorganisms that leads to pulp necrosis. Infective necrosis in permanent teeth not-fully-developed causes aberrant root formation. Regeneration endodontic treatments (RETs) have shown promising results by promoting continued root development by stem cells. Critical to the success of RET is the thorough disinfection of the pulpal space. To establish effective antimicrobial protocols for root canal disinfection, the invading microorganisms need to be identified. In the present study, we use a combination of culture-based and high-throughput molecular sequencing techniques to investigate the microbial profiles from traumatized teeth (30 cases) and controls, i.e., teeth with pulp infections not caused by trauma (32 cases). Overall, a high microbial diversity in traumatized necrotic teeth was observed. Eubacterium yurii subsps. yurii and margaretiae, as well as key ‘bridging oral species’ F. nucleatum sp., Polymorphum and Corynebacterium matruchotti, were highly associated with traumatized teeth. The microbial compositions of traumatized teeth differed considerably from those of infected teeth not caused by trauma. Age and tooth position also influence microbial compositions. In conclusion, we show that the root canal microflora of traumatized teeth is highly diverse, and it differs from root canal infections not caused by trauma.

Evidence-based dental management in the new era of sickle cell disease: A scoping review

BACKGROUND

Sickle cell disease (SCD) is an emerging global health issue with rapid progress in therapy especially since 2017. However, systematic reviews found no clinical trials on dental treatment of SCD.

TYPES OF STUDIES REVIEWED

Using a scoping review approach, the authors examined citations from 13 national SCD guidelines and 10 books spanning 4 decades. The authors also searched the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, Scientific Electronic Library Online, and GoogleScholar. Eligibility criteria included SCD, oral health care and dental treatment, related to oral and systemic health, original data, or observations.

RESULTS

Systemic treatment of SCD might have opposing effects on caries, perhaps explaining the conflicting results published. Malocclusion correlates with marrow expansion. Other unusual orofacial findings reflect ischemia. Of 86 full-text articles examined, only 1, a Brazilian esthetic dentistry study, was a randomized clinical trial. No disease-specific data were found on risk of developing bacterial endocarditis, safety of inhaled nitrous oxide, safety of epinephrine with local anesthetic, or the benefit of comprehensive oral health care.

PRACTICAL IMPLICATIONS

In SCD, oral health and systemic health could be strongly linked. Penicillin, vaccines, and hydroxyurea might impact caries and bone. The interaction of SCD treatments and oral health merit study.

Odontogenic Cutaneous Sinus Tracts: A Clinician's Dilemma

Background:

Odontogenic cutaneous sinus tract (OCST) is one of the rare manifestations of chronic dental infections. Although well reported in literature, it is often misdiagnosed or under diagnosed. Apart from isolated case reports especially in dental literature there is a paucity of comprehensive case series on OCST.

Aims and Objectives:

We undertook this study to observe the prevalence, clinico epidemiological features and management issues in these patients from a dermatological perspective.

Methods:

A retrospective study was undertaken analyzing the clinical records of patients registered at our outpatient department (OPD) from 2011 to 2018. Cases with a clinical and radiological diagnosis of odontogenic cutaneous sinus were included in the study. We studied the following variables: frequency, gender, age, localization, morphology, mean time of evolution and treatment response.

Results:

21 patients with OCST were identified from our records. Females outnumbered males; patients in the age group between 31-40 years were more commonly affected. Three morphological presentations were noted in the form of flesh-colored dry nodules with sinus, adherent plaques with mucopurulent discharge and ulcer. Posterior set of teeth were commonly affected and mandible was the commonest site for location of sinus. The time taken for appropriate diagnosis in these cases ranged from 7-16 months. Almost all the patients responded to endodontal or root canal treatment and there were no recurrences.

Conclusion:

A CST of dental origin is often a diagnostic challenge, especially in cases with minimal or no dental symptoms. A thorough skin and dental examination is required for sinuses on the head and neck area with a high index of suspicion for OCST. Most cases respond to conservative, root canal therapy. An early diagnosis can save the patient from unnecessary and ineffective therapies and sometimes surgeries.

Endodontic-Like Oral Biofilms as Models for Multispecies Interactions in Endodontic Diseases

Oral bacteria possess the ability to form biofilms on solid surfaces. After the penetration of oral bacteria into the pulp, the contact between biofilms and pulp tissue may result in pulpitis, pulp necrosis and/or periapical lesion. Depending on the environmental conditions and the availability of nutrients in the pulp chamber and root canals, mainly Gram-negative anaerobic microorganisms predominate and form the intracanal endodontic biofilm. The objective of the present study was to investigate the role of different substrates on biofilm formation as well as the separate and collective incorporation of six endodontic pathogens, namely Enterococcus faecalis, Staphylococcus aureus, Prevotella nigrescens, Selenomonas sputigena, Parvimonas micra and Treponema denticola into a nine-species "basic biofilm". This biofilm was formed in vitro as a standard subgingival biofilm, comprising Actinomyces oris, Veillonella dispar, Fusobacterium nucleatum, Streptococcus anginosus, Streptococcus oralis, Prevotella intermedia, Campylobacter rectus, Porphyromonas gingivalis, and Tannerella forsythia. The resulting endodontic-like biofilms were grown 64 h under the same conditions on hydroxyapatite and dentin discs. After harvesting the endodontic-like biofilms, the bacterial growth was determined using quantitative real-time PCR, were labeled using fluorescence in situ hybridization (FISH) and analyzed by confocal laser scanning microscopy (CLSM). The addition of six endodontic pathogens to the "basic biofilm" induced a decrease in the cell number of the "basic" species. Interestingly, C. rectus counts increased in biofilms containing E. faecalis, S. aureus, P. nigrescens and S. sputigena, respectively, both on hydroxyapatite and on dentin discs, whereas P. intermedia counts increased only on dentin discs by addition of E. faecalis. The growth of E. faecalis on hydroxyapatite discs and of E. faecalis and S. aureus on dentin discs were significantly higher in the biofilm containing all species than in the "basic biofilm". Contrarily, the counts of P. nigrescens, S. sputigena and P. micra on hydroxyapatite discs as well as counts of P. micra and T. denticola on dentin discs decreased in the all-species biofilm. Overall, all bacterial species associated with endodontic infections were successfully incorporated into the standard multispecies biofilm model both on hydroxyapatite and dentin discs. Thus, future investigations on endodontic infections can rely on this newly established endodontic-like multispecies biofilm model.

Endodontic management of an autotransplanted mandibular third molar: A simplified approach

BACKGROUND AND OVERVIEW

In this case report, the authors aim to review the standard protocols for endodontic treatment of autotransplanted molars and report on the 5-year follow-up of a clinical transplantation case.

CASE DESCRIPTION

The authors transplanted a mandibular third molar into the position of the adjacent second molar. The authors performed extraoral apicoectomy and retrograde restoration after atraumatic extraction of the donor tooth and before transplantation. The authors did not perform conventional orthograde root canal treatment after transplantation. The patient was followed up 5 years after the autotransplantation. Results of follow-up radiography showed a regular root surface without evidence of periapical lesions or root resorption.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

If appropriate sterility of the working field is maintained during surgery and a tight apical seal is achieved during the extraoral treatment, orthograde endodontic treatment should be delayed or avoided.

Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association

BACKGROUND

An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated clinical recommendations for the urgent management of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis and symptomatic apical periodontitis, or pulp necrosis and localized acute apical abscess using antibiotics, either alone or as adjuncts to definitive, conservative dental treatment (DCDT) in immunocompetent adults.

TYPES OF STUDIES REVIEWED

The authors conducted a search of the literature in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature to retrieve evidence on benefits and harms associated with antibiotic use. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and the Evidence-to-Decision framework.

RESULTS

The panel formulated 5 clinical recommendations and 2 good practice statements, each specific to the target conditions, for settings in which DCDT is and is not immediately available. With likely negligible benefits and potentially large harms, the panel recommended against using antibiotics in most clinical scenarios, irrespective of DCDT availability. They recommended antibiotics in patients with systemic involvement (for example, malaise or fever) due to the dental conditions or when the risk of experiencing progression to systemic involvement is high.

CONCLUSION AND PRACTICAL IMPLICATIONS

Evidence suggests that antibiotics for the target conditions may provide negligible benefits and probably contribute to large harms. The expert panel suggests that antibiotics for target conditions be used only when systemic involvement is present and that immediate DCDT should be prioritized in all cases.

Diagnosis and Management of Transverse Root Fractures

BACKGROUND

Root fractures are not a common injury, but a thorough understanding of their etiology, healing responses, diagnosis, management, and prognosis is essential.

REVIEW

The prognosis is largely related to the patient's age; degree of displacement, if any, of the coronal fragment; and the location and orientation of the fracture. The more apical the fracture is located, the better the prognosis. Teeth with root fractures located supracrestally may have the worst prognosis, but their management and outcome depend on many factors, with the most influential factor being the ability to restore the tooth because the coronal fragment usually needs to be removed. In contrast, root fractures located in the apical and middle thirds and those subcrestally in the coronal third of the root have a good prognosis and usually require little, if any, treatment apart from immediate repositioning (if the coronal fragment has been displaced) and stabilization. Monitoring of root-fractured teeth over time is essential to determine the healing response and to assess whether the pulp survives or not. In some cases, the pulp in the coronal fragment may necrose and become infected, thus requiring root canal treatment, but this should only be done to the fracture line. Pulp necrosis and infection typically occur within the first 3-4 months if it is a direct result of the trauma. However, pulp necrosis and infection can also occur many years later, in which case it is likely to be a result of bacterial penetration via cracks or breakdown of restorations.

CONCLUSION

Overall, root fractures should be managed conservatively unless they are located supracrestally.

[Outcomes of traumatic dental injuries in children]

The aim of the study was to review literature data on incidence and outcomes of traumatic dental injuries (TDI) in pediatric population. A systematic search was conducted using Elibray, Pubmed/Medline, Scopus databases in October 2018. Reference lists were also hand-searched to identify additional literature. The most prevalent complication of TDI is pulp necrosis (PN) which triggers inflammatory root resorption (IRR). PN and IRR are however much more specific for mature permanent teeth. In immature teeth pulp revascularization may occur even after avulsion. Pulpectomy timing is well defined for mature teeth only. It is accepted that pulp extirpation should be performed in the first 10 days after trauma. In immature teeth no criteria exist with pulp electrosensitivity having very low negative prognostic value as drop of pulp sensitivity because of trauma not necessary indicate PN. Follow-up protocol for immature teeth with various TDI would be useful for proper timing of pulpectomy and prevention of IRR.

Effect of different dry-polishing regimens on the intrapulpal temperature assessed with pulpal blood microcirculation model

OBJECTIVE

The aim of the study was to evaluate the effect of different dry-polishing regimens on the intrapulpal temperature assessed using a pulpal blood microcirculation model.

MATERIALS AND METHODS

Eighty extracted human mandibular premolar teeth were used. Standardized class V cavity preparations were performed and were then restored. Teeth were divided into four main groups (n = 20): Fine polishing disc (SSF; 3M Sof-Lex, 3M ESPE, Minnesota); Super-fine polishing disc (SSS; 3M Sof-Lex); Spiral finishing wheel (SSW; 3M Sof-Lex); Enhance PoGo-One step diamond micro-polisher cup (EPO; Dentsply Sirona, Inc, Delaware). The main groups were divided: the low-load pressure (0.4N) and the high-load pressure (0.8N). The average change in intrachamber temperatures (Δt), from initial to highest, were measured.

RESULTS

The highest temperature increase was recorded in SSF08 (9.55°C). The lowest value was recorded in EPO04 (1.9°C). SSS08, SSW08, and EPO08 demonstrated significantly higher Δt values than the low-load mode in SSS04, SSW04, and EPO04, respectively (P < .0001).

CONCLUSIONS

Temperature was the least affected by the diamond cup in both pressure modes, and it was also less affected by the spiral finishing wheel in the low-load mode than in the high-load mode. Fine and super-fine discs had the greatest effect on intrachamber temperatures.

CLINICAL SIGNIFICANCE

The present study suggests intrachamber temperature can rise among different dry-polishing regimes. Dental practitioners should pay attention to dry-polishing regimens and pressures for reducing heat-related dental problems.

There is no pulp necrosis or calcific metamorphosis of pulp induced by orthodontic treatment: biological basis

To biologically explain why the orthodontic treatment does not induce pulp necrosis and calcific metamorphosis of the pulp, this paper presents explanations based on pulp physiology, microscopy and pathology, and especially the cell and tissue phenomena that characterize the induced tooth movement. The final reflections are as follows: 1) the orthodontic movement does not induce pulp necrosis or calcific metamorphosis of the pulp; 2) there is no literature or experimental and clinical models to demonstrate or minimally evidence pulp alterations induced by orthodontic movement; 3) when pulp necrosis or calcific metamorphosis of the pulp is diagnosed during orthodontic treatment or soon after removal of orthodontic appliances, its etiology should be assigned to concussion dental trauma, rather than to orthodontic treatment; 4) the two pulp disorders that cause tooth discoloration in apparently healthy teeth are the aseptic pulp necrosis and calcific metamorphosis of the pulp, both only induced by dental trauma; 5) the concussion dental trauma still requires many clinical and laboratory studies with pertinent experimental models, to increasingly explain its effects on the periodontal and pulp tissues.

Prognosis and complications of immature teeth following lateral luxation: A systematic review

BACKGROUND/AIMS

Lateral luxation injuries are a type of traumatic dental injury in which the tooth becomes displaced in the palatal/lingual or labial direction. This injury is common among children and can result in pulp canal obliteration or pulp necrosis. The objective of this systematic review was to gather existing data on lateral luxation injuries to immature teeth to evaluate their overall prognosis.

METHODS

A systematic search was conducted using Medline, Pubmed, Scopus, Lilacs, EMBASE and Cochrane databases in October 2017. Reference lists were also hand-searched to identify additional literature. Prospective and retrospective observational studies were included. A total of 502 articles were screened and six articles were included in the study.

RESULTS

Pulp canal obliteration was the most frequent complication of immature teeth with lateral luxation (31.3%). This was followed by pulp necrosis (17.5%), inflammatory resorption (5.7%), and surface resorption (3.2%). Due to the heterogeneity of the studies, a meta-analysis was not attempted. There was great variation in the reported outcomes among the studies.

CONCLUSION

Accurate prognosis evaluation of traumatic dental injuries is difficult due to the nature of current studies being retrospective or prospective cohort studies. Lateral luxation is a common traumatic dental injury and has life-long concerns for a patient. It is important for future studies to report on the same outcomes to increase the quality of evidence regarding prognosis and treatment interventions, not only for lateral luxation injuries, but for all traumatic dental injuries.

A review of regenerative endodontics: current protocols and future directions

This review outlines the biological basis and clinical protocols currently used in regenerative endodontic procedures (REPs) and discuss future directions in pulp regeneration approaches. The treatment of immature teeth with REPs has been described as a ‘paradigm shift’ as there is the potential for further root maturation. Clinically, REPs involve disinfection of the root canal system without damaging the endogenous stem cell potential present in the apical papilla and other tissues. These stems cells are introduced into the root canal space by inducing a blood clot followed by placement of an intracanal barrier to prevent microleakage. The biological concept of REPs involves the triad of stem cells, scaffold and signalling molecules. Currently, repair rather than true regeneration of the ‘pulp-dentine complex’ is achieved and further root maturation is variable. However, may clinicians consider the treatment of teeth with REPs as the optimal treatment approach for immature teeth with pulp necrosis.

Allogeneic stem cells derived from human exfoliated deciduous teeth (SHED) for the management of periapical lesions in permanent teeth: Two case reports of a novel biologic alternative treatment

Stem cells are the pluripotent cells that have the capacity to differentiate into other specialized cells. Recently, many experiments have been conducted to study the potentiality of stem cells in the tissue regeneration. We report two cases treated utilizing stem cells from human exfoliated deciduous teeth (SHED) in the management of periapical lesions in permanent teeth. Two normal human deciduous teeth from children, 7‒8 years of age, were collected to isolate stem cells. Two patients, one with periapical pathology alone and the other with periapical lesion along with an open apex in young permanent teeth, were selected for the study. After initial debridement of the root canals, homing of SHED was carried out and the access cavity was sealed using glass-ionomer cement. Clinical examination after 7 days, 30 days, 90 days, 180 days and 365 days revealed no symptoms. Closure of open apex and periapical tissue healing were observed radiographically at one-month review and maintained until 365-day review. Positive response to electric pulp testing was recorded for the treated teeth from the 3- to 12-month follow-ups. The treated cases demonstrated complete resolution of periapical radiolucency in a span of 30 days, which was faster than the conventional methods. SHED could be considred effective in treating the periapical lesions and open apex in permanent teeth.

Periapical abscess – etiology, pathogenesis and epidemiology

Inflammation of the pulp and periapical tissues is the main cause of tooth loss in patients worldwide, therefore endodontics is one of the most rapidly developing specialties in dentistry. Despite proper endodontic treatment, in many cases it is not possible to determine the etiology of infection or the reason for its relapse. Many research studies indicate that infections of the periapical tissues are mainly caused by strictly anaerobic bacteria. At present, more and more often the composition of the microflora within the inflammatory lesions is being evaluated with the use of molecular techniques, which showed that classical culture methods are not able to determine the etiology of infections of the periapical tissues. The results of these studies contributed to the major changes in our understanding of the microbiome composition in the endodontium. Purulent endodontic lesions are particularly important, as they may lead to many severe – even life-threatening – systemic complications.

Scandinavian multicenter study on the treatment of 168 patients with 230 intruded permanent teeth - a retrospective cohort study

BACKGROUND/AIM

The aim of the study was to evaluate the survival of intruded permanent teeth related to treatment in a large number of patients, with special focus on development of pulp necrosis and replacement resorption (ankylosis-related resorption).

MATERIALS AND METHODS

The material consisted of 168 patients (mean age 9.6 years) with 230 intruded permanent teeth from dental trauma clinics in Copenhagen, Denmark, Stockholm, Sweden, and Oslo, Norway. The degree of intrusion was classified as mild (1-<3 mm), moderate (3-7 mm), and severe (>7 mm). Root development was categorized with respect to root formation and development of the apex into three groups of increasing tooth maturity: very immature, immature, and mature.

RESULTS

Awaiting re-eruption was the treatment of choice in 107 teeth (47%), orthodontic repositioning in 28 (12%) and surgical repositioning in 95 (41%) teeth. Pulp necrosis was diagnosed in 173 teeth (75%), infection-related root resorption in 57 (25%) and replacement resorption in 50 teeth (22%). Very immature teeth, teeth diagnosed with mild intrusion, and teeth awaiting re-eruption had significantly (P < 0.05) fewer complications. In a stepwise discriminant function analysis, choice of treatment, root development, and degree of intrusion were significantly (P < 0.05) associated with the development of replacement resorption. Root development and degree of intrusion were significantly (P < 0.05) associated with the development of pulp necrosis.

CONCLUSION

This study indicates that root development and degree of intrusion may be important for the development of pulp necrosis as well as replacement resorption, whereas choice of treatment only seems to influence the development of replacement resorption in intruded permanent teeth. Awaiting re-eruption resulted in the lowest risk for developing replacement resorption.

Nonsurgical management of an extensive endodontic lesion in an orthodontic patient by calcium-enriched mixture apical plug

Periapical lesion is a general term used to describe the periapical inflammatory process that occurs in response to the invasion of micro-organisms in the root canal system as well as inflamed vital pulp. This phenomenon necessitates endodontic intervention and if the necrosis has occurred prior to tooth maturation, wide patency of the apical foramen requires some treatment modalities such as apexification or apical plug. Orthodontic treatment, on the other hand, is cautiously done for previously traumatized teeth due to increased risk for necrosis of the compromised tooth. This article tends to review the successful treatment process with calcium-enriched mixture (CEM) cement apical plug for an immature previously traumatized incisor tooth with an extensive periapical lesion, which was under orthodontic treatment as well.

Estimates of sensitivity and specificity of electric pulp testing depend on pulp disease spectrum: a modelling study

AIM

To demonstrate how the spectrum of diseased pulps may influence sensitivity and specificity in diagnostic studies on pulp status.

METHODOLOGY

An original sample from a previous study consisting of 59 teeth scheduled for root canal treatment was used where the relationship between the response to electric pulp testing and the visual status of the pulp was evaluated. To alter the spectrum of diseased pulps, a hypothetical sample of asymptomatic teeth with deep caries lesions was added to the original sample. Sensitivity and specificity were then compared for the two samples.

RESULTS

In the original sample of 59 teeth, sensitivity was 72% and specificity 90%. When the spectrum of diseased pulps was altered, sensitivity decreased to 67% and specificity increased to 97%. The change in disease spectrum also decreased the prevalence of necrotic pulps.

CONCLUSIONS

The spectrum of diseased pulps included in a diagnostic study on the accuracy of electric pulp testing, and indirectly also disease prevalence (here pulp necrosis), influences estimates of sensitivity and specificity. This implies that estimates of diagnostic accuracy from one study with a particular tooth population spectrum may not apply to another tooth population with a different disease spectrum.

Regeneration potential of pulp-dentin complex: Systematic review

Aim:

The aim is to review and discuss the strategies available for the regeneration of tooth tissues based on principles of tissue engineering.

Background:

Tissue engineering is a multidisciplinary approach that aims to regenerate functional tooth-tissue structure based on the interplay of three basic key elements: Stem cells, morphogens and scaffolds. A number of recent clinical case reports have revealed the possibilities that many teeth that traditionally would be treated byapexification may be treated by apexogenesis.

Materials and Methods:

Electronic and hand search of scientific papers were carried out on the Entrez Pubmed, and the Cochrane Central Register of Controlled Trials databases using specific keywords. Specific inclusion and exclusion criteria were predetermined. The search yielded 1619 papers; out of which 65 were identified as conforming to the predetermined inclusion criteria and the remaining 1554 were excluded. Out of 65 papers, 34 papers were excluded again as different key words led to the same publications. Only 31 papers were selected, out of which 27 full-text papers were found and 4 papers were included based on only the abstracts. These 31 papers formed the basis of this review. The data were extracted from the selected studies. The data were synthesized by pooling the extracted data.

Conclusion:

The field of tissue engineering has recently shown promising results and is a good prospect in dentistry for the development of the ideal restorations to replace the lost tooth structure.