Contemporary endodontic treatment choices for adult patients with dens evaginatus and apical periodontitis: a case report with a 2-year follow-up.

Dens evaginatus (DE) frequently leads to pulp exposure and subsequent pulpal inflammation, pulpal necrosis, and periapical inflammation. This case report describes the application of regenerative endodontic therapy and mineral trioxide aggregate (MTA) apexification in a 22-year-old man with mandibular second premolars affected by DE and apical periodontitis. Regenerative endodontic therapy was performed after thorough debridement and placement of calcium hydroxide in the root canal of the left premolar. In contrast, an apical plug of MTA was placed prior to gutta percha compaction in the root canal of the right premolar. Both teeth were restored with adhesive composite resin. A 2-year follow-up examination revealed complete periapical healing.

Use of Vital Pulp Therapies in Primary Teeth 2024.

Purpose: The purpose of this study was to present an evidence-based guideline for primary teeth with deep caries or trauma requiring vital pulp therapies (VPT). Methods: A systematic review/meta-analysis on vital primary teeth resulting from trauma or caries was conducted using GRADE to assess the certainty of evidence for clinical recommendations. A decision tree was provided for choosing VPTs. Results: No articles on trauma VPT were found. For VPT in primary teeth with deep caries, indirect pulp treatment (IPT) or pulpotomy using the calcium silicate cement (mineral trioxide aggregate [MTA] or Biodentine®) show increased success over using direct pulp capping (DPC) and other pulpotomies. Different liners do not affect IPT success (high certainty) or DPC capping agents' success (very low certainty) after 24 months. It is strongly recommended, with high certainty from 24-month data, that calcium silicate cement pulpotomy is preferred over formocresol, ferric sulfate, zinc oxide eugenol pulpotomy, and other pulpotomies. Using selective caries removal and IPT for deep caries is strongly recommended with moderate certainty over complete and stepwise removal. Statistically, this results in significantly fewer pulp exposures. No caries removal and Hall technique crown may be used when indicated (moderate certainty at 24 months). For vital primary incisors with deep caries, pulpotomy was significantly better statistically than pulpectomy. Teeth diagnosed with/without reversible pulpitis pain showed comparable success after 12 months of treatment by IPT or calcium silicate cement pulpotomy. The following had little or no significant effect on MTA pulpotomy success: coronal pulp removal methods; irrigation solution; method to control hemorrhage; base over MTA; treatment in one or two visits; anterior or posterior teeth. Conclusions: Indirect pulp treatment or calcium silicate cement pulpotomy is likely to increase vital pulp therapy success over other VPTs such as direct pulp capping and other pulpotomies after 24 months (moderate certainty).

The Evolving Landscape of the American Board of Endodontics Certification Process: What it Means for the Future of the Specialty.

INTRODUCTION: The American Board of Endodontics certification is an evolving process to ensure the continuing existence of the specialty of endodontics. Recent examination changes have resulted in greater numbers of Diplomates. To fully understand the implications of such changes and evaluate current Diplomates' views of the examination process, a specific set of questions was developed focusing on beliefs and perceptions, age relationships, test components, and hypotheticals for potential changes. An analysis of the examination process has never been reported in the literature, and, as such, the survey was designed to provide the endodontic community with critical information on the past, current, and potentially future examination process. METHODS: A Web-based survey consisting of 25 questions was e-mailed to 1522 Diplomates. RESULTS: A total of 736 Diplomates responded to the survey for a response rate of 48.4%. Descriptive statistics and regression analysis (p < .05) were used to explore relationships in the data. CONCLUSIONS: A lack of perceived importance of being board certified was a major barrier. Respondents opposed de-emphasizing literature, offering the oral examination in a videoconferencing virtual format, eliminating mandatory recalls, and entirely removing 1 component of the examination to increase the numbers of Diplomates. Respondents supported reviewing the case history portfolio examination on a rolling basis. Respondents disagreed that molar cases alone demonstrated clinical competency. Older Diplomates felt the strongest that the meaning of being a Diplomate has been diluted by the changes in the certification process. The authors believe the American Association of Endodontists, program directors, and the College of Diplomates must continually emphasize the importance and value of board certification as the process continues to evolve.

Retrospective Analysis of Root-end Microsurgery Outcomes in a Postgraduate Program in Endodontics Using Calcium Silicate-based Cements as Root-end Filling Materials.

INTRODUCTION: The purpose of this retrospective study was to determine the clinical and radiographic outcomes of root-end microsurgery in a postgraduate program in endodontics using modern techniques and calcium silicate-based root-end filling materials (ProRoot MTA; Dentsply International, Johnson City, TN, and EndoSequence Root Repair Material [ERRM]; Brasseler USA, Savannah, GA) and to identify any potential prognostic factors that may have affected healing outcomes. METHODS: Clinical records and periapical radiographs were collected from patients who had undergone endodontic microsurgery between 2007 and 2018 in a postgraduate endodontic clinic with a minimum follow-up interval of 6 months. Either ProRoot MTA or ERRM was used as the root-end filling material. Outcomes were categorized into healed, healing, and nonhealing based on clinical and radiographic findings. Healed and healing cases were pooled and considered as successes, whereas nonhealing cases were considered as failures. RESULTS: A total of 129 patients with 142 teeth were included in the final analysis. Seventy-six cases were root-end filled with ProRoot MTA and 66 root-end filled with ERRM. The ProRoot MTA group had a success rate of 92.1%, and the ERRM group had a success rate of 92.4% with no significant difference between the groups (P > .05). Vertical root fracture was found to be the predominant cause of failure. No patient- or treatment-related factor was identified to have any significant impact on healing. CONCLUSIONS: High overall success can be achieved in a postgraduate endodontic program when either ProRoot MTA or ERRM is used as the root-end filling material.

Periradicular Lesions in Cancellous Bone Can Be Detected Radiographically.

INTRODUCTION: The purpose of this study was to evaluate whether naturally occurring periradicular lesions confined to cancellous bone can be detected on periapical digital radiography and whether the size of the lesion had any effect on lesion detection. METHODS: One hundred twenty-nine roots were chosen based on cone-beam computed tomographic imaging and categorized as having no lesion, a lesion confined to cancellous bone, a lesion that encroaches on junctional corticocancellous trabeculae, or a lesion with cortical involvement. The largest buccolingual dimension of the lesions was measured on cone-beam computed tomographic imaging. Two observers separately viewed the corresponding periapical radiographs in their original version as well as in the edge-enhanced setting on MiPACS (LEAD Technologies Inc, Charlotte, NC). Observers were asked to evaluate and interpret the periapical radiographs as having a lesion present, absent, or "unsure." Evaluations of images were conducted at 2 times 1 week apart. Data were analyzed, and the level of significance was set at P = .05. RESULTS: Lesion size, not the degree of cortical involvement, significantly affected the observers' ability to accurately detect lesions. As the size of the lesion increased, the probability of correctly identifying a lesion increased (P = .0008). Lesions were correctly identified 97.6%, 94.1%, 91.6%, and 89.3% of the time, respectively, when in cortical bone, at the junction of corticocancellous bone, in cancellous bone, and when no lesion was present. Observers were "unsure" whether a lesion was present or absent 10.7% of the time. Only lesions in cortical bone significantly increased observers' certainty in making a diagnosis. CONCLUSIONS: This study concluded that lesions confined to cancellous bone can be detected radiographically at a high rate. Lesion size was positively correlated with correct lesion identification, whereas the degree of cortical involvement had no significant effect. This suggests that lesion size may be a better predictor for correct lesion identification than lesion location.

Effectiveness of Gutta-percha/Sealer Removal during Retreatment of Extracted Human Molars Using the GentleWave System.

INTRODUCTION: The goal of endodontic retreatment is to address the etiology responsible for failure. In order to achieve this, the contents of the previous treatment must be removed. The aim of this study was to compare the effectiveness of the removal of residual obturation material (gutta-percha and sealer) using side-vented needle, EndoVac, and GentleWave (Sonendo, Inc, Laguna Hills, CA) irrigation protocols. METHODS: Thirty freshly extracted mandibular molars were instrumented to a master apical file size of 20.06, obturated using continuous wave of condensation and AH Plus sealer (Dentsply Tulsa, Tulsa, OK), restored, and placed in phosphate-buffered saline for 7 days. Teeth were retreated using a crown-down method to a master apical file size of 20.04. Radiographs and micro-computed tomographic images were obtained to confirm the presence of residual obturation material. Teeth were randomly divided among the following treatment groups: a side-vented needle, EndoVac, or GentleWave. Following strict irrigation protocols, postirrigation micro-computed tomographic scans were obtained and used to calculate the percentage of the residual obturation removed. RESULTS: GentleWave removed more residual obturation material (26%) than the side-vented needle (16%) and EndoVac (9%); the differences between the GentleWave group and the other 2 groups were not statistically significant (P > .05). The difference between the side-vented needle and EndoVac was statistically significant (P = .04). CONCLUSIONS: None of the irrigation techniques were able to completely remove all of the residual obturation material from the canals. The side-vented needle and the GentleWave groups were able to remove on average more residual obturation material than EndoVac; however, the differences were not significant.

A Novel Prefabricated Grid for Guided Endodontic Microsurgery.

INTRODUCTION: This study aimed to introduce a novel method using cone-beam computed tomographic (CBCT) imaging and prefabricated grids to guide apical access during endodontic microsurgery and to compare its accuracy with that of the nonguided method. METHODS: Forty-two roots from human cadaver jaws were selected. Twenty-one were randomly assigned to the experimental group (grid based) and their contralateral counterparts to the control group (nonguided). Preoperative CBCT images were used to design a drill path that intended to reach the palatal/lingual aspect of the roots without attempting to complete the osteotomy or to resect the entire root end. In the experimental group, prefabricated metal grids used during imaging and surgery acted as a reference in the design and drilling. Postoperative CBCT volumes were superimposed on the preoperative volumes, and the distances between the actual drill paths and the target points were measured. A dichotomized outcome of success versus failure was also recorded and compared. Statistical analysis was performed using the paired t test and Fisher exact test. RESULTS: The mean deviation of the drill paths from the target points was 0.66 mm ± 0.54 mm (mean ± standard deviation) for grid-based drilling and 1.92 mm ± 1.05 mm (mean ± standard deviation) for nonguided drilling (P < .001). Grid-based drilling was on average 1.27 mm (95% confidence interval, 0.81-1.72 mm) closer to the target point than nonguided drilling. The probability of successful drilling was also significantly higher with grids than without grids (P = .02). CONCLUSIONS: The proposed method of guided osteotomy and root-end resection using prefabricated grids was more accurate than the nonguided method.

Accuracy of 3-dimensional-printed Endodontic Surgical Guide: A Human Cadaver Study.

INTRODUCTION: Cone-beam computed tomographic (CBCT)-based 3-dimensional-printed surgical guides, such as those used in implant placement and orofacial surgery, allow for accurate planning and performance of surgical procedures. The objective of this study was to evaluate the accuracy of CBCT-designed surgical guides for use during endodontic surgery. METHODS: A split-mouth design was conducted using 48 roots in a cadaver model. In the experimental group, using information from the preoperative CBCT scans and digital impressions, surgical guides were designed using Blue Sky Bio (Grayslake, IL) planning software and printed using a Form 2 3-dimensional printer (Formlabs, Somerville, MA). The guides were designed to allow for surgical access at 3 mm from the apex of each root with depth control to the lingual or palatal surface of the root. In the control group, surgical access was completed "freehand" by visually approximating measurements from the CBCT scan only. The planned and postoperative CBCT images were superimposed, and the deviation of the surgical access point from the planned target was measured using Invivo software (Anatomage, San Jose, CA). A 2-tailed t test and the Fisher exact test were conducted to compare the deviation in the experimental CBCT-guided group versus the control CBCT-approximated freehand group. RESULTS: The mean deviation for the guided group (1.743 mm) was significantly less than that of the approximated freehand group (2.638 mm, P < .001). Only in 11 of the 24 samples of the control group was surgical access considered clinically successful (within the apical area of the root), whereas all 24 of the experimental samples were considered clinically successful. CONCLUSIONS: Using a CBCT-designed printed surgical guide is a more accurate method for access to the apical portion of the root during surgical endodontics compared with a "freehand" CBCT-approximated method.

Resveratrol represses tumor necrosis factor α/c-Jun N-terminal kinase signaling via autophagy in human dental pulp stem cells.

OBJECTIVES: To study the effects of polyphenol resveratrol on TNFα-induced inflammatory signaling as well as the underlying mechanism in human dental pulp stem cells (DPSCs). MATERIALS AND METHODS: Human DPSCs were cultured and treated by TNFα in the presence or absence of resveratrol. NF-κB and mitogen-activated protein kinase (MAPK) signaling pathways were analyzed by Western blotting and immunofluorescence staining. Interleukin 6 (IL6) and interleukin 8 (IL8) mRNA levels were analyzed by reverse transcription polymerase chain reaction. For the mechanistic study, autophagy was examined and further manipulated by gene silencing of Atg5 using siRNAs. Statistical analysis was performed by Student's t- test, and values of p < 0.05 were considered significant. RESULTS: Upon TNFα treatments, neither degradation of IκBα nor the phosphorylation and nuclear translocation of p65 NF-κB were inhibited by resveratrol at different concentrations. In contrast, resveratrol dramatically inhibited TNFα-induced phosphorylation of c-Jun N-terminal kinase (JNK) MAPK. Furthermore, resveratrol activated autophagy, as evidenced by the accumulated autophagic puncta formed by lipid bound LC3B in resveratrol-treated cells. Intriguingly, both resveratrol and JNK inhibitor SP600125 suppressed TNFα-induced IL6 and IL8 mRNA expression (P < 0.05). Silencing autophagy gene Atg5 led to the hyper-activation of JNK and augmented TNFα-induced IL6 and IL8 mRNA expression (P < 0.05). CONCLUSIONS: The results suggest that resveratrol suppresses TNFα-induced inflammatory cytokines expressed by DPSCs through regulating the inhibitory autophagy-JNK signaling cascade. Resveratrol might be beneficial to ameliorate pulpal damage during the acute phase of inflammation in vital pulp therapy.

Contemporary perspectives on vital pulp therapy: views from the endodontists and pediatric dentists.

The purpose of this study was to determine the level of agreement between pediatric dentists and endodontists at a pulp therapy symposium conjointly sponsored by the American Association of Endodontists (AAE) and the American Academy of Pediatric Dentistry (AAPD) on November 2-3, 2007. Presymposium and postsymposium tests were administered, and respondent answers were compared between pediatric dentists and endodontists. Opinions on 3 areas were sought: pulp therapy for cariously involved primary teeth; indirect pulp treatment (IPT) for cariously involved immature permanent teeth; and innovative treatment options including pulpal revascularization and regeneration. Results were analyzed with chi2 tests. Comparisons of presymposium and postsymposium responses and between the 2 groups of attendees indicated that the pediatric dentistry and endodontic communities agree that formocresol will be replaced as a primary tooth pulpotomy agent, that mineral trioxide is the first choice to take its place, that IPT in primary teeth holds hope as a replacement for pulpotomy, and that IPTis an acceptable pulp therapy technique for cariously involved young permanent teeth. Both groups believe that pulp revascularization and regeneration will be viable treatment modalities in the future. The AAE and the AAPD are positioned to begin preparation of best practice guidelines that share common language and treatment recommendations for pulp therapies performed by both specialties.

Interobserver and Intraobserver Reliability of Cone-beam Computed Tomography in Identification of Apical Periodontitis.

INTRODUCTION: Accurate radiographic interpretation is of the utmost importance in the diagnosis and treatment of patients. Previous studies have indicated subjectivity in the radiographic interpretation of periapical tissues irrespective of using conventional radiography, digital radiography, or cone-beam computed tomographic (CBCT) imaging. No studies to date have evaluated the reliability of the interpretation of periapical tissues based on the size of periapical radiolucency (PAR). The purpose of this study was to assess the interobserver and intraobserver reliability of CBCT interpretation by observers from different specialties and different levels of experience when identifying PARs of various sizes. METHODS: Limited field of view CBCT scans were selected such that a variety of PARs with various sizes were included. Six observers with different levels of experience and fields of specialty evaluated periradicular tissues of 28 roots on the CBCT scans at 3 separate sittings each a month apart. RESULTS: The overall Fleiss kappa coefficient for interobserver reliability and intraobserver reliability was 0.88 and 0.85; the larger the PAR, the more reliable the radiographic interpretation. Increased experience level improved the intraobserver reliability. CONCLUSIONS: CBCT imaging appears to be a reliable method for the interpretation of PAR. The larger the PAR is the more reliable the radiographic interpretation.

Clinical Outcome of Non-Surgical Root Canal Treatment Using a Single-cone Technique with Endosequence Bioceramic Sealer: A Retrospective Analysis.

INTRODUCTION: One of the important steps in root canal treatment is to create a well-sealed root canal system. EndoSequence BC Sealer (BC; Brasseler USA, Savannah, GA) has several beneficial properties and thus has been incorporated into the practitioner's armamentarium. No studies to date have evaluated the clinical success of using BC. The purpose of this study was to evaluate the outcome of nonsurgical root canal treatment using a single-cone and BC technique and to identify factors associated with success or failure. METHODS: This retrospective cohort study included patients treated in a private practice environment between 2009 and 2015. All cases, including initial and retreatment, were obturated with BC using a single-cone technique with a minimum of a 1-year recall. Patient and treatment factors were analyzed to determine their significance as prognostic factors. Outcome was evaluated based on clinical and radiographic findings at recall. Teeth were classified as healed, healing (success), or not healed (failure). Statistical analysis of potential prognostic factors was performed using the chi-square test (α = 0.05). RESULTS: Three hundred seven teeth were included in the analysis, and the average follow-up time was 30.1 months. The overall success rate was 90.9%. Lesions <5 mm in diameter had a significantly higher success rate than lesions >5 mm in diameter. Sealer extrusion was observed in 47.4% of the cases. The presence of sealer extrusion did not have any significant effect on the treatment outcome. CONCLUSIONS: BC used with a single-cone technique is a viable option for obturation.