Investigation of the early apical release from endodontic hydrogels: A 3D printed model.

AIM: Regenerative Endodontic Procedures (REPs) using new materials such as hydrogels aim to replace current endodontic treatments, but numerous limitations are to overcome. Apical release was little explored in previous studies, especially regarding hydrogels that incorporate molecules, such as growth factors and antibiotics. Apical release is a key mechanism in achieving regeneration, as it could regulate disinfection or cell colonization. Few models exist for apical release, limiting the transfer of these devices from bench to bedside. This study aims to design a simple and standardized model to identify parameters that influence the early apical release kinetic of molecules from endodontic hydrogels. METHODOLOGY: Endodontic Release Inserts (ERI) were designed to mimic the situation of an immature incisor using three different diameters (Ø 0.5 to 2 mm) and to allow the study of the early release from a hydrogel in a 96-well plate. ERI was produced with a 3D printing machine. The kinetic release was investigated using 2 fluorescent, hydrophobic (BDP-500) and hydrophilic (Fluorescein) molecules, in different hydrogels (fibrin and agarose) and in various media (PBS or serum). The release kinetics were estimated by measuring the fluorescence at different time points (1 to 24 h). RESULTS: ERI use made it possible to report that apical diameters increase from 500 to 1000 µm was associated with an increase in release from 4.02 ± 1.63% to 11.53 ± 2.38% over 24 h. It also allowed us to report that bottom solution composition change from PBS to human serum was associated with an increase in the release of fatty acid molecules, whilst a decrease in the hydrogel concentration was associated with a variation in release kinetics. Moreover, nano-encapsulation of a molecule was associated with a decreased release over the first 24 h from 5.25 to 0%. CONCLUSION: ERI use enables investigation of the parameters influencing release kinetics from endodontic hydrogels. Further investigations are necessary to evaluate the interaction of these parameters with each other, in animal models and clinic.

Concordance of judgement: A tool to foster the development of professionalism in dentistry.

INTRODUCTION: Developing professionalism notably involves learning how to make professional judgements in ambiguous situations. The Concordance of Judgement Test (CJT) is a learning tool that was proposed to develop professionalism competencies, but it was never performed in dentistry or used with a synchronous methodology. The present study evaluated the feasibility of the use of CJT in the context of dental education, to foster professionalism and stimulate reflexivity and discussion. MATERIALS AND METHODS: After different steps of optimization, a questionnaire presenting 12 vignettes was submitted to 33 Canadian students. Second, after an additional optimization, a questionnaire of 7 vignettes was submitted to 87 French students. An immediate educational feedback was proposed after each vignette to promote reflexivity and discussions during the experience. RESULTS: The overall experience of the students was reported as good, thanks to the feedback of real-life situations. This promoted reflexivity and stimulated discussion between students and educators regarding professionalism issues. The students considered CJT as a relevant and well-adapted tool, and reported positive feelings regarding the inter-university aspect of the activity. The mean score of the panel members was close to 80/100 and the mean score of the students was 5 to 10 points lower, which is in agreement with docimological performance. CONCLUSION: The results suggested that the use of CJT in a synchronous way was a feasible and relevant tool to motivate the students to improve their professionalism, and to stimulate their reflexivity and discussion. The students reported positive experience with CJT, and we believe that this tool can be integrated in the dental curriculum.

Artificial intelligence and smile design: An e-Delphi consensus statement of ethical challenges.

PURPOSE: Smile design software increasingly relies on artificial intelligence (AI). However, using AI for smile design raises numerous technical and ethical concerns. This study aimed to evaluate these ethical issues. METHODS: An international consortium of experts specialized in AI, dentistry, and smile design was engaged to emulate and assess the ethical challenges raised by the use of AI for smile design. An e-Delphi protocol was used to seek the agreement of the ITU-WHO group on well-established ethical principles regarding the use of AI (wellness, respect for autonomy, privacy protection, solidarity, governance, equity, diversity, expertise/prudence, accountability/responsibility, sustainability, and transparency). Each principle included examples of ethical challenges that users might encounter when using AI for smile design. RESULTS: On the first round of the e-Delphi exercise, participants agreed that seven items should be considered in smile design (diversity, transparency, wellness, privacy protection, prudence, law and governance, and sustainable development), but the remaining four items (equity, accountability and responsibility, solidarity, and respect of autonomy) were rejected and had to be reformulated. After a second round, participants agreed to all items that should be considered while using AI for smile design. CONCLUSIONS: AI development and deployment for smile design should abide by the ethical principles of wellness, respect for autonomy, privacy protection, solidarity, governance, equity, diversity, expertise/prudence, accountability/responsibility, sustainability, and transparency.

Next generation antibacterial strategies for regenerative endodontic procedures: A scoping review.

BACKGROUND: The clinical results following regenerative endodontic procedures (REPs) vary according to numerous parameters, including the presence of bacteria. This limitation reduces the indications for REPs and calls for the development of next generation antibacterial strategies (NGAS) providing alternatives to current antibacterial strategies (CAS) such as double or triple antibiotic paste (DAP/TAP) and (Ca(OH)2). OBJECTIVES: The present scoping review aims to describe the current trends regarding the use of such strategies and highlight future perspectives. METHODS: Four databases (PUBMed, Cochrane, ClinicalTrials and Science Direct) were searched until 1st May 2023. RESULTS: A total of 918 records were identified, 133 were screened and assessed for eligibility, and 87 articles were included. The findings show that (1) clinical studies are only available for CAS, (2) although next generation strategies are the most studied approach since 2017, they are all at the pre-clinical stage, (3) most of the next generation strategies use galenic forms which offer cell support and colonization and which simultaneously contain antibacterial molecules as alternatives to CAS and to antibiotics in general, (4) standardization is required for future research, specifically regarding the bacterial strains studied, the use of biofilm studies and the cellular behaviour assessments. CONCLUSION: Although NGAS are promising strategies to improve REPs in the context of infection, the current evidence is mostly limited to pre-clinical studies. Further methodological improvement is required to allow relevant comparisons between studies and to reduce the time from bench to bedside.

Bioactive Endodontic Hydrogels: From Parameters to Personalized Medicine.

Regenerative endodontic procedures (REPs) aim at recreating dental pulp tissue using biomaterials such as hydrogels. Their bioactivity is mostly related to the nature of biomolecules or chemical compounds that compose the endodontic hydrogel. However, many other parameters, such as hydrogel concentration, bioactive molecules solubility, and apex size, were reported to influence the reciprocal host-biomaterial relationship and hydrogel behavior. The lack of knowledge regarding these various parameters, which should be considered, leads to the inability to predict the clinical outcome and suggests that the biological activity of endodontic hydrogel is impossible to anticipate and could hinder the bench-to-bedside transition. We describe, in this review, that most of these parameters could be identified, described, and studied. A second part of the review lists some challenges and perspectives, including development of future mathematical models that are able to explain, and eventually predict, the bioactivity of endodontic hydrogel used in a clinical setting.

A critical analysis of research methods and experimental models to study pulpitis.

Pulpitis is the inflammatory response of the dental pulp to a tooth insult, whether it is microbial, chemical, or physical in origin. It is traditionally referred to as reversible or irreversible, a classification for therapeutic purposes that determines the capability of the pulp to heal. Recently, new knowledge about dental pulp physiopathology led to orientate therapeutics towards more frequent preservation of pulp vitality. However, full adoption of these vital pulp therapies by dental practitioners will be achieved only following better understanding of cell and tissue mechanisms involved in pulpitis. The current narrative review aimed to discuss the contribution of the most significant experimental models developed to study pulpitis. Traditionally, in vitro two (2D)- or three (3D)-dimensional cell cultures or in vivo animal models were used to analyse the pulp response to pulpitis inducers at cell, tissue or organ level. In vitro, 2D cell cultures were mainly used to decipher the specific roles of key actors of pulp inflammation such as bacterial by-products, pro-inflammatory cytokines, odontoblasts or pulp stem cells. However, these simple models did not reproduce the 3D organisation of the pulp tissue and, with rare exceptions, did not consider interactions between resident cell types. In vitro, tissue/organ-based models were developed to better reflect the complexity of the pulp structure. Their major disadvantage is that they did not allow the analysis of blood supply and innervation participation. On the contrary, in vivo models have allowed researchers to identify key immune, vascular and nervous actors of pulpitis and to understand their function and interplay in the inflamed pulp. However, inflammation was mainly induced by iatrogenic dentine drilling associated with simple pulp exposure to the oral environment or stimulation by individual bacterial by-products for short periods. Clearly, these models did not reflect the long and progressive development of dental caries. Lastly, the substantial diversity of the existing models makes experimental data extrapolation to the clinical situation complicated. Therefore, improvement in the design and standardisation of future models, for example by using novel molecular biomarkers, databased models and artificial intelligence, will be an essential step in building an incremental knowledge of pulpitis in the future.

Precision medicine using patient-specific modelling: state of the art and perspectives in dental practice.

The dental practice has largely evolved in the last 50 years following a better understanding of the biomechanical behaviour of teeth and its supporting structures, as well as developments in the fields of imaging and biomaterials. However, many patients still encounter treatment failures; this is related to the complex nature of evaluating the biomechanical aspects of each clinical situation due to the numerous patient-specific parameters, such as occlusion and root anatomy. In parallel, the advent of cone beam computed tomography enabled researchers in the field of odontology as well as clinicians to gather and model patient data with sufficient accuracy using image processing and finite element technologies. These developments gave rise to a new precision medicine concept that proposes to individually assess anatomical and biomechanical characteristics and adapt treatment options accordingly. While this approach is already applied in maxillofacial surgery, its implementation in dentistry is still restricted. However, recent advancements in artificial intelligence make it possible to automate several parts of the laborious modelling task, bringing such user-assisted decision-support tools closer to both clinicians and researchers. Therefore, the present narrative review aimed to present and discuss the current literature investigating patient-specific modelling in dentistry, its state-of-the-art applications, and research perspectives.

Communication tools and patient satisfaction: A scoping review.

OBJECTIVE: This scoping review aimed to present an overview of the literature on communication tools in esthetic dentistry. A variety of communication tools have been proposed to include patients in the shared decision-making (SDM) workflow. Only little is known about implementing communication tools in dentistry and their impact on patient communication and patient satisfaction. A systematic literature search was performed in Medline, Embase, Cochrane, and World of Science to identify if communication tools have an impact on patient satisfaction. MATERIAL AND METHODS: The search included studies from January 1, 2000 to March 3, 2020 published in English, focusing on patient communication tools and patient satisfaction in esthetic dentistry. RESULTS: Out of 6678 records, 53 full-texts were examined. Ten studies were included. Data of the included studies were extracted systematically and subsequently analyzed. All studies found that patient communication utilizing specific communication tools positively impacted either patient satisfaction, patient-dentist relationship, information retention, treatment acceptance, quality of care or treatment outcome. CONCLUSIONS: Additional communication tools besides conventional verbal communication are able to enhance patient satisfaction, improve quality of care and establish a better patient-dentist relationship. It seems essential to further develop standardized communication tools for SDM in dental medicine, which will allow the comparison of research on this topic. CLINICAL SIGNIFICANCE: This scoping review shows the importance of patient involvement in the decision-making process for improved patient satisfaction with esthetic dental treatments. With an increased implementation of communication tools, patient satisfaction and SDM may further improve in the future.

Improving digital scans by using a peripheral custom tray: A dental technique.

A digital dental technique is described for registering functional borders of immediate complete dentures, by using an intraoral scanner, a dental computer-aided design software program, and a peripheral custom tray. This article also illustrates how to virtually match the recorded information in order to transform the initial intraoral scan into definitive digital scans.

Script concordance tests: A call for action in dental education.

The Script Concordance Test (SCT) is an educational tool that aims to assess the ability to interpret medical information under conditions of uncertainty. It is widely used and validated in health education, but almost unknown in dentistry. Based on authentic clinical problem-solving situations, it allows to assess clinical reasoning that experienced health workers develop over the years. A specific scoring system, dedicated to SCT, considers the variability of responses of practitioners in the same clinical situations. Finally, the scores generated by SCT reflect the respondents' ability to interpret clinical data compared to experienced clinicians. This article aims to familiarise the dental educators' community with SCT construction, optimisation and its possible applications.

Digital prosthodontic management of a young patient with Papillon-Lefèvre syndrome: A clinical report.

Papillon-Lefèvre syndrome (PLS) is a rare disorder that leads to symptoms including the early progressive loss of deciduous and permanent teeth. Prosthodontic management of children and adolescents affected by PLS sometimes requires an immediate complete denture. Tooth mobility presents a challenge to the dentist, especially during impression-making. This clinical report describes the management of a 14-year-old boy with PLS by using an intraoral scanner to prevent conventional impressions and a fully digital workflow for the design and fabrication of immediate complete dentures.

CAD-CAM immediate to definitive complete denture transition: A digital dental technique.

The present article describes a digital workflow for the fabrication of definitive complete dentures in 2 appointments by reproducing the cameo surface and tooth arrangement of computer-aided design and computer-aided manufacturing (CAD-CAM) immediate dentures. This straightforward technique, which requires limited time and effort, can be easily applied by using an intraoral scanner, a dental CAD software program, and a milling machine.

Latest advances in augmented reality technology and its integration into the digital workflow.

Smile reconstruction is achieved using rigorous and detailed methodologies that are technically demanding and both time and cost intensive. These methodologies do not include the patient during the primary conception phase. New digital technologies using augmented reality (AR) offer the option of immediate diagnosis and pre-visualization of the potential outcome before the start of treatment. A 22-year-old patient with a congenitally missing maxillary right canine, peg-shaped maxillary lateral incisors, and multiple visible diastemas required an esthetic rehabilitation. An AR virtual mock-up using specialized software was used to preview and modify the restoration proposal in real time. Using the novel 'CAD-link' workflow, the final AR proposal could be imported into CAD software and transformed into a digital wax-up with the new virtual wax copy function. After a minimally invasive preparation, the final veneer reconstructions were precisely planned according to the previously developed design proposal and bonded according to the well-known adhesive protocol. The workflow described in this article links AR with CAD/CAM technology and is expected to be time and cost efficient. This patient-centered approach involves the patient from the very beginning and is therefore an excellent communication tool between the patient and the restorative team.

Development of a Checklist to Prevent Reconstructive Errors Made By Undergraduate Dental Students.

PURPOSE: To design a checklist in order to reduce the frequency of reconstructive preventable errors (PE) performed by undergraduate dental students at McGill University. MATERIALS AND METHODS: The most common PE occurring at a university dental clinic were identified by three reviewers analyzing the refunded cases, and used to create a preliminary checklist. This checklist was then validated by a panel of dental educators to produce a finalized 20-item checklist. The 20-question checklist was then submitted to students in a cross-sectional survey-based study to evaluate its relevance to undergraduate clinical education needs. RESULTS: As many as 81% of students reported to have forgotten at least one item of the checklist during care of their last patient, and the most forgotten checklist items corresponded to the pretreatment stage. The students also reported that 17 of the 20 items in the checklist were relevant to a considerable extent or highly relevant. CONCLUSION: Common PE identified in the undergraduate clinic could be used to create a checklist of relevant items designed to reduce errors made by students and practitioners performing prosthodontic and reconstructive treatments. However, further studies are required to evaluate the implementation and efficiency of the checklist.

Manufacturing of an immediate removable partial denture with an intraoral scanner and CAD-CAM technology: a case report.

BACKGROUND: Incisor loss constitutes a strong aesthetic and psychologic traumatism for the patient and it remains a challenging situation for the dental practitioner because of the necessity to rapidly replace the lacking tooth. Various therapeutic procedures have been proposed to replace the incisor concerned, for example by using a removable partial denture. However, the manufacturing of such a denture with classical procedures is often subject to processing errors and inaccuracies. The computer-aided design and computer-aided manufacturing (CAD-CAM) technology could represent a good alternative, but it is currently difficult because of the lack of dental softwares able to design easily immediate removable partial dentures. CASE PRESENTATION: A 30-year- patient complained about pain caused by a horizontally and vertically mobile maxillary right central incisor. After all options were presented, extraction of the traumatized incisor was decided due to its very poor prognosis, and the patient selected the realization of a removable denture for economic reasons. The present paper proposes an innovative procedure for immediate removable denture, based on the use of an intraoral scanner, CAD with two different softwares used sequentially, and CAM with a 5-axis machine. CONCLUSIONS: We show in this report that associating an intraoral scanner and CAD-CAM technology can be extended to immediate dentures manufacturing, which could be a valuable procedure for dental practitioners and laboratories, and also for patients.

Dental Pulp Defence and Repair Mechanisms in Dental Caries.

Dental caries is a chronic infectious disease resulting from the penetration of oral bacteria into the enamel and dentin. Microorganisms subsequently trigger inflammatory responses in the dental pulp. These events can lead to pulp healing if the infection is not too severe following the removal of diseased enamel and dentin tissues and clinical restoration of the tooth. However, chronic inflammation often persists in the pulp despite treatment, inducing permanent loss of normal tissue and reducing innate repair capacities. For complete tooth healing the formation of a reactionary/reparative dentin barrier to distance and protect the pulp from infectious agents and restorative materials is required. Clinical and in vitro experimental data clearly indicate that dentin barrier formation only occurs when pulp inflammation and infection are minimised, thus enabling reestablishment of tissue homeostasis and health. Therefore, promoting the resolution of pulp inflammation may provide a valuable therapeutic opportunity to ensure the sustainability of dental treatments. This paper focusses on key cellular and molecular mechanisms involved in pulp responses to bacteria and in the pulpal transition between caries-induced inflammation and dentinogenic-based repair. We report, using selected examples, different strategies potentially used by odontoblasts and specialized immune cells to combat dentin-invading bacteria in vivo.

[The challenges of artificial intelligence in odontology]. / Les enjeux de l'intelligence artificielle en odontologie.

Artificial intelligence has numerous potential applications in dentistry, as these algorithms aim to improve the efficiency and safety of several clinical situations. While the first commercial solutions are being proposed, most of these algorithms have not been sufficiently validated for clinical use. This article describes the challenges surrounding the development of these new tools, to help clinicians to keep a critical eye on this technology.

Title: Les enjeux de l'intelligence artificielle en odontologie. Abstract: Les applications potentielles de l'intelligence artificielle, ces algorithmes visant à améliorer l'efficacité et la sécurité de diverses décisions cliniques, sont nombreuses en odontologie. Alors que les premiers logiciels commerciaux commencent à être proposés, la plupart des algorithmes n'ont pas été solidement validés pour une utilisation clinique. Cet article décrit les enjeux entourant le développement de ces nouveaux outils, afin d'aider les praticiens à garder un regard éclairé et critique sur cette nouvelle approche.

Developing Advanced Patient-Specific In Silico Models: A New Era in Biomechanical Analysis of Tooth Autotransplantation.

INTRODUCTION: As personalized medicine advances, there is an escalating need for sophisticated tools to understand complex biomechanical phenomena in clinical research. Recognizing a significant gap, this study pioneers the development of patient-specific in silico models for tooth autotransplantation (TAT), setting a new standard for predictive accuracy and reliability in evaluating TAT outcomes. METHODS: Development of the models relied on 6 consecutive cases of young patients (mean age 11.66 years ± 0.79), all undergoing TAT procedures. The development process involved creating detailed in silico replicas of patient oral structures, focusing on transplanting upper premolars to central incisors. These models underpinned finite element analysis simulations, testing various masticatory and traumatic scenarios. RESULTS: The models highlighted critical biomechanical insights. The finite element models indicated homogeneous stress distribution in control teeth, contrasted by shape-dependent stress patterns in transplanted teeth. The surface deviation in the postoperative year for the transplanted elements showed a mean deviation of 0.33 mm (±0.28), significantly higher than their contralateral counterparts at 0.05 mm (±0.04). CONCLUSIONS: By developing advanced patient-specific in silico models, we are ushering in a transformative era in TAT research and practice. These models are not just analytical tools; they are predictive instruments capturing patient uniqueness, including anatomical, masticatory, and tissue variables, essential for understanding biomechanical responses in TAT. This foundational work paves the way for future studies, where applying these models to larger cohorts will further validate their predictive capabilities and influence on TAT success parameters.

Prosthetic Management of Albers-Schönberg Disease with Osteomyelitis: A 10-Year Follow-up Case Report.

Albers-Schönberg disease is a rare bone syndrome characterized by increased bone density and infectious complications after dental extraction or minor surgery. The prosthodontic management of such edentulous patients with osteomyelitis is very challenging and requires special strategies due to a high risk of failure and worsening of the condition. This clinical report describes the rehabilitation of a 31-year-old edentulous woman presenting with Albers-Schönberg disease, secondary chronic osteomyelitis, maxillary hypoplasia, compromised oral conditions, temporomandibular disorders, and psychologic distress. The treatment included a mandibulectomy and removable prostheses. A crucial element for the successful long-term treatment and quality of life improvement observed in this patient was the 1-year transitional phase with interim dentures and frequent follow-up appointments. The complications and management proposed during a 10-year follow-up are presented. Int J Prosthodont 2023;36:642-648.

Artificial Intelligence as a Decision-Making Tool in Forensic Dentistry: A Pilot Study with I3M.

Expert determination of the third molar maturity index (I3M) constitutes one of the most common approaches for dental age estimation. This work aimed to investigate the technical feasibility of creating a decision-making tool based on I3M to support expert decision-making. Methods: The dataset consisted of 456 images from France and Uganda. Two deep learning approaches (Mask R-CNN, U-Net) were compared on mandibular radiographs, leading to a two-part instance segmentation (apical and coronal). Then, two topological data analysis approaches were compared on the inferred mask: one with a deep learning component (TDA-DL), one without (TDA). Regarding mask inference, U-Net had a better accuracy (mean intersection over union metric (mIoU)), 91.2% compared to 83.8% for Mask R-CNN. The combination of U-Net with TDA or TDA-DL to compute the I3M score revealed satisfying results in comparison with a dental forensic expert. The mean ± SD absolute error was 0.04 ± 0.03 for TDA, and 0.06 ± 0.04 for TDA-DL. The Pearson correlation coefficient of the I3M scores between the expert and a U-Net model was 0.93 when combined with TDA and 0.89 with TDA-DL. This pilot study illustrates the potential feasibility to automate an I3M solution combining a deep learning and a topological approach, with 95% accuracy in comparison with an expert.