Endodontic variables in patients with SARS-CoV-2 infection (COVID-19) in relation to the severity of the disease.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) is the cause of the ongoing coronavirus disease 2019 (COVID-19) pandemic. It has been hypothesized oral health may be related to the severity and complications of COVID-19. The aim of this study was to analyze the prevalence of apical periodontitis and the frequency of root canal treatment in a sample of patients with SARS-CoV-2 infection (COVID-19), correlating them with the severity of the disease. MATERIAL AND METHODS: This retrospective study was conducted following the Strengthening Reporting Observational Studies in Epidemiology (STROBE) guidelines. The study examined 280 patients with positive real time PCR COVID-19 test whose treatment was performed in our hospital. Fifty-two patients aged 52.3 ± 17.3 years, including 30 males and 22 females, who had an orthopantomography in their clinical record, performed in the last 2 years, were included. Patients with SARS-CoV-2 infection were grouped as mild or moderate (MM) and severe or critical (SC) illness groups, according to the NIH COVID-19 Treatment Guidelines (Wu & McGoogan 2020). Radiographic records were analyzed and apical periodontitis (AP) was diagnosed as radiolucent periapical lesions (RPLs), using the periapical index score (PAI). Student's t test, χ2 test and multivariate logistic regression were used in the statistical analysis. RESULTS: The number of carious teeth was significantly higher in the SC group (3.4 ± 4.1), which showed more than twice as many teeth with carious lesions than the MM group (1.4 ± 1.8) (p = 0.02). Multivariate regression analysis showed association between the number of carious teeth and the severity of SARS-CoV-2 disease (OR = 1.5; 95% CI = 1.1-2.1; p = 0.017). Endodontic status (OR = 7.12; 95% CI = 1.2-40.9; p = 0.027) also correlated with the disease severity. CONCLUSIONS: The results suggest that the oral health status of COVID-19 patients correlated with the severity of the SARS-CoV-2 virus infection. Significant association has been found between the severity of COVID-19 disease and the presence of a greater number of teeth with caries lesions, as well as with endodontic status.

Evaluation of undergraduate Endodontic teaching in dental schools within Spain.

AIM: To evaluate the current situation of undergraduate endodontic teaching in Spanish dental schools. METHODOLOGY: An online version, translated into Spanish, of a survey conducted in the UK (Int Endod J 52, 2019, 1077) was sent via email to the undergraduate endodontic programme leads in all 23 Spanish dental schools. RESULTS: The response rate was 96%. In 95% of dental schools, endodontics is taught in the fourth year. Students treat simple root canal treatment cases in 100% of schools and only in 40% treat moderate cases. In 65% of schools, students are supervised by full-time professors who are specialists in Endodontics, significantly more frequently in private dental schools (P = 0.002). Spanish dental schools use both rotary and reciprocating instrumentation systems during endodontic training, with consistency on methods of working length determination, use of silicate-based endodontic cements, irrigating solutions, inter-visit medicaments and canal filling techniques. No type of magnification is used in 90% of dental schools, and only 25% use ultrasonic instruments. Private dental schools have a significantly better staff: student ratio during clinical practice (P = 0.041), spend significantly more hours in clinical training (P = 0.04) and have significantly greater number of clinical areas specifically dedicated to Endodontics (P = 0.010). CONCLUSIONS: Undergraduate endodontic teaching in Spanish dental schools follows the key recommendations of the ESE Undergraduate Curriculum Guidelines (Int Endod J 46, 2013, 1105), being, in most respects, comparable to that carried out in the UK (Int Endod J 52, 2019, 1077). The use of magnification and ultrasonic instruments needs to be increased. Private schools reported better results than public schools in some of the variables that were analysed.

Prevalence of endodontic infection in patients with Crohn´s disease and ulcerative colitis.

BACKGROUND: Previous studies have linked apical periodontitis (AP) to inflammatory bowel disease (IBD). The aim of this study was to compare the prevalence of AP and root canal treatment (RCT) in patients with ulcerative colitis (UC) and Crohn´s disease (CD). MATERIAL AND METHODS: A cross-sectional study, including 28 patients with Crohn´s disease and 26 with ulcerative colitis, was conducted. AP was diagnosed as radiolucent periapical lesions (RPLs), using the periapical index score (PAI). Student's t test, 2 test and multivariate logistic regression were used in the statistical analysis. RESULTS: Multivariate logistic regression run with age, gender, number of teeth, number of RFT, periodontal disease and the type of IBD as covariates, taking as dependent variable and outcome "periapical status" (0 = no tooth with RPL; 1 = at least one tooth with RPL), showed that both UC and CD patients had the prevalence apical periodontitis (OR = 1.03; C.I. 95% = 0.25 - 4.31; p = 0.97). The multivariate analysis, including all the above covariates, shows that both in UC and CD patients the prevalence of RCT was similar (OR = 0.76; C.I. 95% = 0.17 - 7.31; p = 0.73). Periapical status was significantly associated with endodontic status (OR = 42.72; C.I. 95% = 3.87 - 472.15; p = 0.002), regardless of IBD type. CONCLUSIONS: The results of the present study show similar frequency of AP and RFT in both UC and CD patients. The type of IBD does not appear to affect the prevalence of radiographically detectable periapical lesions or the prevalence of root canal treatment.

Association between dental anxiety and intraoperative pain during root canal treatment: a cross-sectional study.

AIM: To investigate whether dental anxiety influences the intraoperative pain felt by patients during root canal treatment. METHODOLOGY: In a cross-sectional design, 180 patients (90 men and 90 women) were included. Pre-operative anxiety levels were assessed using the short-form Dental Anxiety Inventory (S-DAI). Pain during root canal treatment was evaluated using a 10-cm visual analogue scale (VAS) that ranked the level of pain between 'Absence of pain' and 'Unbearable pain'. The minimal sample size was determined using the software of the National Center for Advancing Translational Sciences (NIH, UK). Multivariate logistic regression analysis was used to identify relationships between variables. RESULTS: Mean pain level during root canal treatment was 2.2 ± 2.1. The mean anxiety S-DAI score was 27.2 ± 12.5. Fifty percent of men had mild anxiety levels, while in 70% of women anxiety was moderate or high (P = 0.017). Anxiety correlated positively with intraoperative pain (R = 0.406). Multivariate logistic regression analysis revealed that anxiety was significantly associated with intraoperative pain felt by patients (OR = 4.0; 95% C.I. = 1.7-9.3; P = 0.001). CONCLUSIONS: Anxious patients were more than twice as likely to feel moderate or intense intraoperative pain during root canal treatment. To know the patient´s degree of anxiety could help the dentist to decide whether to use anxiolytic premedication and/or supplemental local anaesthesia to assure better control of pain during root canal treatment.

Cardiovascular diseases and apical periodontitis: association not always implies causality.

BACKGROUND: Several studies published in the last two decades have found an association between the prevalence of apical periodontitis (AP) or root canal treatment (RCT) and cardiovascular diseases (CVDs). However, the demonstration of association does not prove by itself the existence of a cause-effect relationship. Two diseases can appear as statistically related without any of them directly affecting the values of the other, resulting in a non-causal relationship. The aim of this narrative review is to summarize the current state of knowledge regarding the association between AP and CVDs, analysing it according to the Hill's causality criteria. MATERIALS AND METHODS: Epidemiological studies carried out on the association between CVDs and AP or RCT published in English until 8 December 2019 were identified. Forty-four articles were selected and its results were analysed. RESULTS: Numerous cross-sectional epidemiological studies have found significant relationship between CVDs and AP. The odds ratio values range 1.6 - 5.4. However, other studies have not found significant association. Respect to RCT, some studies found correlation, but others found no association or even found that RCT is a protective factor against CVDs. CONCLUSIONS: The results are inconsistent and a causal relationship between CVDS and endodontic disease cannot be stablished. The risk factors common to both diseases can act as confounding factors, biasing the results. To reach definitive conclusions about the type of association (causal or non-causal) between both diseases, longitudinal epidemiological studies must be carried out to establish the temporal relationship and the dose-response gradient.

Endodontics and diabetes: association versus causation.

Endodontic Medicine has gained more attention and is becoming a more important issue in Endodontics. As an example, more than one hundred articles on this topic have been published in the last eight years. Several of these studies have found an association between endodontic variables, that is the prevalence of apical periodontitis, the prevalence of root canal treatment (RCT) and the outcome of RCT assessed as root filled teeth (RFT) with radiolucent periapical lesions (RPL) or non-retained RFT, and several systemic diseases, such as diabetes, cardiovascular disease, smoking habits, osteoporosis, inherited coagulopaties, biological medications, low birth weight or physical fitness. However, the demonstration of association does not prove by itself the existence of a cause-effect relationship. Two variables can be related statistically to each other without either variable directly affecting the values of the other thus resulting in a non-causal relationship. Causality is assumed when one variable is shown to contribute to the development of the other, and its removal is shown to reduce the frequency of disease. Therefore, once a significant statistical association has been found between two variables, it is necessary to exclude the presence of bias, which would imply that the association is artefactual, and to analyse if the causation criteria defined by Hill (Proceedings of the Royal Society of Medicine 1965; 58: 295-300) are fulfilled to establish a causal relationship. Only if they are satisfied, can it be concluded that the association is causal. The aim of this study was to analyse the difference between association and causation, applying the criteria of causality to the specific case of the association between endodontic disease and diabetes mellitus.

Association between diabetes and nonretention of root filled teeth: a systematic review and meta-analysis.

Previous studies have found an association between the outcome of root canal treatment (RCT) and diabetic status. This systematic review and meta-analysis aimed to analyse the potential relationship between diabetes and the occurrence of extracted root filled teeth (RFT). The clinical PICO question was as follows: in adult patients with RFT, does the absence or presence of diabetes influence the prevalence of RFT extraction? The key words used in the systematic search were as follows: (Diabetes OR Diabetes Mellitus OR Hyperglycaemia OR Diabetic) AND (Endodontic OR Endodontics OR Endodontic Treatment OR Root Canal Treatment OR Root Canal Preparation OR Root Canal Therapy OR Root Filled Teeth OR Endodontically Treated Teeth) AND (Extraction OR Retention OR Survival OR Success OR Failure OR Outcome). The primary outcome variable was odds ratio (OR) for the frequency of extracted RFT in diabetics and healthy subjects. The method of DerSimonian-Laird with random effects was used to calculate the overall OR. Three hundred titles were identified, and three studies achieved the inclusion criteria. Data from 54 936 root canal treatments, 50 301 in nondiabetic control subjects and 4635 in diabetic patients, were analysed. The calculated overall odds ratio (OR = 2.44; 95% CI = 1.54-3.88; P = 0.0001) implies that diabetics had a significantly higher prevalence of extracted RFT than healthy nondiabetic subjects. The results of available studies indicate a significant relationship between DM and increased frequency of nonretained root filled teeth. Diabetes mellitus should be considered an important preoperative prognostic factor in root canal treatment.

Effectiveness and clinical implications of the use of topical antibiotics in regenerative endodontic procedures: a review.

Regenerative endodontic procedures (REPs) are biologically based procedures planned to replace damaged tissues, including dentinee and root structures, as well as cells of the pulp-dentine complex. Effective sterilization of the root canal is essential in REPs, and antibiotics have been widely used to disinfect root canals. The aim of this paper was to review the scientific literature on (i) Effectiveness of antibiotics used in REPs against bacteria implicated in endodontic disease; (ii) Scientific evidence supporting the use of topical antibiotics in REPs; (iii) Clinical implications of the use of antibiotics in REPs and the possible side effects; (iv) Effect of antibiotics on dental pulp stem cells; and (v) Ongoing research on the use of antibiotics in REPs. Antibiotics used in REPs are effective against bacteria implicated in endodontic infections. Triple antibiotic pastes with minocycline attain complete disinfection of immature teeth with necrotic pulps, without affecting SCAP. Experimental studies carried out in dogs support the use of antibiotics in REPs. Clinical studies report high success rates of RET using antibiotics as intracanal dressings. However, tooth discolouration is an important side effect of the use of TAP. An antibiotic paste containing only metronidazole and ciprofloxacin could be a good alternative to the use of TAP. The use of antibiotic-containing scaffolds or clindamycin-modified triple antibiotic (metronidazole, ciprofloxacin and clindamycin) polymer could be a biologically safe antimicrobial drug delivery system in REPs.

Endodontic medicine: connections between apical periodontitis and systemic diseases.

The prevalence of apical periodontitis (AP) in Europe has been reported to affect 61% of individuals and 14% of teeth, and increase with age. Likewise, the prevalence of root canal treatment (RCT) in Europe is estimated to be around 30-50% of individuals and 2-9% of teeth with radiographic evidence of chronic persistent AP in 30-65% of root filled teeth (RFT). AP is not only a local phenomenon and for some time the medical and dental scientific community have analysed the possible connection between apical periodontits and systemic health. Endodontic medicine has developed, with increasing numbers of reports describing the association between periapical inflammation and systemic diseases. The results of studies carried out both in animal models and humans are not conclusive, but suggest an association between endodontic variables, that is AP and RCT, and diabetes mellitus (DM), tobacco smoking, coronary heart disease and other systemic diseases. Several studies have reported a higher prevalence of periapical lesions, delayed periapical repair, greater size of osteolityc lesions, greater likelihood of asymptomatic infections and poorer prognosis for RFT in diabetic patients. On the other hand, recent studies have found that a poorer periapical status correlates with higher HbA1c levels and poor glycaemic control in type 2 diabetic patients. However, there is no scientific evidence supporting a causal effect of periapical inflammation on diabetes metabolic control. The possible association between smoking habits and endodontic infection has also been investigated, with controversial results. The aim of this paper was to review the literature on the association between endodontic variables and systemic health (especially DM and smoking habits).

Expression and immunohistochemical localization of leptin receptor in human periapical granuloma.

AIM: To investigate the expression and immunohistochemical localization of leptin receptor (LEPR) in human periapical granulomas. METHODOLOGY: Periapical inflammatory lesions were obtained from extracted human teeth and teeth which underwent periapical surgery. After their histopathological categorization as periapical granulomas (n = 20), they were examined by immunohistochemistry using human LEPR monoclonal antibodies. LEPR mRNA expression was also determined by quantitative real-time PCR (qRT-PCR), and the amount of LEPR protein was analysed by immunoblot. RESULTS: All granuloma samples expressed LEPR. Amongst inflammatory cells, only macrophages showed expression of LEPR. Western blot analysis revealed the presence in the samples of a protein with apparent molecular weight of ~120 kDa, corresponding to the estimated molecular weight of LEPR. The qRT-PCR analysis demonstrated the expression of LEPR mRNA, corresponding the size of the amplified fragment (338 bp), assessed by agarose gel electrophoresis, to that of LEPR mRNA. CONCLUSIONS: Human periapical granulomas express LEPR. In periapical granulomas, only macrophages showed expression of LEPR. This finding suggests that leptin can play a role in inflammatory and immune periapical responses.

Leptin expression in healthy and inflamed human dental pulp.

AIM: To investigate the expression of leptin in healthy and inflamed human dental pulp. METHODOLOGY: Twenty-one pulp samples were obtained from freshly caries- and restoration-free extracted human third molars. In seven-third molars (inflamed pulp group), inflammation was induced prior to extraction. Pulp samples were processed, and leptin expression was determined by quantitative real-time PCR (qRT-PCR) and the amount of leptin by immunoblot. RESULTS: All healthy and inflamed dental pulp samples expressed leptin. Western blot analysis revealed the presence of a protein with an apparent molecular weight of ~16 kDa in human dental pulp, which corresponds to the estimated molecular weight of leptin. The expression of leptin mRNA in dental pulp was confirmed by qRT-PCR analysis, and the size of the amplified fragments (296 bp for leptin and 194 bp for cyclophilin) was confirmed by agarose gel electrophoresis. The expression of leptin in the inflamed pulp group was significantly greater (P < 0.05) than in healthy teeth. The relative amount of leptin in inflamed pulps was almost twice than in healthy pulps. CONCLUSIONS: For the first time, the presence of leptin in human dental pulp tissues has been demonstrated. The upregulation of leptin expression in inflamed pulp samples suggests that leptin can play a role in pulpal inflammatory and immune responses.

The limitations of scaling laws in the prediction of performance in endurance events.

In the twentieth century, scientists have examined running speed over various distances, analyzing world records and studying the ability of an athlete to sustain a given speed. Assuming that running speed expresses the response of a non-linear multisystemic behavior, the relationship between these two variables (distance vs. velocity) can therefore be evaluated by applying scaling laws that fulfill the key principles of specificity and individuality of each athlete, yet responding to bioenergetic and functional patterns that are well-known to sports physiology. Since speed loss as distance increases exhibits fractal behavior, with small changes in the speed-reduction curve due to the effect of fatigue, it must be recognized that no universal scaling law can account, with acceptable precision, for the effect exerted by fatigue on potential speed at any given moment in a race. Power laws using a range of scaling exponents provide technical staff and athletes with a reliable, non-invasive tool for planning of training schedules, predicting athletes' performances over various distances and comparing the performance of specialists in different track events. The equations for the scaling laws for the distances investigated here were: V1500=15.00 × D⁻°·¹° (R²=0.99); V3000=12.76 × D⁻°·°8 (R²=0.99); V5000=11.55 × D⁻°·°7 (R²=0.99); V10,000=11.59 × D⁻°·°7 (R²=0.99); V21,095=10.78 × D⁻°·°6 (R²=0.97); V42,175=10.27 × D⁻°·°57 (R²=0.99).

Diabetes mellitus, periapical inflammation and endodontic treatment outcome.

The possible connection between chronic oral inflammatory processes, such as apical periodontitis and periodontal disease (PD), and systemic health is one of the most interesting aspects faced by the medical and dental scientific community. Chronic apical periodontitis shares important characteristics with PD: 1) both are chronic infections of the oral cavity, 2) the Gram-negative anaerobic microbiota found in both diseases is comparable, and 3) in both infectious processes increased local levels of inflammatory mediators may have an impact on systemic levels. One of the systemic disorders linked to PD is diabetes mellitus (DM); is therefore plausible to assume that chronic apical periodontitis and endodontic treatment are also associated with DM. The status of knowledge regarding the relationship between DM and endodontics is reviewed. Upon review, we conclude that there are data in the literature that associate DM with a higher prevalence of periapical lesions, greater size of the osteolityc lesions, greater likelihood of asymptomatic infections and worse prognosis for root filled teeth. The results of some studies suggest that periapical disease may contribute to diabetic metabolic dyscontrol.

[Perception of ethical attitudes of intensive care nurses on treatment limitation]. / Percepción de las actitudes éticas de la enfermería de cuidados intensivos ante la limitación del tratamiento.

OBJECTIVE: Analyze the perception of intensive care nurses regarding the limitation of therapeutic efforts (LET). METHOD: A 2-month cross-sectional, descriptive study carried out among Intensive Care nursing staff of our Hospital. An anonymous survey was used to assess the attitudes of intensive care nurses on LET. RESULTS: Fifty-two nurses (86.6%), 57.7% women, with a working experience of 8.8±4.8 years and 17.7%, had some additional training in ethics. The decision not to hospitalize a patient whose short term quality of life is very poor changes when the patient's opinion is considered (36.5% vs 61.5%, p=0.008), a difference that is greater in male nurses without prior training in ethics. A total of 23.1% were not aware of the existence of agreed on guidelines on LET in the Service. A total of 17.3% consider that limiting treatment, either by not providing it or by withdrawing it, is a form of passive euthanasia, which would be an acceptable practice as opposed to euthanasia and 84.6% consider that administering a treatment is not the same as withdrawing it. Of those surveyed, 36.5% felt that the neither the nursing staff should not participate in the decision to limit treatment nor the patients (34.6%) nor family (23.1%). CONCLUSIONS: Nursing is not aware of the importance it can have, along with the family and patient, in decision making in relationship to the limitation of the treatment of the critical patient, providing a humanizing and ethical view of the care.

Male powerlifting performance described from the viewpoint of complex systems.

This paper reflects on the factors that condition performance in powerlifting and proposes that the result-generating process is inadequately described by the allometric equations commonly used. We analysed the scores of 1812 lifters belonging to all body mass categories, and analysed the changes in the results achieved in each weight category and by each competitor. Current performance-predicting methods take into account biological variables, paying no heed to other competition features. Performance in male powerlifting (as in other strength sports) behaves as a self-organised system with non-linear interactions between its components. Thus, multiple internal and external elements must condition changes in a competitor's score, the most important being body mass, body size, the number of practitioners, and the concurrency of favourable factors in one individual. It was observed that each behaved in a specific form in the high level, according to the individuals' circumstances, which make up the main elements of the competitive system in every category. In powerlifting, official weight categories are generally organised in three different groups: light (<52.0 to <60 kg), medium (<67.5 to <90.0 kg) and heavy (<100 to >125 kg) lifter categories, each one of them with specific allometric exponents. The exponent should be revised periodically, especially with regard to the internal dynamics of the category, and adjusted according to possible changes affecting competition.

Applying graphs and complex networks to football metric interpretation.

This work presents a methodology for analysing the interactions between players in a football team, from the point of view of graph theory and complex networks. We model the complex network of passing interactions between players of a same team in 32 official matches of the Liga de Fútbol Profesional (Spain), using a passing/reception graph. This methodology allows us to understand the play structure of the team, by analysing the offensive phases of game-play. We utilise two different strategies for characterising the contribution of the players to the team: the clustering coefficient, and centrality metrics (closeness and betweenness). We show the application of this methodology by analyzing the performance of a professional Spanish team according to these metrics and the distribution of passing/reception in the field. Keeping in mind the dynamic nature of collective sports, in the future we will incorporate metrics which allows us to analyse the performance of the team also according to the circumstances of game-play and to different contextual variables such as, the utilisation of the field space, the time, and the ball, according to specific tactical situations.