Subgingival scaling and root planing during minimally invasive periodontal surgery: A randomized controlled split-mouth trial.

BACKGROUND: The purpose of this randomized, controlled split-mouth study was to evaluate a videoscope as a visual adjunct to scaling and root planing when utilized in combination with minimally invasive surgery. METHODS: Twenty-five pairs (89 interproximal surfaces) of periodontally hopeless teeth planned for extraction were scaled and root planed with minimal surgical access using surgical loupes (control) or adjunctive use of a videoscope (test). Teeth were extracted with minimal trauma, stained with methylene blue, and photographed with a digital microscope for analysis. The primary outcome of residual calculus was calculated as a percentage of the total interproximal area of interest. Secondary outcomes included treatment time, as well as residual calculus according to probing depth, tooth location, and treatment date. Data were analyzed using Student's paired t-tests, two-way analyses of variance, and Spearman's correlation tests. RESULTS: Residual calculus area was 2.61% on control and 2.71% on test surfaces with no significant difference between groups. Subgroup analysis showed no difference in residual calculus between groups at moderate or deep sites. Treatment time per surface was significantly longer in the test group compared to the control group. Treatment order, tooth location, and operator experience did not significantly affect the primary outcome. CONCLUSIONS: Though the videoscope provided excellent visual access, it did not improve the efficacy of root planing for flat interproximal surfaces during minimally invasive periodontal surgery. Small amounts of calculus remain after instrumentation even with minimal surgical access and when root surfaces appear visually clean and tactilely smooth.

Revolutionizing orofacial pain management: the promising potential of stem cell therapy.

Orofacial pain remains a significant health issue in the United States. Pain originating from the orofacial region can be composed of a complex array of unique target tissue that contributes to the varying success of pain management. Long-term use of analgesic drugs includes adverse effects such as physical dependence, gastrointestinal bleeding, and incomplete efficacy. The use of mesenchymal stem cells for their pain relieving properties has garnered increased attention. In addition to the preclinical and clinical results showing stem cell analgesia in non-orofacial pain, studies have also shown promising results for orofacial pain treatment. Here we discuss the outcomes of mesenchymal stem cell treatment for pain and compare the properties of stem cells from different tissues of origin. We also discuss the mechanism underlying these analgesic/anti-nociceptive properties, including the role of immune cells and the endogenous opioid system. Lastly, advancements in the methods and procedures to treat patients experiencing orofacial pain with mesenchymal stem cells are also discussed.

Understanding painful versus non-painful dental pain in female and male patients: A transcriptomic analysis of human biopsies.

Dental pain from apical periodontitis is an infection induced-orofacial pain condition that presents with diversity in pain phenotypes among patients. While 60% of patients with a full-blown disease present with the hallmark symptom of mechanical allodynia, nearly 40% of patients experience no pain. Furthermore, a sexual dichotomy exists, with females exhibiting lower mechanical thresholds under basal and diseased states. Finally, the prevalence of post-treatment pain refractory to commonly used analgesics ranges from 7-19% (∼2 million patients), which warrants a thorough investigation of the cellular changes occurring in different patient cohorts. We, therefore, conducted a transcriptomic assessment of periapical biopsies (peripheral diseased tissue) from patients with persistent apical periodontitis. Surgical biopsies from symptomatic male (SM), asymptomatic male (AM), symptomatic female (SF), and asymptomatic female (AF) patients were collected and processed for bulk RNA sequencing. Using strict selection criteria, our study found several unique differentially regulated genes (DEGs) between symptomatic and asymptomatic patients, as well as novel candidate genes between sexes within the same pain group. Specifically, we found the role of cells of the innate and adaptive immune system in mediating nociception in symptomatic patients and the role of genes involved in tissue homeostasis in potentially inhibiting nociception in asymptomatic patients. Furthermore, sex-related differences appear to be tightly regulated by macrophage activity, its secretome, and/or migration. Collectively, we present, for the first time, a comprehensive assessment of peripherally diseased human tissue after a microbial insult and shed important insights into the regulation of the trigeminal system in female and male patients.

Outcome of pulpotomy in permanent teeth with irreversible pulpitis: a systematic review and meta-analysis.

Treatment planning is key to clinical success. Permanent teeth diagnosed with "irreversible pulpitis" have long been implied to have an irreversibly damaged dental pulp that is beyond repair and warranting root canal treatment. However, newer clinical approaches such as pulpotomy, a minimally invasive and biologically based procedure have re-emerged to manage teeth with pulpitis. The primary aim of the study was to conduct a meta-analysis to comprehensively estimate the overall success rate of pulpotomy in permanent teeth with irreversible pulpitis as a result of carious pulp exposure. The secondary aim of the study was to investigate the effect of predictors such as symptoms, root apex development (closed versus open), and type of pulp capping material on the success rate of pulpotomy. Articles were searched using PubMed, Scopus, CENTRAL, and Web of Science databases, until January 2021. Outcomes were calculated by pooling the success rates with a random effect model. Comparison between the different subgroups was conducted using the z statistic test for proportion with significance set at alpha = 0.05. A total of 1,116 records were retrieved and 11 studies were included in the quantitative analysis. The pooled success rate for pulpotomy in teeth with irreversible pulpitis was 86% [95% CI: 0.76-0.92; I2 = 81.9%]. Additionally, prognostic indicators of success were evaluated. Stratification of teeth based on (1) symptoms demonstrated that teeth with symptomatic and asymptomatic irreversible pulpitis demonstrated success rate of 84% and 91% respectively, with no significant difference (p = 0.18) using z-score analysis; (2) open apex teeth demonstrated a significantly greater success rate (96%) compared to teeth with closed apex (83%) (p = 0.02), and (3) pulp capping materials demonstrated that Biodentine yielded significantly better success rates compared to Mineral Trioxide Aggregate (MTA), calcium hydroxide, and Calcium Enriched Mixture (CEM.) Collectively, this is the first meta-analytical study to determine the clinical outcome of pulpotomy for carious teeth with irreversible pulpitis and it's predictors for success. Moreover, we identify the stage of root development and type of biomaterial as predictors for success of pulpotomy.

Effect of Sodium Hypochlorite in Dental Unit Waterline on Aerosolized Bacteria Generated from Endodontic Procedures.

INTRODUCTION: Aerosol generation in a dental setting is a critical concern, and approaches that aim at decreasing bacterial load in aerosols are of high priority for dental professionals. The objectives of this study were to evaluate the relative effect of various endodontic procedures on the generation and dissemination of aerosols and the effect of 0.1% sodium hypochlorite (NaOCl) in dental unit waterlines (DUWLs) on the bacterial load in the generated aerosols in a clinical setting. METHODS: The study was completed in 2 phases. The classic passive sampling technique using brain-heart infusion agar plates was used. Agar plates were strategically placed throughout the operatory at predefined locations. In phase 1, to evaluate the effect of different endodontic procedures on the generation and dissemination of aerosols, we collected a total of 38 samples. After baseline collection, test samples were collected during vital pulp therapy (VPT) full pulpotomy (n = 10), nonsurgical root canal therapy (NSRCT, n = 10), surgical root canal therapy (SRCT, n = 10), and incision and drainage (n = 8) procedures. Bacterial growth was expressed as colony-forming units at 48 hours after sample collection. Data were analyzed using 1-way analysis of variance with the Tukey multiple comparison post hoc test. In phase 2, to evaluate the effect of 0.1% NaOCl in the DUWL on the bacterial load in the generated aerosols, a total of 30 samples were collected. All procedures including VPT (n = 10), NSRCT (n = 10), and SRCT (n = 10) were performed with 0.1% NaOCl in the DUWL. Bacterial growth was expressed as colony-forming units at 48 hours after sample collection. Data were analyzed using 2-way analysis of variance with the Tukey multiple comparison post hoc test. RESULTS: All endodontic procedures generated aerosols at all tested locations, except incision and drainage. Aerosols were disseminated as far as 3 m from the patient's head with no significant difference between various locations (P > .05). VPT procedures generated the maximum number of aerosols compared with NSRCT and SRCT. Adding 0.1% NaOCl to DUWLs significantly reduced the bacterial load in the generated aerosols in all treatment groups compared with groups treated with untreated waterlines (P < .05). No significant difference was noted in the bacterial load between all groups with treated waterlines (P > .05). CONCLUSIONS: All tested endodontic procedures led to the generation and dissemination of contaminated aerosols, and the addition of 0.1% NaOCl as a biocide to the DUWL led to a statistically significant reduction in the bacterial load.

Effect of Maleic Acid Root Conditioning on Release of Transforming Growth Factor Beta 1 from Infected Root Canal Dentin.

INTRODUCTION: Chemically released growth factors play a vital role in regenerative endodontics. Transforming growth factor beta 1 (TGF-ß1) is 1 of the most extensively studied bioactive molecules that promotes cell proliferation, differentiation, and chemotaxis. The goal of the current research was to analyze the effect of 7% maleic acid (MA) root conditioning of an infected root canal on the release of TGF-ß1. METHODS: Single-rooted human teeth were decoronated, and the canals were enlarged with a Peeso reamer. The samples were divided into biofilm and nonbiofilm groups. Subsequently, all the samples of both groups were flushed with 10 mL of each irrigant, namely, 1.5% sodium hypochlorite (NaOCl), 7% MA, 17% EDTA, and a combination of 1.5% NaOCl with 17% EDTA or 7% MA, for 10 minutes each. TGF-ß1 was estimated quantitatively using an enzyme-linked immunosorbent assay kit. RESULTS: TGF-ß1 release was lowest among the biofilm samples compared with nonbiofilm among all the groups. MA 7% with 1.5% NaOCl rendered higher amounts of growth factor release in contrast to the combination of 17% EDTA and 1.5% NaOCl in both the biofilm and nonbiofilm groups (P < .048). The nonbiofilm samples treated with 7% MA alone illustrated higher growth factor release compared with 17% EDTA only (P < .006), but there was no significant difference in growth factor release among the biofilm samples treated with 7% MA and 17% EDTA. CONCLUSIONS: Bacterial biofilms modified the release of TGF-ß1. MA 7% was observed to be significantly more efficacious than 17% EDTA in TGF-ß1 growth factor release from radicular dentin.

Bupivacaine for Root Canal Treatment - Practitioner Behaviors and Patient Perspectives: Survey Studies.

INTRODUCTION AND OBJECTIVES: Local anesthesia is essential in dentistry in providing intraoperative analgesia and anesthesia. However, knowledge related to its use for management of post-operative pain is limited. Perioperative pain management is especially important for root canal treatment (ie, endodontic therapy), performed by endodontists. In this study, we sought to better understand endodontists' attitudes regarding the use of long-lasting anesthetic, namely 0.5% bupivacaine HCl with 1:200,000 epinephrine, for the management of post-endodontic pain. Additionally, we aimed to understand the perspectives of dental patients about receiving longer lasting anesthesia for endodontic therapy and to determine factors that affect their anesthetic preferences within the orofacial region. METHODS: An email invitation to participate in an anonymous online survey was sent to members of the American Association of Endodontists. Also, 82 patients attending an in-person visit to an endodontic clinic were recruited to the study. RESULTS: Data from 474 endodontic practitioners and 82 patients included in analysis. Among practitioners, the majority reported to either never (33.31%) or rarely (34.84%) using bupivacaine. Most chose "I don't think I need it" (47%) and "patient discomfort because of longer duration of soft tissue anesthesia" (30.81%) as reasons for not preferring the use of bupivacaine. Of the practitioners who reported at least rare use, most chose bupivacaine for post-operative pain management (78.02%). Conversely, 52% of patients reported that they were likely/most likely to request long-lasting anesthetics for post-operative pain control. CONCLUSION: Bupivacaine is rarely used as a post-operative pain management strategy for endodontic therapy. Specifically, bupivacaine is not preferred not because of adverse events, toxicity, or slow onset concerns, but rather, because of longer duration of soft tissue anesthesia. However, our data suggest that patients may be willing to receive long-lasting anesthesia. Further patient-centered research should investigate the use of long-lasting anesthetic agents for management of post-endodontic pain.

Material Pulp Cells and Tissue Interactions.

Two increasingly common endodontic procedures, vital pulp therapy (VPT) and regenerative endodontic procedures, rely on dental tissue regeneration/repair mechanisms with the aid of biomaterials. These materials are applied in close contact to the pulpal tissue and are required to be biocompatible, form an antimicrobial seal, not induce staining, and be easy to manipulate. Historically, calcium hydroxide played an important role in VPT. However, over the last 3 decades, significant efforts in research and industry have been made to develop various biomaterials, including hydraulic tricalcium silicate cements. The present review summarized various hydraulic tricalcium silicate cements and their biological properties in clinical procedures, namely VPT and regenerative endodontic procedures.

To Drill or Not to Drill: Management of Endodontic Emergencies and In-Process Patients during the COVID-19 Pandemic.

INTRODUCTION: Dental professionals are at high risk of contracting coronavirus disease 2019 (COVID-19) infection because of their scope of practice with aerosol-generating procedures. Recommendation by the Centers for Disease Control and Prevention to suspend elective dental procedures and avoid aerosol-generating procedures posed significant challenges in the management of patients presenting with endodontic emergencies and uncertainty of outcomes for endodontic procedures initiated, but not completed, before shutdown. The purpose of this study was to evaluate the success of palliative care on endodontic emergencies during the COVID-19 pandemic and to evaluate the stability of teeth with long-term Ca(OH)2 placement because of delays in treatment completion. METHODS: Patients presenting for endodontic emergencies during COVID-19 Shelter-in-Place orders received palliative care, including pharmacologic therapy and/or non-aerosol-generating procedural interventions. Part I of the study evaluated the effectiveness of palliative care, and need for aerosol-generating procedures or extractions was quantified. Part II of the study evaluated survivability and rate of adverse events for teeth that received partial or full root canal debridement and placement of calcium hydroxide before shutdown. RESULTS: Part I: Twenty-one patients presented with endodontic emergencies in 25 teeth during statewide shutdown. At a follow-up rate of 96%, 83% of endodontic emergencies required no further treatment or intervention after palliative care. Part II: Thirty-one teeth had received partial or full root canal debridement before statewide shutdown. Mean time to complete treatment was 13 weeks. At a recall rate of 100%, 77% of teeth did not experience any adverse events due to delays in treatment completion. The most common adverse event was a fractured provisional restoration (13%), followed by painful and/or infectious flare-up (6.4%), which were managed appropriately and therefore seemed successful. Only 1 tooth was fractured and nonrestorable (3%), leading to a failed outcome of tooth extraction. The remaining 4 outcome failures (13%) were due to patient unwillingness to undergo school-mandated COVID testing or patient unwillingness to continue treatment because of perceived risk of COVID infection. CONCLUSIONS: Palliative care for management of endodontic emergencies is a successful option when aerosol-generating procedures are restricted. This treatment approach may be considered in an effort to reduce risk of transmission of COVID-19 infection during subsequent shutdowns. Prolonged Ca(OH)2 medicament because of COVID-19 related delays in treatment completion appeared to have minimal effect on survival of teeth.

Clinical Outcomes of Immature Teeth Treated with Regenerative Endodontic Procedures-A San Antonio Study.

INTRODUCTION: Factors that influence clinical outcomes for regenerative endodontic procedures (REPs) are unknown. This retrospective study aimed to assess tooth healing, root development, pulp vitality, and esthetics post-REPs and categorize them into clinician- and patient-centered outcomes. Furthermore, this study identified significant predictors affecting such outcomes. METHODS: Immature permanent teeth diagnosed with pulp necrosis treated with REPs between 2008 and 2018 with a minimum of 1-year follow-up were included. Outcomes included success and survival rates, changes in root development using 2-dimensional radiographic root area (RRA) and 3-dimensional measurements, pulp vitality, and tooth discoloration. Predictor variables of success included age, sex, etiology of pulp necrosis (PN), type of medicament, sodium hypochlorite (NaOCl) concentration, type of biomaterial used over the blood clot, and preoperative apical diagnosis. Statistical analyses included Cox proportional hazard analyses and generalized regression models. RESULTS: Fifty-one teeth with an average of 2.1 years of follow-up satisfied the criteria. The survival rate was 92%. The success rate was 84.3% with age, etiology of PN, type of medicament, and NaOCl concentration being significant predictors of failure. Root development occurred in 91.4% of cases with age, sex, etiology of PN, type of medicament, NaOCl concentration, and apical diagnosis being significant predictors for RRA change. Positive pulp sensibility responses were associated with greater RRA change, and, finally, the type of biomaterial was a significant predictor for tooth discoloration after treatment. CONCLUSIONS: REPs provide a high survival rate. Patient and clinical factors may affect outcomes, and this knowledge may help to define the criteria for optimal treatment planning of REPs.

Reliable approaches to extract high-integrity RNA from skin and other pertinent tissues used in pain research.

INTRODUCTION: Comprehensive mRNA sequencing is a powerful tool for conducting unbiased, quantitative differential gene expression analysis. However, the reliability of these data is contingent on the extraction of high-quality RNA from samples. Preserving RNA integrity during extraction can be problematic, especially in tissues such as skin with dense, connective matrices and elevated ribonuclease expression. This is a major barrier to understanding the influences of altered gene expression in many preclinical pain models and clinical pain disorders where skin is the site of tissue injury. OBJECTIVE: This study developed and evaluated extraction protocols for skin and other tissues to maximize recovery of high-integrity RNA needed for quantitative mRNA sequencing. METHODS: Rodent and human tissue samples underwent one of the several different protocols that combined either RNA-stabilizing solution or snap-freezing with bead milling or cryosectioning. Indices of RNA integrity and purity were assessed for all samples. RESULTS: Extraction of high-integrity RNA is highly dependent on the methods used. Bead-milling skin collected in RNA-stabilizing solution resulted in extensive RNA degradation. Snap-freezing in liquid nitrogen was required for skin and highly preferable for other tissues. Skin also required cryosectioning to achieve effective penetration of RNA-stabilizing solution to preserve RNA integrity, whereas bead milling could be used instead with other tissues. Each method was reproducible across multiple experimenters. Electrophoretic anomalies that skewed RNA integrity value assignment required manual correction and often resulted in score reduction. CONCLUSION: To achieve the potential of quantitative differential gene expression analysis requires verification of tissue-dependent extraction methods that yield high-integrity RNA.

A Volumetric Assessment of External Cervical Resorption Cases and Its Correlation to Classification, Treatment Planning, and Expected Prognosis.

INTRODUCTION: External cervical resorption (ECR) is a relatively uncommon type of external resorption; its treatment planning and prognosis are largely dependent on the clinician's subjective assessment. This study aimed to provide a volumetric assessment of ECR cases while correlating them to the Heithersay classification, treatment decision, and prognosis determined by 3 calibrated, independent evaluators. METHODS: A total of 168 ECR cases with corresponding periapical radiographs and cone-beam computed tomographic (CBCT) imaging were included in this study. An oral and maxillofacial radiologist calculated the volume occupied by the resorptive defects in root structures on CBCT imaging using Amira software (Thermo Scientific, Waltham, MA). Also, 3 board-certified endodontists evaluated anonymized and randomized periapical radiographs and corresponding CBCT images in separate sessions. Examiners were asked to provide a Heithersay classification, whether they would surgically repair the ECR lesion, and the expected prognosis of each case. RESULTS: The percentage of radicular volume affected by ECR ranged from 0.5%-58% with a median of 12%. The volumetric quantification of ECR best correlated with classification and prognosis assigned by the independent examiners using CBCT evaluation. The greatest variation in agreement was observed on whether to surgically repair the ECR. However, examiners agreed more uniformly on not to treat when the resorptive port of entry was found on either the lingual or proximal surfaces of the tooth. CONCLUSIONS: For the first time, the volumetric quantification of resorptive defects was calculated in vivo and correlated to the Heithersay classification and prognosis. Because the longevity of teeth affected with ECR depends on the integrity of the remaining root, the findings of this study provide important information to help clinicians decide on treatment planning and inform their patients of the expected prognosis. Future studies should focus on automating volumetric assessments of ECR to aid in unbiased chairside treatment planning decisions.

Coronavirus Disease 19 (COVID-19): Implications for Clinical Dental Care.

The recent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated coronavirus disease has gripped the entire international community and caused widespread public health concerns. Despite global efforts to contain the disease spread, the outbreak is still on a rise because of the community spread pattern of this infection. This is a zoonotic infection, similar to other coronavirus infections, that is believed to have originated in bats and pangolins and later transmitted to humans. Once in the human body, this coronavirus (SARS-CoV-2) is abundantly present in nasopharyngeal and salivary secretions of affected patients, and its spread is predominantly thought to be respiratory droplet/contact in nature. Dental professionals, including endodontists, may encounter patients with suspected or confirmed SARS-CoV-2 infection and will have to act diligently not only to provide care but at the same time prevent nosocomial spread of infection. Thus, the aim of this article is to provide a brief overview of the epidemiology, symptoms, and routes of transmission of this novel infection. In addition, specific recommendations for dental practice are suggested for patient screening, infection control strategies, and patient management protocol.

Effect of a Residual Biofilm on Release of Transforming Growth Factor ß1 from Dentin.

INTRODUCTION: Several studies have reported regeneration of the pulp-dentin complex when treating noninfected root canal systems. However, current protocols applied to infected root canal systems are much less predictable for the formation of dentin. Converging lines of evidence implicate residual biofilm as an important factor for these variable histologic outcomes. Here we studied the effect of a residual polymicrobial biofilm on the release of transforming growth factor beta 1 (TGF-ß1) from dentin. We hypothesized that the presence of bacterial biofilm attenuates the release of bioactive molecules from dentin. METHODS: Using bacteria commonly found in infected immature teeth, we developed a multispecies biofilm in an organotypic root canal model. Root segments were then subjected to various irrigation or intracanal medicament protocols. Subsequently, the release of TGF-ß1 from dentin was measured using the enzyme-linked immunosorbent assay. RESULTS: Our data show that sterile root segments released greater amounts of TGF-ß1 when conditioned with 17% EDTA alone (P < .001) or with the combination of 1.5% sodium hypochlorite and 17% EDTA (P < .05) compared with root segments infected with the multispecies biofilm. Similar results were also observed with the intracanal medicament protocol. Sterile root segments medicated with various concentrations of triple antibiotic paste and full-strength calcium hydroxide released greater amounts of TGF-ß1 when compared with their infected counterparts. CONCLUSIONS: This is the first study to report the detrimental effects of a residual biofilm on dentin conditioning and, therefore, the release of growth factors critical for regenerative procedures.

Comprehensive Characterization of 2 Immature Teeth Treated with Regenerative Endodontic Procedures.

INTRODUCTION: Regeneration of the pulp-dentin complex is the penultimate goal of regenerative endodontic procedures (REPs). Histological outcomes have demonstrated reparative tissue formation in human teeth extracted post-REPs. However, lack of accurate characterization has precluded identification of the true nature of tissues formed post-REP. METHODS: Here, we present 2 case reports of tooth #29 and #9 treated with REPs and demonstrate their clinical, radiographic, and histological outcomes. RESULTS: Clinical outcomes revealed healing of apical periodontitis in both teeth and re-establishment of vitality responses in tooth #29. Moreover, radiographic assessments using 2D and 3D-volumetric analyses demonstrate considerable increase in root development for both teeth. Further, histological outcomes evaluated using Hematoxylin and Eosin and immunohistochemical staining demonstrates presence of vascular and lymphatic structures as well as immune cell markers indicative of regeneration of an immunocompetent pulp. Lastly, examination of hard tissue deposition shows dentin-like tissue in parts of tooth #29 demonstrating for the first time, regeneration of a pulp-dentin complex post-REP. CONCLUSIONS: Collectively, this is the first study demonstrating recapitulation of several tissues commonly found as part of a pulp-dentin complex in teeth treated with REPs.

Cone beam computed tomography image optimization to detect root fractures in endodontically treated teeth: an in vitro (phantom) study.

OBJECTIVES: The aim of this study was to evaluate the effect of an optimization filter (OF) and voxel size on the accuracy of root fracture detection. STUDY DESIGN: Half of 40 endodontically treated roots were fractured, and the other half were left intact. All teeth were randomly placed into 5 bovine ribs. Each rib was scanned with the Planmeca ProMax 3-D using 4 different settings: 75 µm and 100 µm voxel size with and without an OF. Five reviewers reported if a fracture was present by using a 5-point scale. Intra-/interobserver agreement, area under the receiver operative characteristic curve, accuracy, sensitivity, and false-positive rates were analyzed. RESULTS: High κ-values indicated strong intra-/interobserver agreement. There was no significant difference in fracture detection between any of the evaluated techniques. CONCLUSIONS: Because of the decreased cost, dose area product, and time required, compared with the other imaging modalities studied, the high-resolution mode (100 µm) without an OF is recommended for root fracture detection in endodontically treated teeth.

Effect of Bacterial Biofilm on the Osteogenic Differentiation of Stem Cells of Apical Papilla.

INTRODUCTION: Although clinical success in regenerative endodontics is substantially high, histological success is limited to finding bone/cementum-like tissue instead of dentin within the canal space. The aims of this study were to investigate (1) the effect of bacterial biofilm on osteogenic gene expression in stem cells of the apical papilla (SCAP) and (2) the effect of bacterial antigens on the functional differentiation of SCAP into a mineralizing phenotype. METHODS: Using an ex vivo organotypic root canal model and an American Association of Endontists-recommended regenerative endodontic procedures, we evaluated SCAP differentiation in the presence and absence of an Enterococcus faecalis biofilm. Gene expression analysis for dentinogenic and osteoblastic markers was performed with real-time polymerase chain reaction. The effect of E. faecalis antigens on SCAP differentiation into mineralizing cells in vitro was evaluated with 2 functional assays: Alizarin Red and alkaline phosphatase activity assays. RESULTS: After regenerative endodontic procedures, residual bacteria continued to sustain within the root canal system. SCAP in the presence of E. faecalis biofilm significantly downregulated dentinogenic genes such as dentin sialophosphoprotein and upregulated osteoblastic genes such as bone sialoprotein, osteocalcin, distal-less homeobox 5, and runt-related transcription factor 2. E. faecalis antigens significantly inhibited SCAP differentiation into a mineralizing phenotype when alizarin red staining and alkaline phosphatase assays were used in vitro. CONCLUSIONS: Current disinfection protocols were ineffective in eliminating bacteria from root tips and the levels of the residual bacterial biofilm, and its byproducts, were able to significantly alter osteogenic-differentiation of SCAP.