Effectiveness of adjunct therapy for the treatment of apical periodontitis: A systematic review and meta-analysis.

BACKGROUND: Adjunct therapy refers to any intracanal procedure going beyond chemomechanical preparation with instruments and traditionally delivered irrigants (excluding interim dressings). It is not clear whether and which of these adjunct therapies have a significant impact on the outcome of root canal treatment [healing of apical periodontitis (AP) and other patient-related outcomes]. OBJECTIVES: This systematic review aimed to analyse available evidence on the effectiveness of adjunct therapy for the treatment of AP in permanent teeth, according to a population, intervention, comparison, outcome, time and study design framework formulated a priori by the European Society of Endodontology. METHODS: Five electronic databases (PubMed, Embase, Scopus, Cochrane and Web of Science) were searched up to October 2021 to identify clinical studies comparing adjunct therapy to no adjunct therapy in adult patients with AP. Animal studies, reviews, studies with less than 10 patients per arm and studies with a follow-up time of less than 1 year, or less than 7 days for postoperative pain, were excluded. The quality of the included studies was appraised by the appropriate tools [Risk of Bias 2 (RoB2) for randomized clinical trials (RCTs) and Newcastle-Ottawa Scale for observational studies]. Meta-analysis was performed using a random-effects model. The certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS: Fourteen studies (13 RCTs and one retrospective cohort) fulfilled the inclusion criteria for this review. They evaluated different types of adjunct therapy: antimicrobial photodynamic therapy (aPDT; three studies), diode laser canal irradiation (3), Nd:YAG laser canal irradiation (2), Er;Cr:YSGG laser canal irradiation (1), ozone therapy (2) and ultrasonically activated irrigation (UAI) (4). Radiographical healing was reported in seven studies, but meta-analysis was only possible for UAI (two studies), showing no statistically significant difference in healing after 12 months. Pain after 7 days was reported in seven studies. Meta-analysis on three studies that used aPDT and on two studies using diode laser irradiation showed no significant difference in the prevalence of pain after 7 days between the control and adjunct therapy. According to RoB2 tool, six studies had a high risk of bias, five studies had some concerns, and two studies low risk of bias. The GRADE assessment revealed a very low strength of evidence for diode laser, and low strength of evidence for PDT, ozone and UAI studies. DISCUSSION: The included studies displayed significant heterogeneity in terms of type of adjunct therapy, technical details per adjunct therapy, outcome reporting and several combinations of these, limiting the potential for meta-analysis. CONCLUSIONS: There is insufficient evidence to recommend any adjunctive therapy for the treatment of apical periodontitis. REGISTRATION: Prospero CRD42021261869.

Microbiological profile of root canals indicated for endodontic retreatment due to secondary endodontic infections or for prosthetic reasons.

OBJECTIVE: The objective of this study was to evaluate the microbiological profile of root canals indicated for endodontic retreatment due to secondary endodontic infections evidenced by the presence of chronic apical periodontitis (G1) or for prosthetic reasons, without clinical and radiographic signs of endodontic reinfection (G2). METHODS: Microbiological samples were collected from thirty teeth (N=30) out of which 15 were indicated for retreatment due to the presence of chronic apical periodontitis (G1) and 15 were indicated exclusively for prosthetic reasons (G2). Samples were collected from root canals before (S1), after chemomechanical preparation (S2), and after 30 days of intracanal medication composed of calcium hydroxide and 2% chlorhexidine gel (S3). The molecular analysis was performed using Nested-PCR for the detection of 17 bacterial species. The efficacy of each stage of the retreatment in reducing the microbial load was verified by counting colony-forming units (CFU). The statistical analysis considered a significance level of 5%. RESULTS: The results showed that bacteria were detected in 100% of the cases in S1, in both groups, by Nested PCR. The most frequently found species in S1 in both groups were Enterococcus faecalis, Fusobacterium nucleatum, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Parvimonas micra. The microbial load of G1 was higher than G2 in the initial samples (S1). Endodontic retreatment was effective in reducing the microbial load in G1 and G2. Statistically significant associations were found between specific bacteria and clinical signs and symptoms. CONCLUSION: It was concluded that the microbial community present in the root canal of teeth indicated for endodontic retreatment is mixed and heterogeneous. G1 and G2 differ in the number of species per case and microbial load. CLINICAL RELEVANCE: Endodontic retreatment was effective in reducing the microbial load. Statistically significant associations were found between specific bacteria and clinical signs and symptoms.

Identification of Fusobacterium nucleatum in primary and secondary endodontic infections and its association with clinical features by using two different methods.

OBJECTIVE: Fusobacterium nucleatum is an important oral pathogen involved in endodontic infections. This study aimed to assess the frequency of Fusobacterium nucleatum in primary and secondary endodontic infections and its associations with the clinical features in a Brazilian population by using both culture and nested PCR methods. METHODS: A total of 100 microbial samples from patients with primary (n=50) and secondary endodontic infections (n=50) were analyzed by using culture and nested PCR methods. Strict anaerobic techniques were used for culture and identification of F. nucleatum. The DNA extracted from the samples was analyzed for the presence of target species by using species-specific primers. RESULTS: Culture and nested PCR methods detected F. nucleatum, respectively, in 11/100 and 82/100 root canals. F. nucleatum was isolated by culture from 10/50 (20%) root canals with primary infections and from 1/50 (2%) root canal with secondary/persistent infections. Nested PCR detected F. nucleatum in 42/50 (84%) root canals with primary infections and in 40/50 (80%) root canals with secondary/persistent endodontic infections. F. nucleatum was associated with spontaneous pain, tenderness to percussion, pain on palpation, swelling, tooth mobility, wet root canals, hemorrhagic exudate, tooth decay, inadequate restoration, and poor endodontic filling. CONCLUSION: F. nucleatum was found in more cases of primary endodontic infections than in cases of secondary/persistent ones. A higher prevalence of F. nucleatum was detected by using the nested PCR method than by using culture. The presence of F. nucleatum in the root canals was associated with several clinical features. CLINICAL RELEVANCE: The high prevalence of F. nucleatum in the root canals detected by molecular methods, and its association with several clinical features reveals the importance of these species in the development of apical pathologies and reinforces the need of an endodontic treatment directed to bacterial elimination.

Assessment of the root surface temperature during the use of intracanal agitation systems: In vitro study.

This study aimed to evaluate the temperature changes that the different methods of agitation of irrigants promote on the external dental root surface. Nine extracted human lower premolars were standardized by cone-beam computed tomography and used. The root canal was instrumented with a Reciproc 40.06 file. Temperature measurement was performed using K-type thermocouple sensors attached to the middle, cervical, and apical thirds of the teeth. The teeth had their roots immersed in distilled water at 37ºC, which were distributed into 3 experimental groups according to the mechanical agitation methods to be studied. US Group (n=3), Irrisonic Ultrasonic Tip activated through ultrasound; EC Group (n=3), Easyclean Tip coupled to a contra-angle low-speed handpiece; XP Group (n=3), XP-endo Finisher file coupled to an endodontic electrical motor. Temperature measurements were performed simultaneously with agitation and irrigation of intracanal irrigants. Statistical analysis was performed using SPSS software with a significance level of 5%. For multiple comparisons, the Tukey test was used. The association between mechanical agitation methods and root third was statistically significant. Regarding the temperatures recorded on the external surface of the roots, the ultrasonic tip was significantly higher than the XP-endo Finisher file and the Easyclean tip, which did not differ from each other. Regarding the ultrasonic tip, the external temperature in the middle third (39.46ºC) of the root was significantly lower than in the cervical (40.41ºC) and apical third (40.53ºC). None of the agitation methods of irrigants studied presented heating above 47ºC, and their use is safe for periodontal tissues.

Clinical evaluation of culturable bacteria, endotoxins and lipoteichoic acid in teeth with vital normal pulp tissues.

The objective of this study was to investigate the presence of culturable bacteria, endotoxins (LPS) and lipoteichoic acid (LTA) levels in teeth with normal vital pulp (NVP) with intact crowns (IC) and those with coronal restoration (CR) limited to the enamel level. A total of 20 teeth indicated for endodontic treatment due to prosthetic reasons were selected. Samples were collected from the root canals. The levels of cultivable bacteria, LPS and LTA were assessed. Statistical analyses were performed at significance level set at 5%. None of the teeth presented microbial growth. In the IC group, the LPS levels were limited to the lowest concentration of LPS. On the contrary, higher LPS and LTA levels were detected in teeth with CR. It was concluded that teeth with NVP and IC were negative for bacteria, LPS and LTA; while teeth with CR were positive for bacterial virulence factors.

Efficiency of a digital electrofulguration system in contaminated root canals in vitro.

Decontamination of the root canal (RC) system is essential for successful endodontic therapy. In this in vitro study, it was evaluated the disinfection potential of an electrofulguration device, the Endox® Endodontic System (EES), in RC infected with Enterococcus faecalis. Sixty-five human lower premolars were instrumented with MTwo® system. The specimens were distributed into six experimental groups (n = 10), according to the irrigation protocol: 2% chlorhexidine gel (CHX); CHX + EES; 5.25% sodium hypochlorite (NaOCl); NaOCl + EES; saline solution (SS); and SS + EES. Five specimens were untreated (control). RC samples were collected before (C1) and after EES treatment (C2), after chemo-mechanical preparation (CMP) (C3), and after final EES treatment (C4). All samples were plated for colony forming units (CFU/mL) onto solid media. The data were analyzed by Wilcoxon and Friedman tests for intragroup comparisons and by Kruskal Wallis test followed by Dunn's test for intergroup comparisons (α = 0.05). Treatment with the EES did not significantly reduce the number of CFU/mL as compared to baseline levels (C1 vs. C2, p> 0.05). After CMP (C3), all groups showed a significantly reduced amount of CFU/mL (p <0.05), with no difference between CHX- and NaOCl-treated samples (p >0.05). Lastly, treatment with the EES following CMP (C4) did not significantly reduce the amount of CFU/mL (C3 vs. C4, p> 0.05). To conclude, the use of the Endox® Endodontic System did not result in considerable bacterial reduction at all operative times, while treatment with NaOCl and CHX was equally efficient for this purpose.

Analysis of microorganisms in periapical lesions: A systematic review and meta-analysis.

AIMS: The aim of this study was to systematically review the literature on prevalence of microorganisms and their viability/activity in endodontic periapical lesions. DESIGN: Literature research was performed on five electronic biomedical databases from their start dates to June 2020. Only studies evaluating the presence of microorganisms in periapical lesions in human permanent teeth with secondary/persistent infection were included. Two reviewers independently assessed the eligibility for inclusion, extracted data and evaluated the risk of bias. Meta-analysis and binominal tests were used to analyse the resulting data. RESULTS: From the 1,313 records found, 23 full-texts were included for qualitative and quantitative analysis. The prevalence of microorganisms in endodontic periapical lesions was 87 % (95 % CI, 75-94) and the prevalence of viable/active microorganisms was 82 % (95 % CI, 66-91). There were statistical differences in the geographic area subgroup and between viable bacteria and active viruses. The most common detection method of microorganisms was the molecular one (69 %), and the most prevalent bacteria were the species Actinomyces, Fusobacterium and Prevotella (40 %). Most of the included studies had moderate risk of bias. CONCLUSIONS: The prevalence of microorganisms in endodontic periapical lesions was 87 % and the prevalence of viable/active microorganisms was 82 %.

Detection of Fusobacterium in oral and head and neck cancer samples: A systematic review and meta-analysis.

AIMS: This systematic review aimed to analyse: a) the presence and the abundance of Fusobacterium; b) the Fusobacterium species most often found, and c) the most common methods used for their identification in oral/head and neck cancer samples. DESIGN: A protocol was registered on PROSPERO database. This review was conducted following PRISMA guidelines. Literature search was performed on five electronic biomedical databases, namely Pubmed, Scopus, Web of Science, Embase, and Cochrane from their start dates to 30 August 2018. Two reviewers independently assessed the eligibility for inclusion; extracted the data; and evaluated the risk of bias. RESULTS: From 118 unique abstract records, 88 full-text articles were assessed for eligibility. According to inclusion and exclusion criteria, 17 publications were included in this review. Meta-analysis showed an increased prevalence of 6 % (95 % CI, 3-9) of Fusobacterium in tumour lesions than in non-tumour lesions (Fusobacterium prevalence of 16 % in tumour lesions and of 10 % in non-tumour lesions), and a 2.93 higher chance of Fusobacterium being present in tumour lesions (95 % CI, 1.47-5.81). The most common detection methods were based on molecular evidence (64.70 %) (95 % CI, 37.7-84.7). F. nucleatum was the most prevalent species (47.06 %) (95 % CI, 23.5-72). CONCLUSION: In conclusion, Fusobacterium is present and in higher abundance in oral/head and neck cancer samples when compared to non-cancer samples, suggesting that Fusobacterium may contribute to oral/head and neck cancer development.

Potential antibacterial and anti-halitosis activity of medicinal plants against oral bacteria.

This study aimed to evaluate the in vitro activity of the crude extracts obtained from Caesalpinia ferrea Mart. (Jucá), Cinnamomum cassia B. (Cinnamon), Mallow sylvestris L. (Mallow), Punica granatum L. (Pomegranate), Rosmarinus officinalis L. (Rosemary), Aeolanthus suaveolens (Als.) Spreng. (Macassá), Sysygium aromaticum L. (Clove), and Tamarindus indica L. (Tamarind) against oral microorganisms (e.g., Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, and Parvimonas micra) that produce volatile sulfur compounds (VSC). The pure extracts were placed in culture medium for the diffusion test in agar. The Minimum Inhibitory Concentration (MIC) was determined by the microdilution method, and microbial growth was assayed with resazurin. Total polyphenols in the extracts were measured by using the Prussian Blue Method. For the salivary sediment test, the sediments were exposed to the Jucá and Pomegranate extracts, which was followed by incubation and organoleptic measurements with a monitor (Halimeter®) at 1-, 2-, 4-, and 24 -h intervals. The diffusion test revealed mixed results for the extracts. When the zone of inhibition was present, it ranged from 1.6-10.3 mm. The Pomegranate extract was the only extract that inhibited all the evaluated microorganisms; the MIC values ranged from 50 to 400 µg/mL. The Pomegranate and Jucá extracts presented higher levels of polyphenols, 7.3 % and 3.9 %, respectively, and less VSC formation as compared to the negative control. In conclusion, the extracts display antimicrobial activity against the tested microorganisms. The investigated plants have the potential to reduce the main substances related to halitosis of oral origin.

Assessment of the root surface temperature during the use of intracanal agitation systems: In vitro study

Abstract This study aimed to evaluate the temperature changes that the different methods of agitation of irrigants promote on the external dental root surface. Nine extracted human lower premolars were standardized by cone-beam computed tomography and used. The root canal was instrumented with a Reciproc 40.06 file. Temperature measurement was performed using K-type thermocouple sensors attached to the middle, cervical, and apical thirds of the teeth. The teeth had their roots immersed in distilled water at 37ºC, which were distributed into 3 experimental groups according to the mechanical agitation methods to be studied. US Group (n=3), Irrisonic Ultrasonic Tip activated through ultrasound; EC Group (n=3), Easyclean Tip coupled to a contra-angle low-speed handpiece; XP Group (n=3), XP-endo Finisher file coupled to an endodontic electrical motor. Temperature measurements were performed simultaneously with agitation and irrigation of intracanal irrigants. Statistical analysis was performed using SPSS software with a significance level of 5%. For multiple comparisons, the Tukey test was used. The association between mechanical agitation methods and root third was statistically significant. Regarding the temperatures recorded on the external surface of the roots, the ultrasonic tip was significantly higher than the XP-endo Finisher file and the Easyclean tip, which did not differ from each other. Regarding the ultrasonic tip, the external temperature in the middle third (39.46ºC) of the root was significantly lower than in the cervical (40.41ºC) and apical third (40.53ºC). None of the agitation methods of irrigants studied presented heating above 47ºC, and their use is safe for periodontal tissues.

Resumo Este estudo teve como objetivo avaliar as mudanças de temperatura que os diferentes métodos de agitação de irrigantes promovem na superfície externa da raiz dentária. Nove pré-molares humanos extraídos foram padronizados por tomografia computadorizada de feixe cônico e usados. O canal radicular foi instrumentado com uma lima Reciproc 40.06 de 25 mm. A medição da temperatura foi realizada usando sensores termopares do tipo K fixados nos terços médio, cervical e apical dos dentes. Os dentes tiveram suas raízes imersas em água destilada a 37ºC, as quais foram distribuídas em 3 grupos experimentais de acordo com os métodos de agitação mecânica a serem estudados. Grupo US (n=3), Ponta Irrisonic Ultrasonic ativado por ultrassom; Grupo EC (n=3), Ponta Easyclean acoplada a um contra-ângulo de baixa rotação; Grupo XP (n=3), Lima XP-endo Finisher acoplada a um motor elétrico endodôntico. As medições de temperatura foram realizadas simultaneamente com agitação e irrigação de irrigantes intracanal. A análise estatística foi realizada no software SPSS com nível de significância de 5%. Para comparações múltiplas, foi utilizado o teste de Tukey. A associação entre métodos de agitação mecânica e terço radicular foi estatisticamente significativa. Em relação às temperaturas registradas na superfície externa das raízes, a ponta ultrassônica foi significativamente maior que a lima XP-endo Finisher e a ponta Easyclean, que não diferiram entre si. Com relação à ponta ultrassônica, a temperatura externa no terço médio (39,46ºC) da raiz foi significativamente menor do que nos terços cervical (40,41ºC) e apical (40,53ºC). Nenhum dos métodos de agitação dos irrigantes estudados (Irrisonic, XP-endo Finisher e Easyclean) apresentou aquecimento acima de 47ºC, sendo seu uso seguro para os tecidos periodontais.

Efficiency of a digital electrofulguration system in contaminated root canals in vitro

Abstract Decontamination of the root canal (RC) system is essential for successful endodontic therapy. In this in vitro study, it was evaluated the disinfection potential of an electrofulguration device, the Endox® Endodontic System (EES), in RC infected with Enterococcus faecalis. Sixty-five human lower premolars were instrumented with MTwo® system. The specimens were distributed into six experimental groups (n = 10), according to the irrigation protocol: 2% chlorhexidine gel (CHX); CHX + EES; 5.25% sodium hypochlorite (NaOCl); NaOCl + EES; saline solution (SS); and SS + EES. Five specimens were untreated (control). RC samples were collected before (C1) and after EES treatment (C2), after chemo-mechanical preparation (CMP) (C3), and after final EES treatment (C4). All samples were plated for colony forming units (CFU/mL) onto solid media. The data were analyzed by Wilcoxon and Friedman tests for intragroup comparisons and by Kruskal Wallis test followed by Dunn's test for intergroup comparisons (α = 0.05). Treatment with the EES did not significantly reduce the number of CFU/mL as compared to baseline levels (C1 vs. C2, p> 0.05). After CMP (C3), all groups showed a significantly reduced amount of CFU/mL (p <0.05), with no difference between CHX- and NaOCl-treated samples (p >0.05). Lastly, treatment with the EES following CMP (C4) did not significantly reduce the amount of CFU/mL (C3 vs. C4, p> 0.05). To conclude, the use of the Endox® Endodontic System did not result in considerable bacterial reduction at all operative times, while treatment with NaOCl and CHX was equally efficient for this purpose.

Resumo A descontaminação do sistema do canal radicular (CR) é essencial para o sucesso da terapia endodôntica. Neste estudo in vitro, foi avaliado o potencial de desinfecção de um dispositivo de eletrofulguração, o Endox® Endodontic System (EES), em CR infectado com Enterococcus faecalis. Sessenta e cinco pré-molares inferiores humanos foram instrumentados com o sistema MTwo®. As amostras foram distribuídas em seis grupos experimentais (n = 10), de acordo com o protocolo de irrigação: clorexidina gel a 2% (CHX); CHX + EES; Hipoclorito de sódio 5,25% (NaOCl); NaOCl + EES; solução salina (SS); e SS + EES. Cinco amostras não foram tratadas (controle). As amostras de CR foram coletadas antes (C1) e após o tratamento com EES (C2), após preparo químico-mecânico (PQM) (C3) e após o tratamento final com EES (C4). Todas as amostras foram plaqueadas para unidades formadoras de colônias (CFU / mL) em meio sólido. Os dados foram analisados pelos testes de Wilcoxon e Friedman para comparações intragrupos e pelo teste de Kruskal Wallis, seguidos pelo teste de Dunn para comparações intergrupos (α = 0,05). O tratamento com o EES não reduziu significativamente o número de CFU / mL em comparação com os níveis basais (C1 vs. C2, p> 0,05). Após PQM (C3), todos os grupos apresentaram uma quantidade significativamente reduzida de CFU / mL (p <0,05), sem diferença entre as amostras tratadas com CHX e NaOCl (p> 0,05). Por fim, o tratamento com o EES após PQM (C4) não reduziu significativamente a quantidade de CFU / mL (C3 vs. C4, p> 0,05). Concluindo, o uso do Endox® Endodontic System não resultou em redução bacteriana considerável em todos os momentos operatórios, enquanto os tratamentos com NaOCl e CHX foram igualmente eficientes para esse fim.