The impact of bone grafting with/without barrier membrane placement on the outcome of apical surgery: A systematic review and meta-analysis.

BACKGROUND: Regenerative techniques are increasingly being advocated in endodontic apical surgery (AS) to enhance the healing of periapical lesions. Various grafting and membrane materials are employed as adjuncts to modern AS. OBJECTIVES: This systematic review aimed to answer the following PICO question: In patients with apical periodontitis (P) what is the impact of bone grafting with/without barrier membrane materials (I) compared with surgery without grafting materials (C) on the outcome of AS evaluated clinically and radiographically (O). METHODS: A systematic search was conducted in four databases (Embase, Web of Science, PubMed and Cochrane Central Register of Controlled Trials) until 1 August 2023. Google Scholar was also manually searched. Studies with a prospective randomized design were included. Cochrane risk-of-bias (RoB) tool 2.0 assessed bias. Two independent reviewers performed the study selection, data extraction and appraisal of studies. Meta-analysis was performed using R3.5.1 software. RESULTS: From the identified 2582 studies, eight randomized clinical trials were included for meta-analysis. Two studies had low RoB, while six had some concerns. Analysis revealed significantly better outcomes when surgery involved bone regeneration techniques than conventional surgery (OR = 2.18, 95% CI: 1.32-4.31, p = .004). Subgroup analyses on individual grafts (OR = 0.22, 95% CI: -0.99 to 1.44, p = .720) (OR = -0.09, 95% CI: -1.42 to 1.23, p = .885) and membranes (OR = -1.09, 95% CI: -2.94 to 0.76, p = .247) and their combinations (OR = 0.03, 95% CI: -1.50 to 1.55, p = .970) did not yield any significant results. The type of membrane used did not significantly impact the outcome (OR = -1.09, 95% CI: -2.94 to 0.76, p = .247) nor did altering the combination of graft/membrane. DISCUSSION: This systematic review examined the effects of bone grafting with/without membrane placement on the outcome of AS. It highlights the potential advantages of regenerative techniques and the need for further research in this area. CONCLUSIONS: Based on current evidence, bone grafting with/without barrier membrane placement significantly improves healing after AS. Subgroup analysis of resorbable membranes or grafting did not significantly influence the outcome. The combination of membrane and graft was also not significant. Future well-designed, randomized controlled trials in this area are essential before these materials can be recommended for routine use to enhance healing outcomes in AS. REGISTRATION: PROSPERO (CRD42021255171).

Prevalence of and Factors Associated With Vertical Root Fracture in a Japanese Population: An Observational Study on Teeth With Isolated Periodontal Probing Depth.

INTRODUCTION: Previous studies on the prevalence of vertical root fractures (VRFs) were based on extracted teeth, or teeth referred for apical surgery. This study examined teeth with an isolated periodontal probing depth (PD) as an indicator of VRF. The primary aim of this study was to investigate the prevalence of vertical root fracture (VRF) and non-VRF among teeth with an isolated probing depth (PD) ≥ 5 mm. The secondary aim was to assess factors associated with VRF by comparing the teeth with and without VRF in the Japanese population. METHODS: A total of 288 teeth with an isolated PD ≥ 5 mm were grouped pathologically into 8 groups comprising VRF and non-VRF conditions. A descriptive analysis for age, sex, tooth type, endodontically treated teeth (ETT) versus non-ETT, proximal contacts, PD (depth), PD (broadness and location), restoration type, and presence of a post was performed. Moreover, the associations between these factors and VRFs were investigated using the Chi-square test. RESULTS: The prevalence of VRF was 32%. Lower first molars were the most common tooth type in both VRF (31.5%) and non-VRF groups (29.7%), while premolars were exclusively frequent in VRF (30.2%) and not frequent in non-VRF (7.8%). Narrow buccolingual PD was common in VRF (78.1%) whereas wide PD was frequent in non-VRF (67.1%). ETT, narrow buccolingual PD, tooth type (premolars), restoration type (crown), and the presence of a post showed significant associations with VRF (P ≤ .001). CONCLUSIONS: VRFs may be more prevalent in ETT among the Japanese. Careful assessment is necessary to differentiate VRFs from other conditions when the lower first molars show an isolated PD ≥ 5 mm. When an endodontically treated premolar with a post shows a narrow buccolingual PD, the probability of a VRF may be greater than in other tooth types.

The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis-A Systematic Review.

Diagnosis is a key aspect in endodontic treatment, in a decade where invasive interventions are misapprehended as social tendency instead of medical necessity. All diagnostic facets should be considered before intending the operative phase. Intraoral endodontic radiology-based diagnosis has been shown to be limited. Periapical X-ray is the most used endodontic imaging, yet it does not provide high accuracy. Traditionally, dentists have been trained to diagnose a cyst by certain aspects (size, shape and appearance); hence, an assumption that teeth are affected by "periapical cyst" were subjected to unnecessary extraction or apicoectomy. The aim of this systematic review is to critically appraise the publications that relate the histological diagnosis of a periapical lesion (considered the gold standard) to intraoral X-ray investigation. Ovid Medline, PubMed, ScienceDirect, Mendeley and Scopus were searched for English-language studies comparing periapical diagnosis obtained by using two techniques (histopathology and X-ray). Sixteen articles were included for the final analysis (qualitative and quantitative evaluation) out of which only two supported the statement that periapical diagnosis can be coherently assessed through periapical imaging. Although there is not enough evidence to deliver a definitive conclusion, there are many publications that refute the diagnosis of a cyst via periapical X-ray.

Antibacterial and Bonding Properties of Universal Adhesive Dental Polymers Doped with Pyrogallol.

This study investigated the antibacterial activity, bond strength to dentin (SBS), and ultra-morphology of the polymer-dentin interface of experimental adhesive systems doped with pyrogallol (PY), which is a ubiquitous phenolic moiety that is present in flavonoids and polyphenols. A universal adhesive containing 4-META and 10-MDP was used in this study. PY behaves as an antioxidant and anti-cancerogenic agent and it was incorporated into the adhesive at different concentrations (0.5 and 1 wt.%). The antibacterial activity and SBS were analyzed and the results were statistically analyzed. The ultra-morphology of the polymer-dentin interface was assessed using scanning electron microscopy (SEM). At 24 h, a lower antibacterial activity was observed for the control adhesive compared to those with 0.5% and 1% PY. No difference was seen in SBS between the three groups at 24 h. After 6 months, the SBS of the 0.5% PY adhesive was significantly lower than the other tested adhesives. The specimens created with 1% PY adhesive presented a higher bond strength at six months compared with that found at 24 h. No morphological differences were found at the polymer-dentin interfaces of the tested adhesives. Pyrogallol may be incorporated into modern universal adhesive systems to preserve the polymer-dentin bonding interface and confer a certain degree of antibacterial activity.

Two cases of primary vitreoretinal lymphoma: a diagnostic challenge : The supporting role of multimodal imaging in the diagnosis of primary vitreoretinal lymphoma.

PURPOSE: To report two cases of primary vitreoretinal lymphoma (PVRL), which presented as intermediate and posterior uveitis. METHODS: Combined clinical assessment, multimodal imaging with spectral-domain optical coherence tomography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, brain magnetic resonance imaging and vitreous and retinal biopsy. Case 1 was a 48-year-old woman who complained of visual loss in her right eye secondary to a diffuse vitreous opacification and multiple chorioretinal lesions. Case 2, a 74-year-old man, presented with low vision in his right eye due to a wide chorioretinal lesion at the posterior pole, vitreous opacification and posterior uveitis in both eyes. RESULTS: Diffuse large B cell lymphoma was histologically diagnosed in the cerebellum in the first case and in chorioretinal tissue in the second patient. Atypical lymphoid cells were detected and allowed to make a diagnosis of primary central nervous system lymphoma in case 1 and PVRL in case 2. CONCLUSION: PVRL often masquerades ad intermediate or posterior uveitis. The management of the patients needed a team of pathologists, haematologists and ophthalmologists to achieve the correct diagnosis and choose the more appropriate therapy. Some peculiar characteristics on multimodal imaging, even in atypical cases of PVRL, should raise suspicious for PVRL and lead to a diagnostic vitrectomy and/or retinal biopsy.

Bacterial Contamination of Endodontic Materials before and after Clinical Storage.

INTRODUCTION: The aim of this study was to evaluate the bacterial contamination in endodontic consumables (gutta-percha points, rubber dams, paper mixing pads, caulking agents, and endodontic instrument sponges [EISs]) before and after clinical use and storage. METHODS: Materials were randomly sampled in triplicates at 3 time points (t0, at package opening; t1, at 7 days; and t2, at 14 days) during their clinical usage. The gutta-percha points and caulking agent (25 mg) were added to 1 mL phosphate-buffered saline (PBS). The rubber dam, paper mixing pad, and EIS were added to 25 mL PBS. After vortexing, centrifuging, and removing the supernatant, the pellet was resuspended in 1 mL PBS, plated on fastidious anaerobic agar, and incubated aerobically and anaerobically. The grown colonies were identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). The total bacterial load was calculated in the remaining volume (800 µL) from each sample by quantitative polymerase chain reaction after DNA extraction. RESULTS: All tested materials showed a varied number of contaminated samples at the 3 time points (except EIS at t0) using MALDI-TOF MS. The most isolated genera were Propionibacterium (42%) and Staphylococcus (32%). By using non-culture-based approaches, all tested materials at the 3 time points (except gutta-percha at t0 and the caulking agent at t0, t1, and t2) carried bacterial DNA. CONCLUSIONS: The majority of the tested materials harbored bacteria in their samples before and after clinical storage. Nosocomial infection derived from commonly used consumables could have an impact on the outcome of endodontic treatment.

Synchrotron light-based µCT to analyse the presence of dentinal microcracks post-rotary and reciprocating NiTi instrumentation.

OBJECTIVES: The purpose of this study was to determine in vitro using a synchrotron radiation-based µCT (SRCT) whether rotary and reciprocating nickel titanium (NiTi) instrumentations lead to the formation of dentine microcracks. MATERIAL AND METHODS: Fourteen extracted human molars were obtained with ethical approval. Seven distobuccal roots of the maxillary molars and seven mesial roots of the mandibular molars were assigned to two experimental groups: (A) prepared with rotary Pro Taper instrumentation (n = 6) and (B) reciprocating WaveOne (n = 6). Irrigation with 1 % NaOCl and 17 % EDTA solutions was carried out. The remaining roots served as positive control with induced fractures (group C). SRCT was used to scan all samples pre and post-operatively. An imaging software was used to determine the number and length of microcracks. Statistical analyses weighed differences between pre and post-instrumentation and between shaping methods. RESULTS: A significant increase in the number and length of microcracks was detected post-shaping. No significant difference between rotary and reciprocating instrumentation was observed. CONCLUSIONS: Within the limitations of this in vitro study, an increased number and length of microcracks was induced by mechanical instrumentation. Reciprocating and rotary instrumentation are similar in terms of effect. CLINICAL SIGNIFICANCE: Dentinal damage may occur following rotary and reciprocating instrumentation.

In vitro and in vivo osteoinductive and osteoconductive properties of a synthetic bone substitute.

PURPOSE: The present study tested a recently introduced bone substitute material (BSM) with a novel structure to determine its osteoinductive and osteoconductive properties in vitro and in vivo. The specific aims were to determine the microstructure of the as-manufactured BSM, as analyzed with scanning electron microscopy, and to characterize different cellular interactions. MATERIALS AND METHODS: Human bone marrow stromal cells were cultured in the presence of the BSM. In vitro, attachment of osteoblastlike cells (SAOS-2) to the BSM was observed with the scanning electron microscope. The expression of genes related to osteogenic differentiation (alkaline phosphatase, bone sialoprotein, type I collagen, and osteocalcin) was determined by reverse-transcriptase polymerase chain reaction. In vivo, bone formation was examined with a murine model of ectopic bone formation through histology and computed tomographic scanning by using tissue-engineered constructs with the BSM and ovine bone marrow stromal cells. RESULTS: Early cellular attachment could be detected as early as 6 hours. Cellular morphology developed in the following 66 hours toward a starlike appearance. Human bone marrow stromal cells cultured in the presence of the BSM showed no reduction in their viability. Osteocalcin was up-regulated during cell culturing, demonstrating an osteoinductive effect of BSM. Histologic and computed tomographic analyses showed the formation of new bone surrounding BSM particles, and a vascular meshwork was observed in the porosity of the particles. CONCLUSION: The analyzed bone substitute of synthetic origin presented osteoinductive properties that may exert a differentiative stimulus upon osteoprogenitor cells. The tested material allowed cellular adhesion of osteoblastlike cells and, following tissue construct implantation in vivo, supported the formation of new bone.

Graft materials and bone marrow stromal cells in bone tissue engineering.

Bone augmentation procedures rely on osteogenic/osteoconductive properties of bone graft material (BGM). A further improvement is represented by use of autologous bone marrow stromal cells (BMSC), expanded in vitro and seeded on BGM before implantation in the bone defect. The effect of different BGMs on BMSC osteogenic differentiation was evaluated. BMSC were cultured in vitro in the presence of different BGM (natural, synthetic, and mixed origins). Cellular morphology was analyzed with scanning electron microscopy. The capability of BMSC to differentiate was determined in vitro by alkaline phosphatase gene expression and enzyme activity at different time points (7, 14, and 28 days) and in vivo by ectopic bone formation of implanted tissue constructs in an immunodeficient murine model. BGM supports the cell adhesion and osteogenic differentiation of BMSC developing a useful tool in the bone tissue engineering.

Photodynamic inactivation of Enterococcus faecalis in dental root canals in vitro.

BACKGROUND AND OBJECTIVES: We previously reported the use of a flexible fiber optic that uniformly distributed light in the root canal space for targeting bacteria after their sensitization with methylene blue (MB). In the present study, we investigated the photodynamic effects of MB on Enterococcus faecalis species in experimentally infected root canals of extracted teeth after their sensitization with a concentration of MB that exhibits reduced dark toxicity. STUDY DESIGN/MATERIALS AND METHODS: In a model of root canal infection, 64 root canal specimens were prepared from extracted, single-rooted teeth and inoculated with E. faecalis (ATCC 29212). Three days later root canal infection was confirmed by scanning electron microscopy. The root canal systems were then incubated with 6.25 microg/ml MB for 5 minutes followed by exposure to light at 665 nm (60 J/cm(2)) that was delivered from a diode laser via a fiber optic with a diameter of 500 microm. Following photodynamic therapy (PDT) the canal content was sampled by flushing the root canals, serially diluted and cultured on blood agar. Survival fractions were calculated by counting colony-forming units. High-performance liquid chromatography (HPLC) was employed to determine the porphyrins content of E. faecalis. RESULTS: Scanning electron microscopy confirmed the presence of bacteria in the root canal system. PDT achieved 77.5% reduction of E. faecalis viability. MB alone and light alone reduced bacterial viability by 19.5% and 40.5%, respectively. HPLC did not reveal any porphyrin patterns expressed by E. faecalis. CONCLUSION: The results of this study support the need to determine the optimum MB concentration and light parameters to maximize bacterial killing in root canals.

Photodynamic therapy for endodontic disinfection.

The aims of this study were to investigate the effects of photodynamic therapy (PDT) on endodontic pathogens in planktonic phase as well as on Enterococcus faecalis biofilms in experimentally infected root canals of extracted teeth. Strains of microorganisms were sensitized with methylene blue (25 microg/ml) for 5 minutes followed by exposure to red light of 665 nm with an energy fluence of 30 J/cm2. Methylene blue fully eliminated all bacterial species with the exception of E. faecalis (53% killing). The same concentration of methylene blue in combination with red light (222 J/cm2) was able to eliminate 97% of E. faecalis biofilm bacteria in root canals using an optical fiber with multiple cylindrical diffusers that uniformly distributed light at 360 degrees. We conclude that PDT may be developed as an adjunctive procedure to kill residual bacteria in the root canal system after standard endodontic treatment.