Managing failed vital pulp therapies in mature permanent teeth in a retrospective cohort study, with success and survival rates of managing protocols.

Despite advancements in vital pulp therapy (VPT), a subset of cases fails to achieve desired outcomes. This study based on a previous large-scale cohort study involving 1257 VPT-treated teeth, aiming to describe the demographic data and clinical characteristics of all failed cases and their management protocols. Clinical records/images of 105 failed cases treated by a single endodontist (2011-2022) were examined, including 10 extracted teeth. Asymptomatic cases with PDL widening received no intervention, while others underwent management protocols, including (selective) RCT and (tampon) re-VPT. These retreatments were assessed for success (defined as radiographic evidence of healing) and survival (characterized by the retention/function of the treated tooth) using Kaplan-Meier analysis. While 51.4% of all initial failures were diagnosed due to symptoms, 48.6% were symptom-free. Notably, failed cases with symptomatic irreversible pulpitis, and apical periodontitis/widened PDL before initial treatment significantly outnumbered asymptomatic cases and normal PDL, respectively (P = 0.001). Moreover, most of the initial failures were observed in teeth with composite resin rather than amalgam restorations (P = 0.002). The success and survival rates for the management protocols were 91.78% and 95.79%, respectively, over an average follow-up period of 36.94 (± 23.30) months. RCT and re-VPT procedures provide successful outcomes for managing unsuccessful VPTs.

Outcomes and predictive factors of vital pulp therapy in a large-scale retrospective cohort study over 10 years.

This cohort study evaluated the long-term success/survival of vital pulp therapies (VPTs) after carious pulp exposure in adult teeth. Additionally, factors influencing long-term success were identified. Teeth treated during 2011-2022 in a private clinic were studied with clinical/radiographic follow-ups. Data included patient demographics, tooth specifics, and treatment details. Outcomes were classified as success/failure based on clinical/radiographic findings, with tooth functionality determining the survival rate. Encompassing 1149 patients and 1257 VPT-treated teeth, the average monitoring period was 42.2 months. Overall VPTs' survival and success rates were 99.1% and 91.6%, respectively. Success rates for 768 direct pulp cappings, 217 miniature pulpotomies, and 272 full pulpotomies were 91.9%, 92.6%, and 90.1%, respectively (P > 0.05). Influencing factors included symptomatic irreversible pulpitis (SIP; HR 1.974, 95% CI 1.242-3.137; P = 0.004), radiographic signs of apical periodontitis (AP; HR 2.983, 95% CI 1.961-4.540; P < 0.001), restoration type (HR 2.263, 95%CI 1.423-3.600; P = 0.001), and restoration surfaces (HR 1.401, 95%CI 1.034-1.899; P = 0.030). This study concludes that VPT techniques consistently exhibit high long-term success/survival rates in treating carious pulp exposures. Critical predictors include initial clinical signs of SIP/AP, caries extent, and use of composite restorations.

Successful Management of a Typical Class 3 Invasive Cervical Root Resorption with Modified Pulpotomy: A Case Report.

Invasive cervical root resorption (ICRR) is a rare and clinically complex condition marked by the progressive loss of dental hard tissues below the junctional epithelium. This case report outlines the management of a 32-year-old female patient presenting with ICRR class 3 affecting a maxillary incisor. Despite the absence of symptoms, the expansive nature of the defect warranted conservative surgical intervention. The procedure involved the surgical removal of inflamed tissues, followed by an ultraconservative modified pulpotomy utilizing calcium-enriched mixture (CEM) cement through a surgical window. The selected intervention is substantiated by its potential benefits, such as minimal removal of tooth structure and the inherent biocompatibility and sealing capabilities of CEM cement. A one-year follow-up revealed arrested resorption, re-establishment of periodontal attachment, and successful esthetic restoration, affirming the efficacy of vital pulp therapy in surgically addressing advanced ICRR. Accurate diagnosis, strategic treatment planning, and a patient-centered approach proved critical in achieving favorable outcomes.

Tampon Vital Pulp Therapy in the Management of Excessive Haemorrhage in Inflamed Pulps: A Hypothesis.

Current principles in vital pulp therapy (VPT) modalities emphasise the importance of haemostasis and normal clotting in the achievement of successful treatment outcomes. However, the aforementioned notion could be challenged by the new and recent emerging evidence; suggesting that prolonged or excessive bleeding/haemorrhage (PB) in cases of intensly inflamed pulps, conventionally infamous as irreversible pulpitis (IP), may not impede the healing potential of the remaining dental pulp tissue following VPTs using endodontic biomaterials. "Tampon VPT (tVPT)" may be considered a treatment approach for the management of stated IP cases; characterised by severe pulpal inflammation and delayed clotting process. The presented hypothesis evaluates clinical studies, experimental research and molecular impacts on clotting within the inflamed dental pulp, so as to explore the efficacy as well as the safety of tVPT as a viable treatment option. Latest clinical investigations have reported positive outcomes with tVPT; even in the presence of IP with PB. It has been shown that inflamed dental pulp tissues exhibit molecular impacts on the clotting cascade, which may contribute to the delayed clotting process. Nonetheless, the healing capacity of the dental pulp is not negatively affected by hyperaemia. Additionally, enhanced blood flow in the inflamed pulpal tissues may be associated with improved healing and boosted hard tissue formation. Moreover, tVPT could possibly promote pulpal healing and/or regeneration through continuing the presentation of essential nutrients, e.g. oxygen, and growth factors to the injured tissue. Furthermore, increased blood flow may facilitate the recruitment of immune and reparative cells; promoting tissue repair and encouraging the formation of dentinal bridge(s) after VPTs. Consequently, the state-of-the-art research and their findings could support the hypothesis that tVPT may effectively manage IP cases with PB and contribute to favourable outcomes.

A Bibliometric Study on the Top 101 Most-Cited Articles of Dental Journals of the Middle East/North Africa Countries From 2011 to 2021.

Introduction: This retrospective descriptive study evaluated the Scopus-indexed dental journals and their most-cited documents affiliated with the Middle East and North Africa (MENA) countries from 2011 to 2021. Methods: Dental journals affiliated with MENA countries, their bibliometric indicators (SJR, CiteScore, SNIP, and H-index), and the 101 most cited articles of the considered journals were extracted and studied through descriptive statistics. In addition, the "citation per year" of each top 101 articles was calculated. Spearman's rho test was used for pairwise comparisons of the correlation coefficient values between each two of the considered bibliometric indicators. Results: The number of citations of the 101 most-cited papers ranged from 35 to 203. The mean (SD) citations of studied articles were 61.33 (37.58) and the median was 46. Furthermore, CiteScore had the highest significant correlation with SJR (r=0.828, P˂0.001). Moreover, the citation per year of the top 101 documents had no significant relationship with any of the journals' bibliometric indicators. Conclusion: Because journal performance and citation rate are multi-dimensional concepts, a single metric cannot express them thoroughly despite correlations between indices. "European Journal of Dentistry" from Turkey, "Saudi Dental Journal" from Saudi Arabia, and "Iranian Endodontic Journal" and "Journal of Lasers in Medical Sciences" both from Iran had the highest ranks in the SCImago portal and the highest scores in bibliometric indices amongst the MENA dental journals.

Tampon Pulpotomy: Long-term Successful Results of a Molar with Irreversible Pulpitis and Previous Vital Pulp Therapy Failure.

Minimally invasive vital pulp therapy (VPT) techniques have become increasingly popular for treating mature permanent teeth with irreversible pulpitis. However, in cases where less invasive VPT approaches, such as miniature pulpotomy, fail to provide symptom relief and desired outcomes, alternative treatment strategies need to be explored. This case report presents the successful application of tampon pulpotomy, a modified full pulpotomy technique, in a vital molar tooth with irreversible pulpitis, after a previous miniature pulpotomy failure. The tampon pulpotomy procedure involved the placement of an endodontic biomaterial (i.e. calcium-enriched mixture cement) over the pulpal wound to stop bleeding and create a favorable environment for pulpal healing/regeneration. The patient was followed up for a period of 10 years, during which the tooth remained asymptomatic, functional, and exhibited normal periodontal ligament. This case report highlights the potential effectiveness of tampon/full pulpotomy as a retreatment option in cases where more conservative VPT techniques have shown limited success, offering a conservative approach to preserve tooth structure and pulpal vitality.

Average and Maximum Papilla Heights around Dental Implants in the Anterior Maxillary Region: A Retrospective Clinical Study.

OBJECTIVE: The aim of this study was to determine the average and maximum height of the papilla around maxillary anterior implants in respect of neighboring structures and location of implants. MATERIALS AND METHODS: 92 dental implants from 63 patients were investigated in this study. Those implants were placed in the anterior maxillary region and had been loaded for a minimum of one year. After receiving written consent, clinical data including the height of interproximal papillae adjacent to the tooth/implant/pontic were obtained through clinical observation. The independent t-test or ANOVA, the regression modeling, and generalized estimating equation (GEE) models were used for statistical analysis (p < 0.05). RESULTS: Papilla height was calculated as 2.8 mm (1-5.5 mm) for implant-tooth sites, 2.6 mm (1-4 mm) in implants beside pontics, and 2.5 mm (1-3.5 mm) for implants adjacent to implants. Despite the lack of a significant difference in the mean papilla height in the studied groups, the maximum values of papilla heights were significantly different. CONCLUSIONS: In this study, no significant differences were found in papilla height mean values in relation to neighboring structures or location of implants in the anterior maxilla. However, the maximum values of papilla heights were observed around implants next to natural teeth.

Grafting with Bone Substitute Materials in Therapy-Resistant Periapical Actinomycosis.

Actinomycosis can be one of the causes of persistent periradicular lesions. This is the report of a patient who was first referred with complaint of pain in maxillary right incisors. A standard root canal therapy was carried out. Unluckily, the patient returned with recurrent symptoms; therefore, surgical endodontic retreatment was decided. While the large periradicular lesion was curetted, a whitish yellow granule-like material came out from the periapical area that was submitted for histopathological examination. The apices of both maxillary right incisors were resected. Root-end cavities were sealed with calcium-enriched mixture (CEM) cement. Finally, the remaining large defect was filled with natural bone substitutes. Since the histopathological diagnosis revealed actinomycotic infection, oral penicillin V was prescribed for four weeks. At two-year recall, the bone healing process was completed. Apical actinomycosis can cause therapy-resistant lesions. Root-end surgery employing CEM and bone substitutes might be an effective method to help bone healing in large periradicular lesions.

Partial Necrosis Consequence of the Infection Spreading from an Adjacent Apical Periodontitis: A Case Report.

As the dental pulp could not be directly inspected before endodontic treatment, indirect evaluation of the pulp status via (para)/clinical tests should be performed which need careful inspection. This report presents a root-treated right maxillary first molar with recurrent abscess formation and a radiolucent periradicular lesion surrounding the distobuccal root of the right maxillary second molar. The patient underwent surgical retreatment, employing CEM root-end filling, which resulted in no relief from sign/symptoms. In the cone-beam computed tomography (CBCT), the relationship of the lesion with the mesio-buccal root of the second maxillary molar was detected. Despite the latest tooth showed positive responses to pulp sensibility tests, endodontic therapy was planned for it. During treatment, it became clear that the mesiobuccal canal pulp was necrotic, although vital pulp tissues were present in two other root canals. Following treatment, full recovery from all discomforts was obtained and the lesion healed after 18 months. This case showed that a more complicated evaluation such as CBCT should be used for diagnosis of perpetuated lesions. Furthermore, it might be probable that root canals of vital teeth become necrotic due to involvement in the adjacent apical lesion, a phenomenon known as anachoresis.

Surgical Endodontics vs Regenerative Periodontal Surgery for Management of a Large Periradicular Lesion.

Treatment success of periodontal-endodontic lesions is dependent on the elimination of both disease causative factors, whether they exist separately or concurrently. This report presents successful endodontic management of a misdiagnosed large periradicular pathology, which had not resolved after a previous periodontal regenerative surgery. A patient complaining of discomfort in the left maxillary region was referred. He had undergone regenerative surgery for treatment of a large periradicular defect; however, there was no further amelioration of the clinical signs/symptoms. Radiographically, a large periradicular lesion filled with bone substitute materials was detected around tooth #25. The endodontic treatment of the tooth was imperfect; therefore, surgical endodontic retreatment was planned. During root-end surgery, the biopsy containing bone substitute materials was obtained. Root-end filling/sealing using calcium-enriched mixture cement was completed. The histopathological examination showed granulation tissues enclosing exogenous materials. In two-year radiographic evaluation, resolving lesion and complete bone healing was observed. The first fundamental step in the management of periradicular lesions is correct diagnosis of the lesion origin and set-by step of the treatment plan according to the main causative factor. Regenerative periodonttal surgery, without considering the defective apical seal, will only cause a painful procedure for the patient without any positive benefit. Following appropriate apical seal, the endodontic lesion healing can be anticipated.

Rapid Bone Healing after Intentional Replantation of a Molar with Apical Actinomycosis.

Actinomycosis is a rare lesion of the jaws and may present as periapical pathosis; therefore, it is essential to be correctly diagnosed and managed. This case presentation describes management of a tooth with a symptomatic apical periodontitis caused by Actinomyces species supplemented with medicine prescription. A woman was referred for endodontic management of tooth #19. The tooth had a history of previous nonsurgical endodontic retreatment. Clinically, the tooth was very sensitive to percussion. Radiographic evaluation showed a large periapical lesion. Intentional replantation (IR) was planned. The tooth was atraumatically extracted. Without any curettage, through the blood flow coming out of the socket, a small yellowish granule was detected and sent for examination. After root-end preparations, the cavities were filled with calcium-enriched mixture cement and the tooth was carefully replanted. Histopathological assessment proved actinomycosis sulfur granule. According to infectious disease specialist recommendation, low-dose and long-term penicillin V was prescribed. Interestingly, at 2-month follow-up, remarkable bone healing was observed. In the cases of apical actinomycosis, IR in combination with antibiotic therapy, even without the curettage of the lesion, may be successfully employed.

Revascularization and Apical Plug in an Immature Molar.

Managing of necrotic permanent teeth with immature apices is a treatment challenges. Treatment of such teeth includes apexification, apical plug and more recently, revascularization technique with the probable advantage of continuation of root development. In the present case report the referred patient had discomfort with a necrotic immature mandibular first molar. Periapical radiography showed a rather large apical lesion around immature roots. Revascularization protocol using calcium-enriched mixture (CEM) cement was indicated for the mesial root. However, in distal canal apical plug technique was applied. At 2-year follow-up, both procedures were successful in relieving patient's symptoms. Dentin formation and increase in length of the mesial root was obvious. Apical plug and revascularization technique proved to be successful in management of necrotic immature teeth; moreover, revascularization carried the advantage of continuation of root development.