Effectiveness of full Pulpotomy compared with Root canal treatment in managing teeth with signs and symptOms indicative of irreversible pulpitis: a protocol for prospectiVE meta-analysis of individual participant data of linked randomised clinical trials (PROVE).

BACKGROUND: Full pulpotomy has been proposed as an alternative to root canal treatment in teeth with signs and symptoms indicative of irreversible pulpitis (IRP), but the evidence is limited, relying on underpowered studies with a high risk of bias. The aim of this study is to conduct a prospective meta-analysis (PMA) of individual participant data of a series of individual randomised trials to provide robust evidence on the clinical and cost-effectiveness of pulpotomy compared with root canal treatment. METHODS: Individual participant data will be obtained from a series of randomised trials designed and conducted by a consortium of multi-national investigators with an interest in vital pulp treatment. These individualised trials will be conducted using a specified protocol, defined outcomes, and outcome measures. Ten parallel-group randomised trials currently being conducted in 10 countries will provide data from more than 500 participants. The primary outcome is a composite measure defined as (1) the absence of pain indicative of IRP, (2) the absence of signs and symptoms indicative of acute or chronic apical periodontitis, and (3) the absence of radiographic evidence of failure including radiolucency or resorption. Individual participant data will be obtained, assessed, and checked for quality by two independent reviewers prior to the PMA. Pooled estimates on treatment effects will be generated using a 2-stage meta-analysis approach. The first stage involves a standard regression analysis in each trial to produce aggregate data on treatment effect estimates followed by an inverse variance weighted meta-analysis to combine these aggregate data and produce summary statistics and forest plots. Cost-effectiveness analysis based on the composite outcome will be undertaken as a process evaluation to evaluate treatment fidelity and acceptability by patients and dentists. RESULTS: The research question and trial protocol were developed and approved by investigators in all 10 sites. All sites use shared resources including study protocols, data collection forms, participant information leaflets, and consent forms in order to improve flow, consistency, and reproducibility. Each site obtained its own Institutional Review Board approval, and trials were registered in appropriate open access platforms. Patient recruitment has started in most sites, as of July 2023. DISCUSSION: PMA offers a rigorous, flexible, and efficient methodology to answer this important research question and provide results with improved generalisability and external validity compared with traditional trials and retrospective meta-analyses. The results of this study will have implications for both the delivery of clinical practice and structured clinical guidelines' development. TRIAL REGISTRATION: PROSPERO CRD42023446809. Registered on 08 February 2023.

Application of a new system for classifying root and canal anatomy in studies involving micro-computed tomography and cone beam computed tomography: Explanation and elaboration.

Adequate knowledge and accurate characterization of root and canal anatomy is an essential prerequisite for successful root canal treatment and endodontic surgery. Over the years, an ever-increasing body of knowledge related to root and canal anatomy of the human dentition has accumulated. To correct deficiencies in existing systems, a new coding system for classifying root and canal morphology, accessory canals and anomalies has been introduced. In recent years, micro-computed tomography (micro-CT) and cone beam computed tomography (CBCT) have been used extensively to study the details of root and canal anatomy in extracted teeth and within clinical settings. This review aims to discuss the application of the new coding system in studies using micro-CT and CBCT, provide a detailed guide for appropriate characterization of root and canal anatomy and to discuss several controversial issues that may appear as potential limitations for proper characterization of roots and canals.

Application of a new system for classifying root canal morphology in undergraduate teaching and clinical practice: a national survey in Malaysia.

AIM: To evaluate and compare the feedback of final year undergraduate dental students in eight Malaysian dental schools on the application of a new system for classifying root canal morphology in teaching and clinical practice. METHODS: One PowerPoint presentation describing two classification systems for root canal morphology (Oral Surgery Oral Medicine Oral Pathology, 1974 38, 456 and its supplemental configurations, International Endodontic Journal 2017, 50, 761) was delivered to final year undergraduate dental students in eight dental schools in Malaysia by two presenters (each presented to four schools). To examine students' feedback on the utility of each system, printed questionnaires consisting of six questions (five multiple choice questions and one open-ended question) were distributed and collected after the lecture. The questionnaire was designed to compare the classification systems in terms of accuracy, practicability, understanding of root canal morphology and recommendation for use in pre-clinical and clinical courses. The exact test was used for statistical analysis, with the level of significance set at 0.05 (P = 0.05). RESULTS: A total of 382 (out of 447) students participated giving a response rate of 86%. More than 90% of students reported that the new system was more accurate and more practical compared with the Vertucci system (P < 0.001). Overall, 97% of students reported the new system helped their understanding of root and canal morphology compared with the Vertucci classification (P < 0.001). Over 97% of students recommended the use of the new system in teaching, pre-clinical courses and clinical practice (P < 0.001). Except for two schools, no significant difference was detected between the responses of students for all questions at the different schools (P > 0.05). The students' responses for all questions were almost similar for both presenters (P > 0.05). CONCLUSIONS: The new system of International Endodontic Journal 2017, 50, 761 for classifying root and canal morphology was favoured by final year undergraduate dental students in Malaysia. The new system has the potential to be included in the undergraduate endodontic curriculum for teaching courses related to root and canal morphology.

Application of a new system for classifying tooth, root and canal morphology in the primary dentition.

Knowledge of root and canal morphology is essential for the effective practice of root canal treatment. Paediatric endodontics aims to preserve fully functional primary teeth in the dental arch; however, pulpectomy procedures in bizarre and tortuous canals encased in roots programmed for physiologic resorption are unique challenges. A new coding system for classifying the roots and main canals (https://doi.org/10.1111/iej.12685), accessory canals (https://doi.org/10.1111/iej.12800) and developmental anomalies (https://doi.org/10.1111/iej.12867) has been introduced recently. This paper discusses challenges for describing root and canal morphology in primary teeth and describes the potential application of the new classification system for root canals in the primary dentition.

Root and canal morphology of maxillary premolar teeth in an Egyptian subpopulation using two classification systems: a cone beam computed tomography study.

AIM: To investigate the number of roots and root canal configurations using two coding systems and the root canal diverging and merging levels in extracted maxillary premolars in an Egyptian subpopulation using cone beam computed tomography (CBCT). METHODOLOGY: A total of 700 maxillary premolars were examined using CBCT in an Egyptian subpopulation. The number of roots was identified, and root canal configurations were classified according to Vertucci's classification and a new system for classifying root and canal morphology. In addition, the position where roots bifurcated and the levels where canals merged or diverged were identified. Fisher's exact test and independent t-test were used for statistical analysis, and the level of significance was set at 0.05 (P = 0.05). RESULTS: More than half of maxillary first premolars were double-rooted, and the majority of maxillary second premolars were single-rooted (P < 0.001). Most of the double-rooted samples had bifurcations in the middle of the root. According to the Vertucci classification, canal configuration type IV was the most common in both first and second maxillary premolars. According to the new system, the code 2 FP B1 P1 was the most common for maxillary first premolars, whilst 2 SP B1 P1 , 1 SP2 and 1 SP2-1 codes were the most common for maxillary second premolars. The three-canalled morphology in double- and three-rooted maxillary premolars had considerable variations. Root canal merging and diverging levels were comparable in both tooth types. CONCLUSION: Maxillary premolars in this Egyptian subpopulation had a wide range of root and canal anatomical variations. Clinicians should be aware of where canals merge and diverge to facilitate the treatment of all canals. The new system for classifying canal morphology describes the root and canal configurations in a more accurate and practical manner compared to the Vertucci classification.

Effect of root canal irrigation protocols on the dislocation resistance of mineral trioxide aggregate-based materials: A systematic review of laboratory studies.

The aim of this systematic review was to address the question: Do different irrigating protocols have an impact on the dislocation resistance of mineral trioxide aggregate (MTA)-based materials? The review was performed using a well-defined search strategy in three databases (PubMed, Scopus, Web of Science) to include laboratory studies performed between January 1995 and May 2017, in accordance with PRISMA guidelines. Two reviewers analysed the papers, assessed the risk of bias and extracted data on teeth used, sample size, size of root canal preparation, type of MTA-based material, irrigants, canal filling method, storage method and duration, region of roots and the parameters of push-out testing (slice thickness, plunger dimensions and plunger loading direction), the main results and dislocation resistance values (in MPa). From 255 studies, 27 were included for full-text analysis. Eight papers that met the inclusion criteria were included in this review. There was a wide variation in dislocation resistance due to differences in irrigation sequence, time and concentration of irrigants, storage method and duration, and the parameters of push-out bond strength testing. A meta-analysis was not done but qualitative synthesis of the included studies was performed. No definitive conclusion could be drawn to evaluate the effect of irrigation protocols on dislocation resistance of MTA-based materials. Recommendations have been provided for standardized testing methods and reporting of future studies, so as to obtain clinically relevant information and to understand the effects of irrigating protocols on root canal sealers and their interactions with the dentine walls of root canals.

A new system for classifying accessory canal morphology.

Thorough knowledge of anatomical complexities of the root canal system has a direct impact on the effectiveness of canal preparation and filling, and is an essential prerequisite for successful root canal treatment. A wide range of complex variations in root canal anatomy exists, including root canal configuration type, developmental anomalies and minor canal morphology such as accessory canals and apical deltas. Accessory canals and apical deltas have been associated with pulp disease, primary canal infection, canal reinfection and post-treatment disease. The current definitions of accessory canal anatomy are not standardized and potentially confusing. Given their role in endodontic disease and their impact on treatment outcomes, there is a need to have a simple classification of their anatomy to provide an accurate description of their position and path from the canal to the external surface of the root. The purpose of this article is to introduce a new system for classifying accessory canal morphology for use in research, clinical practice and training.

A new system for classifying tooth, root and canal anomalies.

Understanding the normal anatomical features as well as the more unusual developmental anomalies of teeth, roots and root canals is essential for successful root canal treatment. In addition to various types of root canal configuration and accessory canal morphology, a wide range of developmental tooth, root and canal anomalies exists, including C-shaped canals, dens invaginatus, taurodontism, root fusion, dilacerations and palato-gingival grooves. There is a direct association between developmental anomalies and pulp and periradicular diseases that usually require a multidisciplinary treatment approach to achieve a successful outcome. A number of classifications have categorized tooth, root and canal anomalies; however, several important details are often missed making the classifications less than ideal and potentially confusing. Recently, a new coding system for classifying root, root canal and accessory canal morphology has been introduced. The purpose of this article is to introduce a new system for classifying tooth, root and canal anomalies for use in research, clinical practice and training, which can serve as complementary codes to the recently described system for classifying root, as well as main and accessory canal morphology.

A new system for classifying root and root canal morphology.

Knowledge of root and root canal morphology is a prerequisite for effective nonsurgical and surgical endodontic treatments. The external and internal morphological features of roots are variable and complex, and several classifications have been proposed to define the various types of canal configurations that occur commonly. More recently, improvements in nondestructive digital image systems, such as cone-beam and micro-computed tomography, as well as the use of magnification in clinical practice, have increased the number of reports on complex root canal anatomy. Importantly, using these newer techniques, it has become apparent that it is not possible to classify many root canal configurations using the existing systems. The purpose of this article is to introduce a new classification system that can be adapted to categorize root and root canal configurations in an accurate, simple and reliable manner that can be used in research, clinical practice and training.

Accessory roots and root canals in human anterior teeth: a review and clinical considerations.

Anterior teeth may have aberrant anatomical variations in the number of roots and root canals. A review of the literature was conducted using appropriate key words in major endodontic journals to identify the available reported cases as well as experimental and clinical investigations on accessory roots and root canals in anterior teeth. After retrieving the full text of related articles, cross-citations were identified, and the pooled data were then discussed. Results revealed a higher prevalence in accessory root/root canal variations in mandibular anterior teeth than in maxillary counterparts. However, maxillary incisor teeth revealed the highest tendency for accessory root/root canal aberrations caused by anomalies such as dens invaginatus and palato-gingival groove. Primary anterior teeth may also exhibit external and internal anatomical variations in the root, especially maxillary canines. Therefore, dental practitioners should thoroughly assess all teeth scheduled for root canal treatment to prevent the undesirable consequences caused by inadequate debridement of accessory configurations of the root canal system.

Rubber dam application in endodontic practice: an update on critical educational and ethical dilemmas.

Proper isolation is an essential prerequisite for successful endodontic treatment. This article aims to provide an update on the prevalence of rubber dam (RD) use, and the role of education along with attitudes of general dental practitioners (GDPs) and patients towards the application of RD in endodontics. Critical ethical issues are also highlighted. Using certain keywords, an electronic search was conducted spanning the period from January 1983 to April 2013 to identify the available related investigations, and the pooled data were then analysed. The results show that although RD is the Standard of Care in endodontic practice, there is a clear discrepancy in what GDPs are taught in dental school and what they practice after graduation. There is little scientific evidence to support the application of RD; however, patient safety and clinical practice guidelines indicate that it is unnecessary and unethical to consider a cohort study to prove what is already universally agreed upon. A few clinical situations may require special management which should be highlighted in the current guidelines. This would pave the way for clear and straightforward universal guidelines.

Anatomical challenges, electronic working length determination and current developments in root canal preparation of primary molar teeth.

Paediatric endodontics is an integral part of dental practice that aims to preserve fully functional primary teeth in the dental arch. Pulpectomy of primary molars presents a unique challenge for dental practitioners. Negotiation and thorough instrumentation of bizarre and tortuous canals encased in roots programmed for physiological resorption are the main challenges for this treatment approach. Consequently, numerous in vitro and in vivo studies have been conducted to validate the application of some contemporary endodontic armamentarium for effective treatment in primary molars whilst maintaining favourable clinical outcomes. Electronic apex locators, rotary nickel-titanium files and irrigation techniques are at the forefront of endodontic armamentarium in paediatric dentistry. Hence, this review aims to map out the root and root canal morphology of primary molars, to discuss the application of electronic apex locators in primary molars and to provide an update on the preparation of their root canal systems.

Discolouration potential of endodontic procedures and materials: a review.

Advances in endodontic materials and techniques are at the forefront of endodontic research. Despite continuous improvements, tooth discolouration, especially in anterior teeth, is considered an undesirable consequence following endodontic treatment as it creates a range of aesthetic problems. This article aims to discuss the intrinsic and internalized tooth discolouration caused by endodontic procedures, and to address the discolouration potential of materials used during root canal treatment, including root canal irrigants, intra-canal medicaments, endodontic and post-endodontic filling materials. In addition, the discolouration patterns caused by combined endodontic and nonendodontic aetiological factors are discussed. The recommended guidelines that should be followed by dental practitioners to prevent and manage tooth discolouration are also outlined.

Accessory roots in maxillary molar teeth: a review and endodontic considerations.

Maxillary molar teeth may have accessory roots. The aim of this paper is to review and discuss the endodontic implications of this anatomical variation. A review of the literature was undertaken to identify studies and reported cases where accessory roots have been recorded in maxillary molar teeth. The results show that although the prevalence of accessory roots in maxillary molar teeth is low, they can exist in all three types of maxillary molar teeth, and they may be located palatally, buccally, mesially or distally. Hence, it is essential that dentists undertaking root canal treatment thoroughly assess all teeth to determine how many roots are present in order to provide the best possible outcome of treatment for the patient.