Successful Management of a Rare Distant Endodontic Lesion: A Case Report.

The current case report aims to document a rare presentation of a distant odontogenic lesion of a 35-year-old male patient with mild clinical discomfort in the mandibular right first molar; exploring the diagnostic and therapeutic intricacies of an uncommon distant endodontic pathosis ultimately resolved through meticulous nonsurgical retreatment. Despite a normal oral examination, diagnostic radiography revealed a suboptimal root canal treatment and apical lesions surrounding mesial- and distal-root apices; including a distinct radiolucency beneath the apex of the second mandibular molar discovered through panoramic radiography, and confirmed via cone-beam computed tomography. In addition, the computed tomography disclosed a previously unreported and unusually large endodontic lesion that extended toward the mandibular canal; highlighting a necessity for the continued exploration of a unique endodontic presentation. A nonsurgical endodontic retreatment led to a remarkable reduction in the radiolucent lesions within one year; emphasizing the significance of comprehensive diagnostic approaches and individualized treatments.

A Scoping Review of Highly Cited Published Articles in the Iranian Endodontic Journal: A Reflection of Trends in Endodontic Research.

Introduction: Highly cited published articles play a critical role in shaping clinical practice, research directions, and advancements in a specific field of science. The current comprehensive scoping review aimed to provide an overview of highly cited articles published in the "Iranian Endodontic Journal" (IEJ), based on the IEJ's H-index (=29); highlighting their key findings and prominent implications in the field of endodontics. Materials and Methods: A systematic search was conducted in Scopus database to identify the top 29 highly cited published articles. The articles were selected based on their citation count (h-index); reflecting their impact and influence within the scientific community. Data extraction was performed to gather relevant information; including authors, titles, publication years, and the main topic(s) of each article. Results: The selected highly cited published articles covered a broad range of endodontic topics; demonstrating the diversity and depth of research in the field. Key findings include significant contributions in vital pulp therapy, antimicrobial agents, root canal disinfection, regenerative techniques, cone-beam computed tomography applications, and intracanal medicaments. The distribution of research areas reflects the importance of evidence-based practice in clinical decision-making and patient care. Conclusions: These highly cited published articles have shown to have substantial impact on the field of endodontics. They have influenced clinical practice, guided research directions, and have improved patient care. The summary of key findings from each topic and the number of articles related to each area can provide readers with valuable insights into the distribution of research areas, and the significance of contributions made by the aforementioned highly cited published articles.

Antibacterial Efficacy of Polymer-Coated Ceramic Microparticles Loaded with a Modified Combination of Antibiotics on the Enterococcus faecalis Biofilm.

Introduction: Nano-technology applied for the local delivery of different agents and/or drugs has made its path to endodontics. In the current study, the antibacterial efficacy of biopolymer-coated ceramic microparticles loaded with a modified combination of triple antibiotics, i.e. Penicillin G, Metronidazole and Ciprofloxacin (PMC), was evaluated against two strains of Enterococcus faecalis (E.faecalis); a standard clinical strain obtained from previously root-filled teeth with persistent periapical lesions, and compared to the most common antimicrobials used in endodontics. Methods and Materials: After synthesis of the polymer-coated microparticles loaded with antibiotics, the 21-day release of antibiotics were evaluated and a stock solution was produced using the maximum released amount of drugs and distilled water. The antibacterial activity of PMC, triple antibiotic paste (TAP), calcium hydroxide (CH), chlorhexidine (CHX) and sodium hypochlorite (NaOCl) against two bacterial strains was determined using "Minimum Inhibitory Concentration" and "Agar Diffusion Test". Additionally, "Microtiter Plate Assay" was performed to assess anti-biofilm properties. Results: Minimum inhibitory concentration values reported for TAP and PMC were 1/256. PMC showed the maximum diameter of growth inhibition in both strains (33 mm and 35 mm), while CH had the minimum diameters (13 mm and13 mm). Based on microtiter plate assay, TAP showed higher biofilm formation than PMC. Biofilm formation was higher in the standard strain for PMC; however, NaOCl, CHX and CH completely inhibited biofilm formation. Conclusions: Based on the findings of the present study, it could be concluded that PMC and TAP were the most effective medicaments against E.faecalis in its planktonic form; however, none could inhibit its biofilm formation. Further studies using larger sample size and "Confocal Scanning Laser Microscopy" are recommended.

Healing of Large Endodontic Lesions Using Long-Term Application of a New Combination of Triple Antibiotics: A Series of Cases.

Apical periodontitis (AP) is defined as an inflammatory and destructive reaction of periapical tissues and a consequence of bacterial invasion to the dental pulp and root canal system. To avoid possible complications and undesirable repercussions of the surgical treatment of large AP, more conservative non-surgical approaches are endorsed. In the presented hopeless cases, a newly introduced modified combination of triple antibiotics, that is Penicillin G, metronidazole, and ciprofloxacin (PMC), was used as a long-term intracanal medication in the non-surgical endodontic retreatments of large AP. In the course of 10-month to 3-year follow-up, the large periapical lesions completely disappeared, and thorough bone healing was evident. Additionally, complete functionality of the involved teeth as well as other favourable treatment outcomes of the addressed cases showed that the long-term use of PMC, as a modified combination of antibiotics, in non-surgical endodontic retreatments may successfully resolve large AP. However, further investigations and well-designed controlled clinical trials are recommended.

Pulp Vitality Preservation of an Involved Tooth in a Large Radicular Cyst: A Case Report with 4-Year Recall.

The current case study presents the surgical endodontic retreatment of a central incisor with a large periapical cyst that had extended to the adjacent lateral incisor. After anaesthesia, a full mucoperiosteal flap was carefully incised and completely reflected. Then, the cyst was cautiously excised without performing curettage of the apical region of the adjacent tooth. A 3-mm deep root-end cavity on tooth #21 was prepared, filled and sealed with calcium-enriched mixture cement. At 6-month and 4-year follow-ups, tooth #21 was fully functional and exhibited no clinical signs/symptoms, and complete periapical healing was evident. This report indicates the importance of proper diagnosis as well as a careful surgical approach in the successful management of comparable cases without the overtreatment of involved teeth.

Healing of large endodontic lesions using a new combination of triple antibiotics: A case report.

In the case report presented, three cases of large endodontic lesions, which were the consequences of endodontic treatment failure, were studied. In all cases, a novel combination of triple antibiotics was used to successfully manage and heal the lesions, showing the promising potential of the antibiotic combination in resolving pathosis.

The effect of two calcium phosphate-containing agents on the enamel resistance of permanent molars to demineralization: An experimental study.

BACKGROUND: The main purpose of this experimental study was to determine the in vitro effects of two calcium phosphate-containing agents (Remin Pro® and GC Tooth mousse™) on the enamel resistance of permanent molars to demineralization. METHODS: Fifty extracted human third molars were randomly divided into four groups; that is the control group and three case groups treated with Remin Pro®, GC Tooth mousse™, and sodium fluoride gel. The three case groups were treated with 0.25 ml of the paste associated with each experimental group for 5 min, kept in fluoride-free artificial saliva, and incubated at 37°C for 28 days. After the treatment regimen, 10 samples of each case group were subjected to demineralization using an acetic acid-containing solution, and remineralization using a remineralizing solution. The morphology of enamel was observed via scanning electron microscopy and their enamel calcium/phosphorus (Ca/P) ratios were measured before/after the demineralization cycle with energy-dispersive X-ray analysis. Data were statistically analyzed using one-way analysis of variance and post hoc Tukey tests. RESULTS: The enamel Ca/P ratios in the case study groups were significantly higher than that of the control group before/after the demineralization regimen (p < .0001). However, the ratios were not significantly different between the case study groups after the treatment regimen and demineralization cycle (p > .05). CONCLUSION: The outcomes of the current study indicated that all three agents seemed to increase the enamel resistance of permanent molar teeth to demineralization.

A comparison of human dental pulp stem cell activity cultured on sandblasted titanium discs decontaminated with Er:YAG laser and air-powder abrasion: an in vitro study.

Decontamination of implant surfaces is important to the treatment of peri-implantitis. Er:YAG laser and air-powder abrasion system are regarded as the most effective means of decontamination of implant surfaces. The aim of this in vitro study was to compare the activity of human dental pulp stem cells (hDPSCs) cultured on decontaminated sandblasted titanium discs using Er:YAG laser irradiation and air-powder abrasion. Forty-five titanium discs were contaminated with Escherichia coli (E. coli) bacteria and fifteen titanium discs served as sterile control groups. Thirty contaminated titanium discs were decontaminated with Er:YAG laser or air-powder abrasion system and fifteen contaminated discs were used as contaminated control group. Afterwards, hDPSCs were seeded on all sixty experimental titanium discs. The effects of two decontamination tools on hDPSCs viability were evaluated by MTT assay. Alkaline phosphatase (ALP) activity assay, quantitative real-time PCR analysis and alizarin red staining method were performed to assess hDPSCs osteogenic differentiation. Scanning microscope electron (SEM) was also used to evaluate the effects of two different decontaminated methods on cellular morphology. Our study showed that decontamination using Er:YAG laser caused maximum cell viability. However, the ALP activity was not different in laser and air-abrasion groups. The significant expression of an osteoblastic marker and stronger Alizarin red staining were observed in laser irradiation groups. In addition, SEM observation indicated that grown cells were more stretched and more filopodia in Er:YAG-treated discs. In the present study, Er:YAG laser and air-powder abrasion improved the activity of the cells cultured on the decontaminated titanium discs. However, in comparison with air-powder abrasion, Er:YAG laser was more effective.

Effects of Two Protocols of Low-Level Laser Therapy on the Proliferation and Differentiation of Human Dental Pulp Stem Cells on Sandblasted Titanium Discs: An In Vitro Study.

Introduction: Stem cell activities have different effects on tissue response and its outcomes. Low-level laser therapy (LLLT) can be considered a trigger to modify stem cell activities. The objective of the present experimental investigation was to study the effects of two protocols of LLLT on the proliferation and differentiation of human dental pulp stem cells (hDPSCs) cultured on sandblasted titanium discs. Methods: Cells obtained from human dental pulp were seeded/cultured on titanium discs and were set in 2 main groups: (i) Radiated cells using the gallium-aluminium-arsenide (GaAlAs) diode laser at a continuous wavelength of 808 nm at 3 J/cm2 for 12 sec or 5 J/cm2 for 20 seconds, and (ii) Non-irradiated cells serving as control groups. The impact of LLLTs on hDPSC-proliferation and viability was investigated using the MTT assay after 24, 72 and 96 hours. The alkaline phosphatase activity was studied with p-nitrophenylphosphate after 14 and 28 days. The ability of hDPSCs to express osteocalcin was investigated using real-time polymerase chain reaction after 28 days, while their attachment was observed under a scanning electron microscope (SEM) after 14 and 28 days. Results: Our study showed that LLLTs caused maximum cell proliferation in 96 hours (P<0.001) with 3 J/cm2 resulting in a higher proliferation rate. The highest activity of alkaline phosphatase and osteocalcin expression was observed in the laser radiation groups after 28 days. Conclusion: The outcomes of the current study showed that cultured hDPSCs on sandblasted titanium discs had a tendency towards increased cellular activity in response to LLLTs. Thus, LLLTs could regulate the activities of hDPSCs on bone repair surrounding the sandblasted titanium discs.

Management of External Inflammatory Root Resorption following Tooth Autotransplantation Using a Modified Combination of Triple Antibiotics.

External inflammatory root resorption (EIRR) is one of the most undesirable potential repercussions of various types of trauma and traumatic injuries to the tooth and its structure. This detrimental phenomenon may lead to severe complications, the consequent destruction of dental tissues, and eventual tooth loss. In the presented case, following the autogenous transplantation of tooth #17 as the host-tissue replacement for tooth #18, signs of EIRR were radiographically detected after 6 months. However, the thorough preparation of root canals, which involves complete cleaning and shaping, in addition to the application of a modified combination of triple antibiotics, consisting of penicillin G, metronidazole, and ciprofloxacin (PMC), managed to arrest EIRR. Moreover, the obturation of root canals using calcium-enriched mixture (CEM) cement as the endodontic biomaterial as well as the proper management of EIRR resulted in the healing of periradicular pathosis, abatement of clinical symptoms, and finally refunctionalisation of the tooth during a follow-up period of 2 years. It seems that the appropriate disinfection of the root canal system using PMC next to the prevention of microbial recontamination using CEM cement can perfectly manage EIRR.

Outcomes of root canal therapy or full pulpotomy using two endodontic biomaterials in mature permanent teeth: a randomized controlled trial.

OBJECTIVE: The concept of minimally invasive endodontics recommends less-invasive vital pulp therapy (VPT) modalities over more aggressive traditional endodontic approaches in mature permanent teeth with carious pulp exposure, including irreversible pulpitis (IP) cases. Consequently, VPT needs to be compared with root canal therapy (RCT) in terms of treatment outcomes. This randomized clinical trial compares the results of full pulpotomy using two calcium-silicate cements, i.e., mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement, with RCT in mature permanent teeth. MATERIALS AND METHODS: A total of 157 carious pulp exposure cases in two academic centers with/without established IP were selected/included/randomly appointed to three study arms; (i) RCT (n = 51) as the reference treatment, (ii) pulpotomy with ProRoot MTA (PMTA; n = 55), and (iii) pulpotomy with CEM cement (PCEM; n = 51) as two alternative VPT treatments. Two-year clinical/radiographic results were the outcomes of interest. Data were statistically analyzed through the analysis of variance, chi-square, Fisher exact test, and Kruskal-Wallis. RESULTS: At 2-year recall, 147 teeth were examined (6.4% dropout). All molars, except for one, were clinically functional/symptom-free, and there was no statistical difference between the three study arms (p = 0.653). The radiographic success rates in RCT, PMTA, and PCEM arms were 98%, 100%, and 97.9%, respectively, without statistically significant differences (p = 0.544). CONCLUSION: In the management of mature permanent teeth with/without established IP, all experimental groups exhibited equivalent/comparable results. CLINICAL RELEVANCE: Simple VPT using MTA/CEM can be suggested/recommended as a viable advantageous alternative to RCT for the management of carious pulp exposures with/without sign/symptoms of IP.

Management of an infected immature tooth with a talon cusp using regenerative endodontic treatment: A case report.

OBJECTIVE: Regenerative endodontic treatment (RET) has been considered a successful approach to manage infected immature teeth; however, cases associated with dental anomalies, i.e., talon cusp, need to be further investigated. CASE REPORT: A 7-year-old girl with local swelling associated with the permanent maxillary right central incisor was referred; cone-beam computed tomography revealed a talon cusp, an immature root and two well-defined endodontic lesions. The treatment consisted of regenerative endodontic treatment (RET); the canal was chemically cleaned and a modified triple antibiotic paste was used as intracanal medication. In the next appointment, RET was performed through the creation of blood clot scaffold in the canal covered/sealed with calcium-enriched mixture (CEM) cement. RESULTS: In the 7-day recall session, clinical examination showed that the swelling had completely resolved. At 24-month recall, the treated tooth was asymptomatic and functional. CBCT images demonstrated evidence of maturation in the apical third of the root, healing of two large endodontic lesions and complete dentinal bridge formation beneath CEM cement. CONCLUSION: RET for an infected immature tooth with a dental anomaly, i.e., talon cusp, may be a desirable treatment option and result in the resolution of endodontic lesions as well as regeneration of new vital tissues; allowing continuous root maturation.

Local Drug Delivery Systems for Vital Pulp Therapy: A New Hope.

Vital pulp therapy (VPT) is deliberated as an ultraconservative/minimally invasive approach for the conservation of vital pulpal tissues, preservation of dental structure, and maintenance of tooth function in the oral cavity. In VPT, following the exposure of the dental pulp, the environment is prepared for the possible healing and probable refunctionalisation of pulpal connective tissue. However, to succeed in VPT, specific biomaterials are used to cover and/or dress the exposed pulp, lower the inflammation, heal the dental pulp, provoke the remaining odontoblastic cells, and induce the formation of a hard tissue, i.e., the dentinal bridge. It can be assumed that if the employed biomaterial is transferred to the target site using a specially designed micro-/nanosized local drug delivery system (LDDS), the biomaterial would be placed in closer proximity to the connective tissue, may be released in a controlled and sustained pattern, could properly conserve the remaining dental pulp and might appropriately enhance hard-tissue formation. Furthermore, the loaded LDDS could help VPT modalities to be more ultraconservative and may minimise the manipulation of the tooth structure as well as pulpal tissue, which could, in turn, result in better VPT outcomes.

Anaesthetic Efficacy of 4% Articaine in Comparison with 2% Lidocaine as Intraligamentary Injections after an Ineffective Inferior Alveolar Nerve Block in Mandibular Molars with Irreversible Pulpitis: A Prospective Randomised Triple-Blind Clinical Trial.

The objective of the current study was to compare the anaesthetic efficacy of supplemental intraligamentary (IL) injection of 4% articaine with that of 2% lidocaine in the mandibular first and second molars with irreversible pulpitis after an ineffective inferior alveolar nerve block injection (IANB) using the same anaesthetic in a randomised triple-blind clinical trial. Seventy-six adult patients, who were diagnosed with irreversible pulpitis in the mandibular first or second molars, were divided into 2 groups and received IANB randomly. In patients with lip numbness, anaesthesia was evaluated with the cold and electrical pulp (EPT) tests, and if the reported number on EPT was below 100, supplemental IL injection was administered using the same anaesthetic. The teeth were retested after 5 minutes. The Heft-Parker visual analogue scale was used to evaluate pain after IANB and IL injections. Statistical analysis was performed using repeated measures ANOVA, chi-square, and independent-sample and paired-sample t-tests. The results showed that there was no significant difference in the success rates of supplemental IL and IANB injections between articaine and lidocaine. Furthermore, there was no significant difference in the success rates of supplemental IL injection with lidocaine between the mandibular first and second molars. However, there was a significant difference in the success rates of supplemental IL injection with articaine between the mandibular first and second molars. Moreover, supplemental IL injections indicated no significant difference in the anaesthetic efficacy between articaine and lidocaine; nevertheless, they were more effective in the mandibular second molars, especially with articaine.

An Innovative Drug Delivery System Loaded with a Modified Combination of Triple Antibiotics for Use in Endodontic Applications.

The objective of the current study was to introduce "Polylactic co-Glycolic Acid- (PLGA-) Coated Ceramic Microparticles" as an innovative drug delivery system, loaded with a new combination of triple antibiotics (penicillin G, metronidazole, and ciprofloxacin (PMC)) for use in endodontic treatments. Ceramic microparticles were made from ß-tricalcium phosphate and hydroxyapatite and examined by "Scanning Electronic Microscope (SEM)." Then, fixed amounts of the selected antibiotics were added to a prepared PLGA solution and stirred thoroughly. Next, the prepared ceramic microparticles were dispersed completely in the drugs solution. The deposited "PMC-loaded PLGA-coated ceramic microspheres (PPCMs)" were dried and incubated in phosphate buffer saline (PBS) for 21 days. The drug release from PPCMs was quantified by a UV spectrophotometer. The antimicrobial activity of PPCMs was investigated using the "Agar Plate Diffusion Test (ADT)," "Minimum Inhibitory Concentration (MIC)," and "Minimum Bactericidal Concentration (MBC)" against Enterococcus faecalis (E. faecalis) and Aggregatibacter actinomycetemcomitans (A.a). The cell viability test (MTT) was conducted for cytotoxicity against human gingival fibroblasts. SEM micrographs of PPCMs showed spherical-like ceramic microparticles with smooth surfaces. Crystal-like antibiotic particles (chunks) were also found on PPCMs. Initial burst of antibiotics (31 µg/mL, 160 µg/mL, and 18 µg/mL for ciprofloxacin, metronidazole, and penicillin G, respectively, in the first 4 days) followed by gradual and sustained release was observed within a period of 21 days. PPCMs demonstrated pH close to normal physiological environment and antibacterial activity against E. faecalis and A.a in the first 2 days. MTT showed cell viability of more than 70% for PPCMs after 24 h and 72 h of exposure. In conclusion, PPCMs demonstrated satisfactory release of antibiotics, antibacterial activity against the selected microorganisms, and biocompatibility. Thus, PPCMs may be used to deliver modified triple antibiotics to the root canal system for use in endodontic applications.

Postendodontic Pain after Pulpotomy or Root Canal Treatment in Mature Teeth with Carious Pulp Exposure: A Multicenter Randomized Controlled Trial.

This equivalence, randomized, clinical trial aimed to compare the postoperative pain of root canal therapy (RCT) with pulpotomy with mineral trioxide aggregate (PMTA) or calcium-enriched mixture (PCEM) in permanent mature teeth. In seven academic centers, 550 cariously exposed pulps were included and randomly allocated into PMTA (n = 188), PCEM (n = 194), or RCT (n = 168) arms. Preoperative "Pain Intensity" (PI) on Numerical Rating Scale and postoperative PIs until day 7 were recorded. Patients' demographic and pre-/intra-/postoperative factors/conditions were recorded/analysed. The arms were homogeneous in terms of demographics. The mean preoperative PIs were similar (P=0.998), the mean sum PIs recorded during 10 postoperative intervals were comparable (P=0.939), and the trend/changes in pain relief were parallel (P=0.821) in all study arms. The incidences of preoperative moderate-severe pain in RCT, PMTA, and PCEM arms were 56.5%, 55.7%, and 56.7%, which after 24 hours considerably decreased to 13.1%, 10.6%, and 12.9%, respectively (P=0.578). The time span of endodontic procedures was statistically different; RCT = 69.73, PMTA = 35.37, and PCEM = 33.62 minutes (P < 0.001). Patients with greater preoperative pain, symptomatic apical periodontitis, or presence of PDL widening suffered more pain (P=0.002, 0.035, and 0.023, resp.); however, other pre-/intra-/postoperative factors/conditions were comparable. Pulpotomy with MTA/CEM and RCT demonstrate comparable and effective postoperative pain relief.