Prevalence of Apical Periodontitis in Patients with Autoimmune Liver Diseases on Immune Suppressants and Immune Modulators: A Cross-sectional Study.

INTRODUCTION: Autoimmune liver diseases (ALDs) are chronic conditions generated by an immune-mediated autoaggressive inflammatory reaction in genetically susceptible individuals. The purpose of this study was to evaluate the prevalence of apical periodontitis (AP) in patients suffering from ALDs undergoing treatment with the immune suppressants glucocorticoids, azathioprine, and/or ursodeoxycholic acid. METHODS: The ALD group included 46 patients (11 men and 35 women, average age = 57.9 ± 11.8 years) and 1186 teeth. The control group included 50 healthy patients not taking any medications (15 men and 35 women, average age = 58.6 ± 10.4 years) and 1251 teeth. Demographic data and medical, pharmacologic, and dental history were recorded. Dental and radiographic examinations were performed. The presence of AP; the periapical index score; decayed, missing, and filled teeth; quality of restoration, and root canal treatment were evaluated. The influence of the medications the patients were taking on the prevalence of AP was also tested. RESULTS: The prevalence of AP was significantly lower in ALDs than in the control group at the patient (P = .019) and tooth level (P = .014). Smoking and age were associated with a significant increase in AP in cases and controls (P = .045 and P = .001, respectively). In both groups, endodontically treated teeth showed a higher prevalence of AP. CONCLUSIONS: Considering the limitations because of the observational nature of the study, the patients affected by ALDs liver diseases and undergoing treatment with immune suppressors (often associated with immune modulators) were found to exhibit a lower prevalence of AP.

What is new in the 2023 European Society of Endodontology S3-level clinical practice guidelines?

BACKGROUND: The European Society of Endodontology published in 2023, the S3-level clinical practice guidelines, which supersede the Quality Guidelines for Endodontic Treatment published in 2006. OBJECTIVES: This review aims to summarize and compare the above guidelines to support their dissemination. METHOD: A narrative synthesis of the main differences alongside tabulation according to the main themes. RESULTS: Three tables were prepared according to the following themes: diagnosis of pulpal and apical condition; treatment of pulpitis; and treatment of nonvital pulp and apical periodontitis. CONCLUSIONS: A compared and simplified message regarding the most recent clinical practice guidelines has been prepared. REGISTRATION: Not applicable as a narrative review.

The role of systemic statins in the inception and healing of apical periodontitis: a systematic review.

OBJECTIVES: Statins are a category of medications widely used to reduce plasma LDL-cholesterol levels, that also possess antibacterial, anti-inflammatory, and immunomodulatory action. The aim of this systematic review was to explore the effects of systemic statins therapy on the development and treatment of apical periodontitis (AP) on humans and animals. MATERIAL AND METHODS: Three electronic databases (PubMed, Web of Science, and Scopus) and grey literature were searched from their inception until February, 20 2023 (PROSPERO CRD42021246231). For the quality assessment and risk of bias, different guidelines were used according to the typology of the studies considered (Animal Research Reporting of In Vivo Experiments, Newcastle-Ottawa Quality Assessment Form for Cohort Studies, Systematic Review Centre for Laboratory animal Experimentation Risk of Bias tool and Tool to assess risk of bias in cohort studies of CLARITY Group). RESULTS: Seven hundred eleven records were screened, and six articles were included for this qualitative review. The eligible studies showed a moderate overall quality and risk of bias. Human patients in treatment with statins exhibited a higher healing rate of AP following root canal treatment. In experimental animal models, statins had a beneficial effect on the development of AP. CONCLUSIONS: Despite the limited number of studies and considering that most of them are on animals, our findings suggest that systemically administered statins make a positive contribution to prevent the development and help healing of AP. CLINICAL RELEVANCE: There is an increased evidence that a pharmacologic adjunct to endodontic treatment may be considered to enhance healing of AP. Among other medications, statins seem to have a positive impact on the disease.

Clinical management of external cervical resorption: A systematic review.

This review investigated whether any therapeutic options influenced the outcome of treatment for teeth with external cervical resorption. Out of 870 articles identified by an electronic search, 60 clinical case reports and six case series were included. No randomised clinical trials were found. Risk of bias was assessed using Joanna Briggs Institute's tools. External surgical intervention was the preferred method of accessing the lesions. Removal of resorptive tissue was most often achieved mechanically. Bioactive endodontic cements were the preferred materials for restoring teeth. The outcome measures were based on clinical and radiographic parameters. Of the cases included in the review, no specific treatment approach had a superior outcome in relation to Heithersay's classification. Furthermore, due to the absence of randomised clinical trials, and the low level of evidence associated with case reports/case series, it was not possible to define the optimum clinical treatment for external cervical resorption.

The Link Between Apical Periodontitis and Gastrointestinal Diseases-A Systematic Review.

INTRODUCTION: This systematic review aimed to examine a potential link between apical periodontitis (AP) and gastrointestinal diseases (GIDs). METHODS: The protocol of the review has been registered in PROSPERO (CRD42022330771). The following engines were used with the aim of searching for relevant literature: PubMed, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, and grey literature, from inception to May 2022. There were no language restrictions included. Study selection, data collection, and synthesis have been performed by 2 independent reviewers. For the purpose of estimating the quality of studies, the Newcastle-Ottawa Scale was used. RESULTS: Four matched case control studies, as well as a single longitudinal cohort study were included in the final review. These were published between 2012 and 2017, and comprised 537 participants whose age range was 18 to 87 years. It was not possible to perform a meta-analysis due to different study designs and evaluated outcomes of included studies. Except for one study that was categorized as "Good," overall, for 4 out of 5 studies the quality was assessed as "Fair". CONCLUSIONS: This review highlighted sparse knowledge present in the literature concerned with the association between AP and GIDs. Available evidence reveals a potential link between impaired endodontic status, assessed by the number of root-filled teeth with periapical radiolucency, and GIDs. More research is needed to ascertain this association.

Clinical, microbiological and immunological short, medium and long-term effects of different strains of probiotics as an adjunct to non-surgical periodontal therapy in patients with periodontitis. Systematic review with meta-analysis.

Introduction/objectives: Probiotics have been proposed as adjuncts to non-surgical periodontal therapy (NSPT), however, the effect of their use remains unclear. The aim of this systematic review and meta-analysis was to analyze the evidence regarding the use of probiotics as an adjunct to NSPT in patients with periodontitis at a clinical, microbiological and immunological level. Data/sources: A comprehensive search to identify clinical studies investigating the use of probiotics as an adjunct to NSPT in patients treated for periodontitis was performed. The data were grouped according to probiotic strain, frequency, form and duration of the probiotic intake. Study selection: A total of 25 articles were included, all articles analysed clinical parameters, 10 included also microbiological findings and only 4 had immunological findings. The difference in probing depth (PD) between the test and the control group was statistically significant in favour of the test group when the probiotics were in the form of lozenges, administered twice a day and when the strain was L. reuteri. In terms of Clinical Attachment Level (CAL) gain the difference was statistically significant in the short and in the medium term but not in the long term. Due to the heterogeneity of the data, it was not possible to compare trough a meta analysis the immunological and the microbiological findings that were therefore analysed only descriptively. Conclusions: The use of probiotics as an adjunct to NSPT in patients with periodontitis appears to provide additional clinical benefits that depend on the duration, the frequency, the form and the strain of probiotic used. Clinical significance: This review not only shows data on the efficacy of probiotics in non-surgical periodontal therapy, but provides important information on their effects over time and which forms of probiotic administration might be most clinically useful.

Prevalence of apical periodontitis in patients with autoimmune diseases: A case-control study.

AIM: The purpose of this case-control study was to compare the prevalence of apical periodontitis (AP) in patients affected by autoimmune disorders (AD) (inflammatory bowel disease [IBD], rheumatoid arthritis [RA] and psoriasis [Ps]) with the prevalence of AP in subjects without AD. The prevalences of AP in patients taking biologic medications, conventional medications and no medication were also compared. METHODOLOGY: Eighty-nine patients (2145 teeth) with AD were investigated and the control group included 89 patients (2329 teeth) with no systemic diseases. Full dental panoramic tomograms were used to determine the periapical status of the teeth. Additional variables investigated included patient's socio-demographic characteristics, medications taken by AD patients, the decayed, missing and filled teeth (DMFT) index. The chi-square test and logistic regression analysis were used to evaluate the correlation between AD and AP. p-Values lower than .05 were considered to be statistically significant. RESULTS: The prevalence of AP was 89.9% in AD patients and 74.2% in control subjects (odds ratio [OR] = 3.75, p = .015). The DMFT score was found to be significantly higher in the AD group (p = .004). Patients with RA had the highest risk of being affected by AP, whereas those with IBD had the lowest risk. Multiple binary logistic regression analysis indicated that the teeth of AD patients who were not taking any medication or were being treated with biologic disease-modifying anti-rheumatic drugs (bDMARDs) had a higher risk of being affected by AP than did the teeth of the control subjects (OR = 1.42 and OR = 2.03, respectively; p = .010). The teeth of patients taking conventional DMARDs (cDMARDs) were less affected by AP compared with those of patients taking bDMARDs. CONCLUSIONS: Patients with AD, whether treated or not with biologic medications, showed a higher prevalence of AP than did those in the control group. The DMFT index score, which was higher in AD patients compared with controls was identified as a significant predictor of AP prevalence.

Present status and future directions: Imaging techniques for the detection of periapical lesions.

Diagnosing and treating apical periodontitis (AP) in an attempt to preserve the natural dentition, and to prevent the direct and indirect systemic effects of this condition, is the major goal in endodontics. Considering that AP is frequently asymptomatic, and is most often associated with a lesion in the periapex of the affected tooth, within the maxillary bones, imaging becomes of paramount importance for the diagnosis of the disease. The aim of this narrative review was to investigate the most relevant classic and current literature to describe which are, to date, the diagnostic imaging systems most reliable and advanced to achieve the early and predictable detection of AP, the best measures of the lesions and the disclosure of the different features of the disease. Dental panoramic tomography (DPT) is a classic exam, considered still useful to provide the basic diagnosis of AP in certain districts of the maxillary bones. Periapical radiographs (PRs) represent a valid routine examination, with few, known limitations. Cone-beam computed tomography (CBCT) is the only system that ensures the early and predictable detection of all periapical lesions in the jaws, with the minor risk of false positives. These techniques can be successfully implemented, with ultrasounds (USI) or magnetic resonance (MRI) imaging, exams that do not use ionising radiations. MRI and USI provide information on specific features of the lesions, like the presence and amount of vascular supply, their content and their relationship with the surrounding soft tissues, leading to differential diagnoses. Further, all the three-dimensional systems (CBCT, USI and MRI) allow the volumetric assessment of AP. Pioneering research on artificial intelligence is slowly progressing in the detection of periapical radiolucencies on DPTs, PRs and CBCTs, however, with promising results. Finally, it is established that all imaging techniques have to be associated with a thorough clinical examination and a good degree of calibration of the operator.

Cytotoxicity and Efficacy in Debris and Smear Layer Removal of HOCl-Based Irrigating Solution: An In Vitro Study.

In the present study we evaluated the cytotoxicity of super-oxidized water on human gingival fibroblasts and its efficacy in debris and smear layer removal from root canal walls. Cultured gingival fibroblasts were exposed to super-oxidized water (Sterilox), which was diluted in Iscove's modified Dulbecco's medium (IMDM) at 30%, 40%, 50%, 60% and 70% concentrations. The control group was maintained in IMDM. The cell viability was evaluated by means of an MTT assay after incubation periods of 1 h, 2 h, 24 h and 48 h. Pathological cellular changes were also observed under fluorescence and phase contrast microscopes. The efficacy in debris and smear layer removal was evaluated in comparison to the conventional application of sodium hypochlorite (NaOCl) and ethylenediaminetetraacetic acid (EDTA). Forty maxillary premolars were randomly divided into two equal groups (n = 20) and shaped with ProTaper NEXT rotary instruments using Sterilox or NaOCl/EDTA for irrigation. Afterwards, roots were split longitudinally and examined under a scanning electron microscope. The results revealed that super-oxidized water and sterile distilled water have acceptable biological properties for endodontic applications at concentrations up to 50% (p > 0.05). Moreover, super-oxidized water is equally effective in debris and smear layer removal as compared to NaOCl/EDTA (p > 0.05).

Periapical status in patients affected by osteoporosis: A retrospective clinical study.

OBJECTIVES: To assess the periapical status in patients with osteoporosis (OP) treated with denosumab (D), bisphosphonates (BPs), or not on medication, and to understand if these conditions influence the prevalence and the progression of apical periodontitis (AP). MATERIAL AND METHODS: Seventy-six patients with OP alone or treated with D, or BPs, formed the study group (O), and those from 76 patients matched for age and sex, without diseases, and not taking medications, constituted the control (C) in this retrospective case-control study. The data from the complete clinical and radiographic examination, medical history, decayed, missing, and filled teeth (DMFT), and periapical index score (PAI) were recorded for each patient. Wilcoxon rank test, χ2 , and Student's t test were used as appropriate. RESULTS: The prevalence of AP was similar in O and C. Furthermore, AP was significantly more frequent in root canal-treated teeth in O patients (p = .03). CONCLUSIONS: OP does not appear to be associated with the development of AP. Moreover, the increased prevalence of AP in root canal-treated teeth in O patients highlights a possible relationship between the healing dynamics of the disease post-therapy and the patients' medication. A larger sample is needed to confirm these findings.

Medium- and Long-Term Re-Treatment of Root Canals Filled with a Calcium Silicate-Based Sealer: An Experimental Ex Vivo Study.

This study investigated the possibility of re-treating a calcium silicate-based sealer (CSBS), compared to an epoxy-resin sealer (RBS), using rotary instrumentation at different times from obturation (1 month/1 year). Thirty-six human mandibular premolars, extracted as a result of orthodontic or periodontal problems, were instrumented and randomly divided into three groups of 12: BR and BR*, which were filled with CSBS and re-treated after one month and one year of storage, respectively, and AH, which was filled with RBS and re-treated after one month. The same re-treatment protocol was used for all teeth, and the times required for the procedure was recorded. The re-treated specimens were longitudinally sectioned and examined at the stereomicroscope (SM) at 20× magnification. Image J Software was used to process the microphotographs. The percentage of residual filling materials in the root canal and the apical third, the ability to reach working length WL and patency, and the time taken to complete the re-treatment were recorded and analyzed by ANOVA and post hoc Bonferroni test (p = 0.05). Scanning electron microscopy (SEM) and coupled energy-dispersive spectroscopy (EDS) were applied to representative samples to evaluate canal cleanliness and chemical elements. Patency and WL were re-established in all of the teeth. Residual filling materials were retained in all specimens of the three groups. The mean percentage of residual materials was significantly different between BR and BR* (p-value = 0.048), with BR* showing the highest values. The mean time to complete re-treatment was significantly lower for AH, followed by BR (p = 0.0001) and BR* (p = 0.0078). Conclusions: After both medium and long storage periods, the CSBS can be concluded to have been successfully removed from canals with simple anatomy.

Prevalence of Apical Periodontitis in Patients with Autoimmune Diseases under Immunomodulators: A Retrospective Cohort Study.

INTRODUCTION: The aim of this retrospective cohort study was to investigate the prevalence of apical periodontitis (AP) in patients affected by autoimmune diseases (ADs) taking biologic medications (BMs). METHODS: Ninety-nine patients (2440 teeth) with ADs referred to the university clinic for dental evaluation were investigated. The controls included 99 patients (2655 teeth) with no systemic diseases and taking no medications. The patients underwent a complete oral, dental, and radiographic examination for the presence of AP. The periapical index and the status of endodontic and restorative treatments were obtained. Statistics were based on descriptive analysis and continuous variables for the total sample and by subgroups. Adjusted odds ratios and 95% confidence intervals were calculated. RESULTS: The prevalence of AP was 65.7% in the autoimmune diseases group (AI) and 46.5% in the controls (P ≤ .05). The association between smoking and AP was significant (P ≤ .05). Among the AI subgroups, rheumatoid arthritis patients at the tooth level had a lower probability of developing AP than patients with inflammatory bowel disease (P ≤ .05). Furthermore, each additional year of age implied a +1% risk of AP; women had a lower periapical index than men in both groups (P ≤ .05), and tocilizumab was associated with a reduced risk of AP compared with infliximab (P ≤ .05). CONCLUSIONS: Patients with ADs taking BMs had a higher prevalence of AP. These results indicate that the status of the patients' immune system may have an effect on the development and prevalence of AP.

[Preoperative dental screening in patients waiting for elective cardiovascular procedures: presentation of the SIC-ANMCO-SICCH-AIE-SIE-SidP intersociety consensus document]. / Lo screening dentale preoperatorio nei pazienti in attesa di interventi chirurgici cardiovascolari elettivi: presentazione del documento di consenso intersocietario SIC-ANMCO-SICCH-AIE-SIE-SidP.

The Italian scientific societies of cardiology (SIC and ANMCO), cardiothoracic surgery, endodontics, and periodontology realized that a specific protocol addressing preoperative dental/peri-dental screening in patients undergoing elective cardiothoracic surgery was lacking in the literature. As a consequence, they projected and then realized in 2019 a consensus document to establish the modalities for such a diagnostic and therapeutic screening, whose related options and timing depend on the patient's physical conditions as well as the time available before surgery. A high level of agreement was reached by the experts involved in the release of the consensus document and each clinical issue was addressed adequately. Three tables were released, with the aim of sharing a standardized protocol for the perioperative dental/peri-dental screening of patients who are waiting for elective cardiothoracic procedures. The authors of the consensus document, which has been widely diffused by all the involved scientific societies, hope that it can be largely accepted and applied, during the multidisciplinary phase preceding cardiovascular surgery the most.

Combined Management of Apical Root Fracture and Avulsion of Two Maxillary Permanent Central Incisors: A Case Report.

As a result of a skiing accident, a ten-year-old girl suffered combined injuries to both maxillary central incisor teeth (#1.1 and #2.1). The injuries were uncomplicated crown fractures, apical horizontal root fractures, and a severe extrusive luxation of the coronal segments of the teeth. Her mother repositioned the teeth immediately, resulting in good initial healing. Nine months later, the patient was referred to a specialist to manage the endodontic consequences of the trauma. The apexification treatment of the fractured roots, using a preformed apical barrier technique with bioactive cement, was the treatment of choice, administered to both the avulsed roots at two separate recall visits. The best option for managing the fractured apical segments was to continue with the follow-up, which was conducted to assess the overall case at 30 months. The fractured apexes remained normally positioned inside the socket and were asymptomatic (as they presumably maintained a physiological vascular-nerve supply and, consequently, their vitality), while the apexification treatment led to the healing of the periodontal tissues and to hard tissue formation in the area of the interrupted roots in the avulsed portion of the teeth. The management of traumatic injuries in teeth often requires multiple treatment approaches, because these injuries rarely represent one single type of trauma.

Management of the Sequelae of a Sport-Related Traumatic Dental Injury Using Ultrasound Examination in the Diagnosis and Follow-Up.

About a quarter of all oral pathologies involving the oral cavity and dental apparatus are traumatic injuries, and a substantial number of these cases are the result of sports injuries affecting adolescents and young adults. Here, we report the case of a 25-year-old healthy female referred to the department of Endodontics for the evaluation and management of teeth 1.2 and 1.1 because of a chronic apical abscess in an area involved in a sport-related dental trauma in the past. A multi-modular diagnostic assessment, comprising conventional periapical radiographs, CBCT imaging, ultrasound, and histopathologic examination, led to a final diagnosis of an apical granulomatous lesion connected to both teeth, and an associated sinus tract. During the follow-up period of three years, the patient was reviewed twice a year and showed progressive healing of the bone and absence of the sinus tract. The present report shows the challenges of diagnosing complications arising from past dental trauma. Furthermore, it is the first documented traumatic case where ultrasound examination was fruitfully used. Emphasis should be put on introducing diagnostic ultrasound for the management of both apical periodontitis and the related sinus tract.

Proresolving Mediators in Endodontics: A Systematic Review.

INTRODUCTION: Proresolving lipid mediators are specialized molecules (SPMs) involved in the active resolution of the inflammatory process by regulating tissue homeostasis. The aim of this study was to investigate the scientific literature to assess the potential of SPMs as an adjunct in the treatment of endodontic infection. METHODS: Three electronic databases (PubMed, Web of Science, and Scopus) were searched from their inception until February 2020 (PROSPERO CRD42020164743). Supplemental research was performed by screening the references of the relevant studies eligible for inclusion. A quality assessment of animal studies was performed using the Animal Research: Reporting of In Vivo Experiments guidelines, whereas the Systematic Review Centre for Laboratory animal Experimentation Risk of Bias tool was used to assess the risk of bias. RESULTS: A total of 3295 records were screened, and 8 articles meeting the criteria were included for this qualitative review. The eligible studies showed a high to moderate overall quality and a low to moderate risk of bias. SPMs positively affected the development of pulpitis and apical periodontitis in experimental animal models. The early treatment of pulpitis with the topical application of SPMs was beneficial to control inflammation within 24 hours from contamination. In addition, SPMs delivered within the root canals after disinfection were found effective in promoting periapical healing. CONCLUSIONS: Our findings suggest that SPMs may play a role in the inception and treatment of pulpal-periapical diseases, and they should be considered for future research for developing new therapeutics as an adjunct to endodontic treatment.

A 12-month follow-up of primary and secondary root canal treatment in teeth obturated with a hydraulic sealer.

OBJECTIVES: This randomized, controlled, pilot study assessed the outcome of non-surgical primary/secondary root canal treatments either with a novel bioactive sealer and the single-cone technique or with gutta-percha, zinc oxide-eugenol sealer (ZOE), and warm vertical compaction. MATERIALS AND METHODS: Sixty-nine patients were randomly divided into two groups that were treated using the single-cone technique with BioRootTM RCS (Septodont) (BIO group) or warm vertical compaction with gutta-percha and ZOE sealer (PCS group). Two subsamples (BIOAP and PCSAP) comprised the cases with apical periodontitis. Treatment was undertaken by four residents using a standardized instrumentation and disinfection protocol. The periapical index (PAI) was recorded, and clinical and radiographic follow-up performed at 1, 3, 6, and 12 months. Treatment success was assessed according to "periapical healing" and "tooth survival". The test for the equality of proportions, t tests for the equality of means, and non-parametric K-sample tests for the equality of medians were applied when appropriate. RESULTS: The survival rate was similar in the BIO and PCS (p = 0.4074) and the BIOAP and PCSAP groups (p = 0.9114). The success rate was higher in the BIO groups, but not statistically significant (p = 0.0735). In both BIOAP and PCSAP groups, a progressive decrease in the PAI was observed. CONCLUSION: At 12 months, both techniques showed reliable results. Further studies and longer follow-ups are needed. CLINICAL RELEVANCE: This study documents the feasibility of using a bioactive sealer in conjunction with the single-cone technique to obturate the root canal and obtaining a predictable outcome. TRIAL REGISTRATION: ClinicalTrials.gov Identifie: NCT04249206.