Spectrophotometric Analysis of Apical Extrusion of Sodium Hypochlorite using Different Irrigation Protocols in an Ex Vivo Model of Immature Teeth.

OBJECTIVE: To evaluate the effect of different agitation methods on apical extrusion of 1.5% sodium hypochlorite (NaOCl) in an ex vivo model of immature teeth. METHODS: Sixty extracted human inferior incisors were prepared to simulate immature teeth and embedded in an artificial root socket made of silicone impression material. The teeth were then divided into four groups: Conventional needle irrigation (CNI) alone, CNI supplemented with Ultrasonic Irrigant Activation (UIA), EasyClean (EC), or XP-endo Finisher (XPF). Extruded NaOCl was collected, reacted with m-cresol purple, and its absorbance values were measured. The data were statistically analyzed using One-way analysis of variance with a significance level of 5%. RESULTS: All groups showed apically extruded irrigating solution, and the mean volumes of extruded NaOCl did not differ significantly between any of the test groups (p⟩0.05). CONCLUSION: The activation of 1.5% NaOCL by UIA, EC, or XPF as supplementary to CNI does not promote greater apical extrusion when compared to CNI alone in simulated immature teeth.

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.

Quantitative analysis of culturable bacteria, levels of endotoxins, inflammatory mediators and substance P in teeth with symptomatic irreversible pulpitis and in teeth with vital normal pulp tissues.

AIM: To comparatively analyse the levels of culturable bacteria, endotoxins (LPS), tumour necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1ß) and substance P in teeth with symptomatic irreversible pulpitis (SIP) and vital normal pulp (VNP) tissues. METHODOLOGY: Thirty-two patients were included (20 teeth with SIP and 12 teeth with VNP tissues) in this cross-sectional study. Samples were collected from the full length of the root canals (microbial analysis) and periapical tissues (2 mm beyond the apex for immunological analysis), using sterile absorbent paper points. The levels of culturable bacteria (culture method), endotoxins (LAL Pyrogent 5000), TNF-α, IL-1ß and substance P (ELISA) were assessed. The Mann-Whitney test was used for comparisons between the levels of CFU/mL, LPS, TNF-α, IL-1ß and substance P in the SIP and VNP groups. The statistical analysis was performed with the significance level set at 5%. RESULTS: Culturable bacteria were recovered from all teeth with SIP. On the other hand, no positive cultures were observed in the VNP tissues group (p > .05). The levels of LPS were approximately four times higher in teeth with SIP than in teeth with VNP tissues (p < .05). Higher levels of TNF-α and substance P were detected in teeth with SIP (p < .05). On the other hand, no difference in the levels of IL-1ß was detected between the two groups (p > .05). CONCLUSION: Teeth with symptomatic irreversible pulpitis present higher levels of culturable bacteria, endotoxins, TNF-α and substance P than those with vital normal pulp tissues. On the other hand, the levels of IL-1ß were similar in teeth from both groups suggesting reduced implications of this inflammatory mediator in the early stages of infection.

Heating stability, physical and chemical analysis of calcium silicate-based endodontic sealers.

AIM: To evaluate possible modifications in root canal sealers subjected to a variety of heating conditions using vibrational spectroscopy and analysis of physical and chemical properties. METHODOLOGY: EndoSequence BC Sealer HiFlow, Bio-C Sealer, BioRoot RCS and AH Plus were analysed chemically using Raman spectroscopy (25-220 °C) and Fourier-transform infrared spectroscopy (FT-IR) (37-100 °C ). For FT-IR, the materials were tested individually and mixed with root dentine powder. Scanning electron microscopy (SEM) and coupled energy dispersive spectroscopy (EDS) were used to evaluate surface and chemical elements. ISO 6876-2012 and ASTM-C266-07 specifications were followed to evaluate flow, setting time (moist and dry), solubility and radiopacity. Also, pH analysis at 37 and 100 °C was performed. Shapiro-Wilk and Mixed ANOVA (within and between the effects of the subjects), Levene, and a post hoc analyses with Bonferroni correction were performed (P < 0.05). RESULTS: Vibrational spectroscopy revealed peaks of tricalcium silicate, dicalcium silicate and zirconium dioxide. Chemical changes in the Raman spectra during heating were discrete, as the inorganic content predominated the signalling for all root canal sealers. FT-IR analysis exhibited spectral changes in water absorption for EndoSequence BC Sealer HiFlow and Bio-C Sealer, probably related to dehydration. For BioRoot RCS and AH Plus, no significant chemical changes were observed. Bio-C Sealer exhibited a band of polyethylene glycol only after heating to 100 °C, probably related to its thermal decomposition. SEM/EDS analysis corroborated the composition results observed in vibrational spectroscopy for all materials. Heating to 100 °C significantly changed the flowability of all calcium silicate-based sealers with a wide variation in setting times at both temperatures, along with solubility levels above ISO standards. For all tested sealers, radiopacity fulfilled the requirements, and pH exhibited alkaline values. CONCLUSIONS: The tested calcium silicate-based sealers were affected by heating. Calcium silicate-based root canal sealers had high solubility which is a concern for their clinical use. AH Plus was the only root canal sealer that was stable after heating.

Investigation of microbial profile, levels of endotoxin and lipoteichoic acid in teeth with symptomatic irreversible pulpitis: a clinical study.

AIM: To investigate the microbial profile, and levels of endotoxin (LPS) and lipoteichoic acid (LTA), in infected dentine (ID) and root canals (RC) at different phases of root canal treatment in teeth with symptomatic irreversible pulpitis. METHODOLOGY: Ten volunteers were included, and samples were collected from infected dentine (ID) and the root canal lumen (RC) using sterile excavators and paper points, respectively. RC samples were taken before (S1) and after (S2) chemo-mechanical canal preparation (CMP), and after intracanal medication (ICM; S3). Checkerboard DNA-DNA hybridization was used for microbial analysis. The levels of LPS and LTA were evaluated using the limulus amebocyte lysate assay and ELISA, respectively. Shapiro-Wilk's test was used to verify data normality. Friedman's test was used to evaluate statistical differences using checkerboard DNA-DNA hybridization in the ID and RC at the different phases of the RC treatment. Post hoc Dunn's multiple comparison test was used to verify significant differences recorded at the different time-points. The levels of LPS and LTA were analysed statistically by using repeated measures anova and Tukey's post hoc test to evaluate differences in both sites. The significance level was set at 5% (P < 0.05). RESULTS: A total of 40 DNA probes were used for microbial investigation of ID and RC samples using checkerboard DNA-DNA hybridization. The levels and complexity of bacteria were similar in the ID and initial RC samples. The levels of LPS and LTA in ID were significantly higher than the initial RC samples (S1; P < 0.05). Canal preparation was effective in significantly decreasing the levels of bacteria, LPS and LTA (P < 0.05). ICM did not provide additional reduction in the levels of bacteria and LPS (P > 0.05). However, a significant reduction in the levels of LTA was observed after ICM (P < 0.05). CONCLUSION: The microbial profile of infected dentine and root canals of teeth with irreversible pulpitis was complex, harbouring different species including Gram-positive and Gram-negative, cocci and bacilli, and facultative and strict anaerobes. Root canal preparation was effective in reducing the levels of bacteria, LPS and LTA from the root canals of teeth with pulpitis.

Bacteria and virulence factors in periapical lesions associated with teeth following primary and secondary root canal treatment.

AIM: This cross-sectional study aimed to investigate the microbial profile and to quantify the levels of endotoxins (LPS) and lipoteichoic acid (LTA) present in periapical lesions associated with root filled teeth and those that had received root canal retreatment. It also aimed to investigate the association between microorganisms and their virulence factors with clinical and radiographic features. METHODOLOGY: Patients with periapical lesions in teeth with post-treatment endodontic disease following primary root canal treatment (n = 19) and unsuccessful root canal retreatment (n = 13) were treatment planned for endodontic microsurgery, where the periapical lesions were collected. Clinical and radiographic data were also collected. For microbiological analysis, nested polymerase chain reaction was used to detect 17 bacterial species. Levels of LPS and LTA were determined using limulus amebocyte lysate and enzyme-linked immunosorbent assays, respectively. The Student t-test or Wilcoxon-Mann-Whitney tests were applied to compare the data on LPS and LTA with clinical and radiographic features. The associations between the clinical and radiographic features and the bacterial species were analysed using the Fisher's exact test. A significance level of 5% was adopted. RESULTS: Bacterial DNA, LPS and LTA were detected in all samples. Parvimonas micra was the most commonly detected species in all groups, followed by Enterococcus faecalis, Fusobacterium nucleatum and Porphyromonas endodontalis. The type of endodontic treatment, whether a primary root canal treatment or retreatment, was not associated with the presence of any bacterial species in periapical lesions. The levels of LPS and LTA in periapical lesions of root filled teeth were not significantly different from those that had been retreated. Associations between the levels of LPS and LTA with clinical signs and symptoms were found. No association was found between specific bacteria and clinical features. CONCLUSION: Periapical lesions associated with teeth after primary root canal treatment and retreatment had similar polymicrobial composition. The levels of LPS and LTA in periapical lesions associated with teeth after primary root canal treatment and retreatment were similar, and both were associated with the same symptomatology.

Efficacy of reciprocating and ultrasonic activation of 6% sodium hypochlorite in the reduction of microbial content and virulence factors in teeth with primary endodontic infection.

AIM: To evaluate in a clinical trial the efficacy of reciprocating and ultrasonic activation of 6% sodium hypochlorite (NaOCl) in the microbial composition and reduction in microbial load as well as in levels of lipopolysaccharide (LPS) and lipoteichoic acid (LTA) in teeth with primary endodontic infections. METHODOLOGY: Samples were collected from 24 root canals with pulp necrosis and periapical lesions, before and after chemo-mechanical canal preparation. The teeth were randomly divided according to the activation protocol as follows: control group without activation (WA, n = 8), reciprocating activation group using Easy Clean tip (EC, n = 8) and ultrasonic activation group using Irrisonic insert (US, n = 8). Microbiological specimens were processed using a culture technique and microbiota composition was analysed using the checkerboard technique. The levels of LPS and LTA were quantified using limulus amebocyte lysate (LAL) and enzyme-linked immunosorbent assay (ELISA), respectively. The Fisher's exact test, Kruskal-Wallis, Dunn's and Wilcoxon's test with a significance level of P < 0.05 were used for statistical analysis. RESULTS: All initial specimens had growth of viable bacteria in fastidious anaerobe agar (FAA), with an average of 105  CFU mL-1 , whereas only one case had such growth after chemo-mechanical canal preparation. LPS and LTA were recovered in 100% of the cases. Chemo-mechanical canal preparation significantly decreased the levels of LPS and LTA (P < 0.05), but no significant differences were found between the groups (P > 0.05). Through the checkerboard technique, bacteria were found in 100% of the initial specimens with concentrations between <105 and 106 . The most frequently identified microorganisms were Prevotella nigrescens and Enterococcus hirae. After chemo-mechanical canal preparation, many species were not detected in any of the three groups tested. A significant reduction occurred in Group US, followed by Groups EC and WA. CONCLUSIONS: Activation of 6% NaOCl reduced the levels of LPS and LTA with no differences between the groups. However, ultrasonic activation was associated with a greater reduction in microbial load within root canals.

Endotoxin levels after chemomechanical preparation of root canals with sodium hypochlorite or chlorhexidine: a systematic review of clinical trials and meta-analysis.

AIM: The aim of this systematic review was to answer the following question: in patients with primary endodontic infection, is there a statistically significant difference in the endotoxin levels after chemomechanical preparation with sodium hypochlorite (NaOCl) or chlorhexidine (CHX)? METHODOLOGY: A protocol was prepared and registered on PROSPERO (CRD42017069996). Four electronic databases (MEDLINE via PubMeb, Scopus, Web of Science and Cochrane Library) were searched from their start dates to 1 March 2017 using strict inclusion and exclusion criteria and reviewed following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Only clinical trials (randomized and nonrandomized) that compared the effectiveness of NaOCl and CHX to reduce endotoxins during chemomechanical preparation of teeth with primary endodontic infection were included. Two reviewers independently assessed the eligibility for inclusion, extracted data and assessed the quality using the risk of bias tool. RESULTS: From 712 articles that resulted from the initial search, 37 studies were included for full-text appraisal; four studies met the inclusion criteria for quantitative synthesis. A single meta-analysis was performed to compare the endotoxin levels before and after chemomechanical preparation with NaOCl or CHX. The forest plot of lipopolysaccharide (LPS) levels indicated that the data were heterogeneous [I2  = 63.9%; Tau2  = 574.5 (P = 0.04)]. The use of NaOCl and CHX during chemomechanical preparation significantly reduced the LPS levels compared to the initial ones. CONCLUSIONS: Chemomechanical canal preparation with both NaOCl and CHX reduced the endotoxin levels compared to the initial ones found in primary endodontic infections. When NaOCl was used during chemomechanical preparation, endotoxins levels were lower than those obtained after chemomechanical preparation with CHX.

Proteomic profile of root canal contents in teeth with post-treatment endodontic disease.

AIM: To characterize the proteome of 20 root canals in teeth with post-treatment endodontic disease using mass spectrometry and to correlate the identified proteins with clinical features. METHODOLOGY: Twenty patients with radiographic evidence of apical periodontitis and need for root canal re-treatment were selected. Samples from the root canal contents were collected and processed using two-dimensional capillary nano-flow liquid chromatography and electrospray ionization tandem mass spectrometry. The acquired spectra were separately searched against specific protein database. The results obtained were analysed using descriptive statistics. Additionally, Pearson's chi-square test or one-sided Fisher's exact test, as appropriate, was chosen to examine the null hypothesis that there is no relationship between each clinical feature and the presence of specific microbial or human proteins. Significance levels were set at 5% (P < 0.05). RESULTS: A total of 1153 human and 720 microbial UniProt accession numbers corresponding to proteins were recovered. The greater prevalence of proteins was related to biological functions, such as cellular and metabolic processes. A considerable number of microbial proteins with clinical relevance functions, such as pathogenesis/virulence, proteolysis, cell adhesion and drug resistance, were detected. Common endodontic pathogens related to post-treatment endodontic disease such as Enterococcus spp., Propionibacterium spp. and Streptococcus spp. were associated with 23, 40 and 94 distinct proteins, respectively. As for human proteins, many factors related to the immune system process were detected. No significant correlations were found between microbial and human proteins and the clinical features investigated (P > 0.05). CONCLUSIONS: A considerable number of microbial and human proteins were identified using proteomic analyses, being mainly related to processes indicating cell viability. No significant correlation was found between proteins and clinical features. These findings suggest a network of important microbial pathogenic functions that may be responsible for the host immune system response.

Relación entre el piso del seno maxilar y las raíces de las piezas posteriores superiores, mediante tomografía computada / Relationship between maxillary sinus floor and the posterior upper teeth roots, by means of computed tomography

Objetivo: El objetivo de este estudio fue evaluar la frecuencia con que las raíces de premolares y molares superiores se encuentran dentro del seno maxilar. Conocer la relación entre dichas estructuras es importante para planificar los procedimientos endodónticos y quirúrgicos a ser realizados en esa región. Materiales y métodos: Se realizó el análisis cualitativo dinámico de 82 tomografías computadas de haz cónico (CBCT) unilaterales, analizándose 738 raíces correspondientes a premolares y molares de una sola hemiarcada superior. Se utilizó sala con iluminación controlada y la observación fue realizada por un solo examinador. El criterio de inclusión requería que la cortical inferior del seno maxilar debía ser visible para poder establecer la relación. Se utilizaron los tres planos tomográficos de visualización, permitiendo ajustes de brillo y contraste. La escala de clasificación de cada raíz consideró su relación como: dentro o fuera del seno maxilar. Los datos obtenidos fueron sometidos a las pruebas de Chi-cuadrado y Test Exacto de Fisher. Resultados: el primer premolar superior mostró una proyección hacia el interior del seno maxilar significativamente menor que las otras piezas dentarias posteriores (p>0.05), observándose su raíz vestibular sin proyección. La raíz palatina del primer premolar superior mostró la mayor incidencia dentro del seno maxilar, con un 39,02% del total de las raíces analizadas (p<0,05). El segundo molar superior mostró considerable proximidad con el seno maxilar, pero con menor incidencia con relación a la raíz palatina del primer molar. Conclusión: los procedimientos endodónticos o quirúrgicos a realizarse en cercanía al seno maxilar deben considerar siempre la relación raíz/seno, para evitar maniobras que lo invadan. La raíz palatina del primer molar superior mostró la mayor incidencia dentro del seno maxilar, con un 39,02% (AU)

Detection and function of lipopolysaccharide and its purified lipid A after treatment with auxiliary chemical substances and calcium hydroxide dressings used in root canal treatment.

AIM: To investigate the influence of auxiliary chemical substances (ACSs) and calcium hydroxide [Ca(OH)2 ] dressings on lipopolysaccharides (LPS)/lipid A detection and its functional ability in activating Toll-like receptor 4 (TLR4). METHODOLOGY: Fusobacterium nucleatum pellets were exposed to antimicrobial agents as following: (i) ACS: 5.25%, 2.5% and 1% sodium hypochlorite solutions (NaOCl), 2% chlorhexidine (CHX) (gel and solution) and 17% ethylenediaminetetraacetic acid (EDTA); (ii) intracanal medicament: Ca(OH)2 paste for various periods (1 h, 24 h, 7 days, 14 days and 30 days); (iii) combination of substances: (a) 2.5% NaOCl (1 h), followed by 17% EDTA (3 min) and Ca(OH)2 (7 days); (b) 2% CHX (1 h), afterwards, 17% EDTA (3 min) followed by Ca(OH)2 (7 days). Saline solution was the control. Samples were submitted to LPS isolation and lipid A purification. Lipid A peaks were assessed by matrix-assisted laser desorption ionization time-of-flight mass spectrom (MALDI-TOF MS) whilst LPS bands by SDS-PAGE separation and silver staining. TLR4 activation determined LPS function activities. Statistical comparisons were carried out using one-way anova with Tukey-Kramer post-hoc tests at the 5% significance level. RESULTS: Matrix-assisted laser desorption ionization time-of-flight mass spectrometry analysis of control lipid A demonstrated the ion cluster at mass/charge (m/z) 1882 and an intense band in SDS-PAGE followed by silver staining of control LPS. In parallel, LPS control induced a robust TLR4 activation when compared to ACS (P ≤ .001). 5.25% NaOCl treatment led to the absence of lipid A peaks and LPS bands, whilst no changes occurred to lipid A/LPS after treatment with others ACS. Concomitantly, 5.25% NaOCl-treated LPS did not activate TLR4 (P < .0001). As for Ca(OH)2 , lipid A was not detected by MALDI-TOF nor by gel electrophoresis within 24 h. LPS treated with Ca(OH)2 was a weak TLR4 activator (P < .0001). From 24 h onwards, no significant differences were found amongst the time periods tested (P > 0.05). The addition of Ca(OH)2 for 7 days to cells treated either with 2.5% NaOCl or 2% CHX led to the absence of lipid A peaks and LPS bands, leading to a lower activation of TLR4. CONCLUSION: 5.25% NaOCl and Ca(OH)2 dressings from 24 h onwards were able to induce both, loss of lipid A peaks and no detection of LPS bands, rendering a diminished immunostimulatory activity through TLR4.

Influence of apical enlargement and complementary canal preparation with the Self-Adjusting File on endotoxin reduction in retreatment cases.

AIM: To compare the effectiveness of large apical preparations and complementary canal preparation with the Self-Adjusting File (SAF) in removing endotoxins from the root canal of teeth with apical periodontitis. METHODOLOGY: Ten single-rooted and single-canaled teeth with post-treatment apical periodontitis were selected. Endotoxin samples were taken after removal of the root filling (S1), after chemomechanical preparation (CMP) using 2.5% NaOCl and an R25 file (S2), after CMP using 2.5% NaOCl and an R40 file (S3) and after complementary CMP using the SAF system (S4). Limulus amebocyte lysate (LAL) was used to measure endotoxin levels. The Friedman and Wilcoxon tests were used to compare endotoxin levels at each clinical intervention (P < 0.05). RESULTS: After root filling removal, endotoxin was detected in 100% of the root canals (S1, 4.84 EU mL-1 ). CMP with the R25 file was able to significantly reduce endotoxin levels (P < 0.05). Increased levels of endotoxin removal were achieved by apical preparation with the R40 file (P < 0.05). Complementary CMP with SAF did not significantly reduce endotoxin levels (P > 0.05) following the use of the R40 instrument. CONCLUSIONS: Apical enlargement protocols were effective in significantly reducing endotoxin levels. Complementary preparation with the SAF system failed to eliminate residual endotoxin contents beyond those obtained with the R40 instrument.

Clinical efficacy of EDTA ultrasonic activation in the reduction of endotoxins and cultivable bacteria.

AIM: This clinical study was conducted to investigate the influence of 17% ethylenediaminetetraacetic acid (EDTA) ultrasonic activation after chemomechanical preparation (CMP) on eliminating/reducing oral bacterial lipopolysaccharides (known as endotoxins) and cultivable bacteria in teeth with pulp necrosis and apical periodontitis. METHODOLOGY: Samples were taken from 24 root canals at several clinical periods: S1 - before CMP; S2 - after CMP; S3 - after EDTA: G1 - with ultrasonic activation (n = 12) and G2 - without ultrasonic activation (n = 12). Root canals were instrumented using Mtwo rotary files. Culture techniques were used to determine the number of colony-forming units (CFU). Limulus amebocyte lysate (LAL) was used to measure endotoxin levels. Friedman's and Wilcoxon signed-rank tests were used to compare the amount of bacteria and endotoxin levels in each period (P < 0.05). RESULTS: Endotoxins and cultivable bacteria were recovered in 100% of the initial samples (S1). CMP was effective in reducing endotoxins and bacterial load (all with P < 0.05). Higher values of endotoxin reduction were achieved with EDTA ultrasonic activation [G1, 0.02 EU mL-1 (range 0.01-0.75)] compared with the no activation group [G2, 1.13 EU mL-1 (range 0.01-8.34)] (P < 0.05). Regarding bacterial reduction, no statistically significant difference was found in S3, regardless of the group (G1, G2, P > 0.05). CONCLUSIONS: Chemomechanical preparation was effective in reducing bacteria and endotoxins, but could not completely eliminate them. The ultrasonic activation of EDTA was effective in further reducing endotoxin levels in the root canals of teeth with pulp necrosis and apical periodontitis.

Pulp revascularization for immature replanted teeth: a case report.

Immature avulsed teeth are not usually treated with pulp revascularization because of the possibility of complications. However, this therapy has shown success in the treatment of immature teeth with periapical lesions. This report describes the case of an immature replanted tooth that was successfully treated by pulp revascularization. An 8-year-old boy suffered avulsion on his maxillary left lateral incisor. The tooth showed incomplete root development and was replanted after 30 minutes. After diagnosis, revascularization therapy was performed by irrigating the root canal and applying a calcium hydroxide paste and 2% chlorhexidine gel for 21 days. In the second session, the intracanal dressing was removed and a blood clot was stimulated up to the cervical third of the root canal. Mineral trioxide aggregate was placed as a cervical barrier at the entrance of the root canal and the crown was restored. During the follow-up period, periapical repair, apical closure and calcification in the apical 4 mm of the root canal was observed. An avulsed immature tooth replanted after a brief extra-alveolar period and maintained in a viable storage medium may be treated with revascularization.

Does the Reciproc file remove root canal bacteria and endotoxins as effectively as multifile rotary systems?

AIM: To evaluate the effectiveness of Reciproc for the removal of cultivable bacteria and endotoxins from root canals in comparison with multifile rotary systems. METHODOLOGY: The root canals of forty human single-rooted mandibular pre-molars were contaminated with an Escherichia coli suspension for 21 days and randomly assigned to four groups according to the instrumentation system: GI - Reciproc (VDW); GII - Mtwo (VDW); GIII - ProTaper Universal (Dentsply Maillefer); and GIV -FKG Race(™) (FKG Dentaire) (n = 10 per group). Bacterial and endotoxin samples were taken with a sterile/apyrogenic paper point before (s1) and after instrumentation (s2). Culture techniques determined the colony-forming units (CFU) and the Limulus Amebocyte Lysate assay was used for endotoxin quantification. Results were submitted to paired t-test and anova. RESULTS: At s1, bacteria and endotoxins were recovered in 100% of the root canals investigated (40/40). After instrumentation, all systems were associated with a highly significant reduction of the bacterial load and endotoxin levels, respectively: GI - Reciproc (99.34% and 91.69%); GII - Mtwo (99.86% and 83.11%); GIII - ProTaper (99.93% and 78.56%) and GIV - FKG Race(™) (99.99% and 82.52%) (P < 0.001). No statistical difference were found amongst the instrumentation systems regarding bacteria and endotoxin removal (P > 0.01). CONCLUSION: The reciprocating single file, Reciproc, was as effective as the multifile rotary systems for the removal of bacteria and endotoxins from root canals.

Root canal content from primary endodontic infection and upregulation of gelatinases in fibroblast cells.

AIM: To investigate endotoxin levels from primary endodontic infections before and after chemomechanical preparation (CMP) and to determine their antigenicity against 3T3 fibroblasts through gelatinolytic activity of matrix metalloproteinases (MMPs). METHODOLOGY: Twenty-four root canals with primary endodontic infection and apical periodontitis were selected. Samples were collected using paper points before (S1) and after chemomechanical preparation (CMP) (S2). The limulus amebocyte lysate assay was used for endotoxin measurement. Fibroblasts were stimulated with root canal contents for 24 h. Supernatants of cell cultures stimulated with root canal contents were collected after 24 h to determine the levels of MMP-2 and MMP-9 gelatinolytic activity using the zymography technique. Friedman and Wilcoxon tests were used to compare the amount of endotoxin before (S1) and after CMP (S2) (P < 0.05). Data obtained from gelatinolytic activity were analysed using anova and Tukey's tests (P < 0.05). RESULTS: Endotoxin was recovered in 100% of the samples. There was a significant reduction in endotoxin levels after CMP (P < 0.05). A correlation was found between the levels of endotoxins and MMP-2 expression (P < 0.05). Root canal contents of initial samples (S1) induced significantly greater MMP-2 expression by fibroblasts when compared to S2 and the nonstimulated group (P < 0.05). No gelatinolytic activity of MMP-9 was observed in S1, S2 and control group. CONCLUSIONS: Root canal contents from primary endodontic infections had gelatinolytic activity for MMP-2. Moreover, CMP was effective in reducing endotoxin levels and their antigenicity against fibroblasts on gelatinolytic activity.

Adhesion of resin-based sealers to dentine: an atomic force microscopy study.

AIM: To evaluate the effect of several final irrigants on the adhesion force (Fad) between dentine and resin-based sealers by means of atomic force microscopy (AFM). METHODOLOGY: Twelve distal roots of mandibular molars were used. The roots were smoothened and cut to obtain 36 specimens. During chemomechanical preparation of the root canals, 5.25% NaOCl was used as the irrigant. The specimens were then divided into six groups according to the final irrigant used: control group - immersed in distilled water (DW) for 1 min; chlorhexidine (CHX) group - in 2% CHX for 1 min; NaOCl group - in 5.25% NaOCl for 1 min; EDTA group - in 17% EDTA for 5 min, EDTA/CHX group - in EDTA, followed by intermediate flushing with DW and then immersed in CHX; EDTA/NaOCl group - in EDTA, followed by intermediate flushing with DW and then immersed in NaOCl. After the treatments, all groups were washed with DW to remove all traces of the irrigants. Afterwards, the samples were dried and attached to a glass base. AFM tips containing AH Plus and Real Seal SE sealers were used to obtain force-distance curves with regard to dentine-treated surfaces. Data were analysed statistically using nonparametric tests with the significance level set at P < 0.05. RESULTS: In the groups with smear layer, a final flush with CHX and NaOCl resulted in significantly higher Fad values than the control group for both sealers (P < 0.001). When smear layer was removed, the highest Fad values associated with AH Plus occurred with a final flush of NaOCl, whilst in Real Seal SE, the highest values were found with a final flush of CHX (all results significant at P < 0.001). CONCLUSION: Irrigants had a positive effect on the adhesion of the resin-based sealers, AH Plus and Real Seal SE, to dentine.

Localización efectiva de un segundo conducto radicular en incisivos inferiores mediante magnificación, radiografía y diafanización / Effective location a second root canal in lower incisors by magnification radiography and diaphanization

Objetivo: Evaluar in vitro, la efectividad del método visual y radiográfico, comparándolos con la técnica de diafanización en la detección del segundo conducto radicular de incisivos inferiores tratados endodónticamente. Material y métodos: Fueron analizados 133 dientes incisivos inferiores permanentes, tratados endodónticamente, a través de métodos visuales (con y sin auxilio de magnificación), radiográficos y de diafanización. El análisis radiográfico fue realizado en negatoscopio utilizando una lupa estereoscópica (10X). Posteriormente, fue realizada la remoción completa de la obstrucción provisional para la exploración visual con y sin auxilio de microscopio clínico (MO) en un aumento de 12X. Finalmente los dientes fueron diafanizados y almacenados en salicilato de metila para posterior análisis. Dos evaluadores calibrados registraron los datos referentes a la presencia o no del segundo conducto radicular para cada uno de los métodos utilizados. Resultados: El análisis radiográfico mostró la presencia del segundo conducto en 24 dientes (18,05%. Visualmente, fue encontrado en 4 dientes (3,00%) sin magnificación y en 16 dientes (12,03%) con ayuda del MO. A través de la diafanización, 34 dientes (25,95%) presentaron segundo conducto. Conclusiones: La asociación de técnicas radiográficas y la magnificación visual obtenida con la utilización del MO se muestran como los aliados clínicos más efectivos para la localización del segundo conducto en incisivos inferiores.

Objective: To evaluate in vitro the effectiveness of the visual, radiographic and clearing technique on detection of two root canals in mandibular incisor teeth endodontically treated. Material and methods: One hundred thirty-three human permanent lower incisors were anlyzed through visual methods (with and without magnification), radiographic and clearing technique. Radiographic analysis was performed in light box using a stereomicroscope (10X). Then, the temporary filling of al specimens was removed for visual exploration with and without clinical microscope (OM) (12X). Finally the teeth were submitted to clearing technique and stored in methyl salicylate for subsequent analysis. Two calibrated reviewers recorded data about the presence or absence of the second root canal for each of the used methods. Results: Radiographic analysis showed the presence of the second root canal in 24 teeth (18.05%). Visually, it was found in 4 teeth (3.00%) and 16 teeth (12.03%) without and with the use of OM, respectively. Through clearing technique, in 334 teeth (25.95%) it was found the second root canal. Conclusion: The association of radiographic techniques and visual magnification with the use of MO has been shown as the most effective clinical partners to locate the second root canal in mandibular incisors.

CBCT for the assessment of second mesiobuccal (MB2) canals in maxillary molar teeth: effect of voxel size and presence of root filling.

AIM: To compare detection of the second mesiobuccal (MB2) canal in maxillary molar teeth using cone-beam computed tomography (CBCT) with different voxel sizes against conventional radiographic examination when the MB1 was unprepared, prepared and filled. METHODOLOGY: Radiographic examination and 0.2-, 0.25- and 0.3-mm CBCT (n = 89) were performed in 3 stages: S1, no first mesiobuccal (MB1) canal preparation or filling; S2, after MB1 preparation and filling; and S3, after MB1 root canal filling removal and canal repreparation. Images were analysed using the i-Cat software. After RE and CBCT acquisition in S3, all the samples were clarified to directly visualize the presence of the MB2 canal. All images were analysed by a blinded, previously calibrated examiner. Accuracy, specificity and sensitivity were compared using analysis of variance (P < 0.05 level of significance). RESULTS: MB2 root canals were detected in 67% of the samples. Overall, radiographic examination was associated with lower mean accuracy values for detecting MB2 than CBCT regardless of the MB1 condition. The MB1 root canal condition did not influence MB2 detection in 0.2-mm voxel images. The presence of root fillings in the MB1 canals reduced the detection of MB2 canals, especially in the 0.3- and 0.25-mm voxel-size images (P < 0.05). CONCLUSION: CBCT was associated with higher mean values of specificity and sensibility than radiographic examination for the detection of MB2 canals. When endodontic retreatment is necessary removal of the root filling prior to the CBCT examination eliminates artefacts, thereby permitting the use of the 0.3-mm voxel protocol that has good diagnostic performance and lower radiation dose.

Microbiological profile and antimicrobial susceptibility pattern of infected root canals associated with periapical abscesses.

The aim of this investigation was to identify microorganisms from root canals with periapical abscesses and assess the susceptibility of specific anaerobic bacteria to selected antimicrobials and their ß-lactamase production. Sixty root canals were microbiologically investigated. The susceptibility of Anaerococcus prevotii, Fusobacterium necrophorum, F. nucleatum, Parvimonas micra, and Prevotella intermedia/nigrescens to antimicrobials was evaluated with the Etest, whereas ß-lactamase production was assessed with nitrocefin. A total of 287 different bacterial strains were recovered, including 201 strict anaerobes. The most frequently strict isolated anaerobes were A. prevotii, P. micra, and F. necrophorum. The selected bacteria were susceptible to all the tested antibiotics, except A. prevotii and Fusobacterium species to azithromycin and erythromycin, as well as A. prevotii and F. necrophorum to metronidazole. None of the microorganisms produced ß-lactamase. Gram-positive anaerobic bacteria predominated in the root canals with periapical abscesses. All microorganisms tested were susceptible to benzylpenicillin, amoxicillin, amoxicillin + clavulanate, cefaclor, and clindamycin, producing no ß-lactamase.