A 22-year follow-up cross-sectional study on periapical health in relation to the quality of root canal treatment in a Belgian population.

AIM: To investigate the prevalence of apical periodontitis (AP) and the technical standard of root canal treatment in a Belgian population, assess the association of different variables with periapical status, and compare the results to a similar study conducted 22 years previously. METHODOLOGY: In this cross-sectional study, 614 panoramic radiographs of first-time adult attendees at the Dental School of the University Hospital of Ghent were examined. Recorded patient-level parameters included gender, age, number of teeth, number of root filled teeth, presence of any AP lesion, and number of implants. The following tooth-level data were collected: tooth presence, coronal status, quality of coronal restoration, post presence, type of root-filling material, length and density of root filling, root-end filling material, presence of AP, and adjacent implant. Multivariable multilevel binary logistic regression was used to explore the association between patient and tooth characteristics and AP prevalence. Risk differences and confidence intervals were calculated to compare the present with the previous study. RESULTS: The prevalence of AP at patient and tooth level was 46.9% and 5.6%, respectively. Fifty-one per cent of the 614 patients had at least one root filled tooth, and 5.9% of the 14 655 teeth studied were root filled. AP was found in 45% of root filled teeth. Fifty-four per cent of the root-filled teeth were rated as inadequate. Multivariable multilevel logistic regression revealed that more teeth, more implants, fewer root-filled teeth, adequate density, adequate coronal restoration, and no caries reduced the likelihood of AP. There were no statistically significant differences between the two studies regarding the prevalence of root-filled teeth or AP and the technical quality of root canal treatment. CONCLUSIONS: The prevalence of AP and the technical quality of root canal treatment in Belgium have not substantially changed over the last 22 years, despite the technological advancements and continuing education in the field.

Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A systematic review and meta-analysis.

OBJECTIVES: Different materials have been used for capping the pulp after exposure during caries removal in permanent teeth. The purpose of this study was to collate and analyze all pertinent evidence from randomized controlled trials (RCTs) on different materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth. MATERIALS AND METHODS: Trials comparing two or more capping agents used for direct pulp capping (DPC) or pulpotomy were considered eligible. An electronic search of four databases and two clinical trial registries was carried out up to February 28, 2021 using a search strategy properly adapted to the PICO framework. Screening, data extraction, and risk of bias (RoB) assessment of primary studies were performed in duplicate and independently. The primary outcome was clinical and radiological success; secondary outcomes included continued root formation, tooth discoloration, and dentin bridge formation. RESULTS: 21 RCTs were included in the study. The RoB assessment indicated a moderate risk among the studies. Due to significant clinical and statistical heterogeneity among the studies, performing network meta-analysis (NMA) was not possible. An ad hoc subgroup analysis revealed strong evidence of a higher success of DPC with Mineral Trioxide Aggregate (MTA) compared to calcium hydroxide (CH) (odds ratio [OR] = 3.10, 95% confidence interval [CI]: 1.66-5.79). MTA performed better than CH in pulp capping (both DPC and pulpotomy) of mature compared to immature teeth (OR = 3.34, 95% CI: 1.81-6.17). The GRADE assessment revealed moderate strength of evidence for DPC and mature teeth, and low to very low strength of evidence for the remaining subgroups. CONCLUSIONS: Considerable clinical and statistical heterogeneity among the trials did not allow NMA. The ad hoc subgroup analysis indicated that the clinical and radiographic success of MTA was higher than that of CH but only in mature teeth and DPC cases where the strength of evidence was moderate. PROSPERO Registration: number CRD42020127239.

Effectiveness of adjunct therapy for the treatment of apical periodontitis: A systematic review and meta-analysis.

BACKGROUND: Adjunct therapy refers to any intracanal procedure going beyond chemomechanical preparation with instruments and traditionally delivered irrigants (excluding interim dressings). It is not clear whether and which of these adjunct therapies have a significant impact on the outcome of root canal treatment [healing of apical periodontitis (AP) and other patient-related outcomes]. OBJECTIVES: This systematic review aimed to analyse available evidence on the effectiveness of adjunct therapy for the treatment of AP in permanent teeth, according to a population, intervention, comparison, outcome, time and study design framework formulated a priori by the European Society of Endodontology. METHODS: Five electronic databases (PubMed, Embase, Scopus, Cochrane and Web of Science) were searched up to October 2021 to identify clinical studies comparing adjunct therapy to no adjunct therapy in adult patients with AP. Animal studies, reviews, studies with less than 10 patients per arm and studies with a follow-up time of less than 1 year, or less than 7 days for postoperative pain, were excluded. The quality of the included studies was appraised by the appropriate tools [Risk of Bias 2 (RoB2) for randomized clinical trials (RCTs) and Newcastle-Ottawa Scale for observational studies]. Meta-analysis was performed using a random-effects model. The certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS: Fourteen studies (13 RCTs and one retrospective cohort) fulfilled the inclusion criteria for this review. They evaluated different types of adjunct therapy: antimicrobial photodynamic therapy (aPDT; three studies), diode laser canal irradiation (3), Nd:YAG laser canal irradiation (2), Er;Cr:YSGG laser canal irradiation (1), ozone therapy (2) and ultrasonically activated irrigation (UAI) (4). Radiographical healing was reported in seven studies, but meta-analysis was only possible for UAI (two studies), showing no statistically significant difference in healing after 12 months. Pain after 7 days was reported in seven studies. Meta-analysis on three studies that used aPDT and on two studies using diode laser irradiation showed no significant difference in the prevalence of pain after 7 days between the control and adjunct therapy. According to RoB2 tool, six studies had a high risk of bias, five studies had some concerns, and two studies low risk of bias. The GRADE assessment revealed a very low strength of evidence for diode laser, and low strength of evidence for PDT, ozone and UAI studies. DISCUSSION: The included studies displayed significant heterogeneity in terms of type of adjunct therapy, technical details per adjunct therapy, outcome reporting and several combinations of these, limiting the potential for meta-analysis. CONCLUSIONS: There is insufficient evidence to recommend any adjunctive therapy for the treatment of apical periodontitis. REGISTRATION: Prospero CRD42021261869.

Explaining the working mechanism of laser-activated irrigation and its action on microbial biofilms: A high-speed imaging study.

AIM: Laser-activated irrigation (LAI) using pulsed erbium lasers has been studied with regard to canal cleaning, but its working mechanism remains poorly understood. This study sought to unravel the method of action of LAI and to assess its effect on bacterial biofilms in a root canal model, by means of high-speed imaging. METHODOLOGY: A root canal model consisting of dentine and glass walls was used. Visualization of the canal space during activation was achieved with a high-speed camera, capturing 20-s activation series at 50 000 frames per second. Recordings were made of canal models filled with water, models filled with water containing glass microspheres, and models with a biofilm (an undefined biofilm originating from oral samples, a 1-week-old Enterococcus faecalis biofilm or a 11-day-old multispecies biofilm) grown on the dentine walls. LAI parameters were 2940 nm, 15 Hz, 50 µs, 20 mJ and 400 µm conical tip held at orifice level. Quantitative (measurement of size, life time and timing of cavitation bubbles; velocity and amplitude of root canal content movement) and qualitative (descriptive) analysis of the intracanal events was performed using imaging software. RESULTS: During the implosion of the primary bubble, smaller cavitation bubbles emerged throughout the entire canal. This process began in the coronal canal part and continued in the apical direction. Expansion of these bubbles was followed by an implosion, and this volumetric change over a time span of a few 100 µs resulted in a very rapid vertical movement of the canal content with a mean amplitude of 900 µm. The succession of these movements with every pulse, resulted in biofilm detachment from the root canal walls and the gradual displacement of fragments coronally, until their complete removal. The pattern of the biofilm removal was the same for all groups. LAI was able to remove biofilm from the root canal models. CONCLUSIONS: The hydrodynamic effect of LAI is based on the generation of small cavitation bubbles throughout the entire canal, far from the primary bubble. Their volumetric oscillation results in a small yet very fast vertical movement of the root canal content and local liquid streaming on each pulse, resulting in biofilm detachment and coronal displacement.

A critical analysis of research methods and experimental models to study intracanal medicaments.

In order to ensure predictable decontamination of the root canal system, chemo-mechanical preparation of the root canal space is sometimes supplemented with the use of intracanal medication. As microbial control of the root canal space is fundamental to the resolution of apical periodontitis, root canal disinfection strategies haven been researched intensively. The use of intracanal medication as a supplementary step to the chemo-mechanical preparation of the root canal space is one of them. Because of the costs and limitations of clinical research it is relevant and common practice to first evaluate alternative or new root canal disinfection modalities in laboratory studies. This involves the simulation of a root canal infection in a laboratory model, on which different disinfection strategies can be tested. When modelling the infected root canal, different levels of infection can be discriminated: suspended bacteria, microbial biofilms and infected dentine. This review describes the experimental models associated with these infection levels and critically appraises their value and methodological details. Suggestions for relevant research methods and experimental models are given, as well as some good practices for laboratory-based microbiological studies.

Model system parameters influence the sodium hypochlorite susceptibility of endodontic biofilms.

AIM: To evaluate in a laboratory setting the influence of several model system parameters on the sodium hypochlorite (NaOCl) susceptibility of endodontic biofilms. Based on these findings, a relevant in vitro endodontic biofilm model is proposed. METHODOLOGY: In vitro biofilms were cultured, varying the following experimental model parameters: biofilm composition (monospecies Enterococcus faecalis and a multispecies biofilm including E. faecalis, Fusobacterium nucleatum, Prevotella intermedia and Porphyromonas gingivalis), incubation time (24 h or 11 days), incubation atmosphere (aerobically or anaerobically) and biofilm substrate (polystyrene microtiter plate wells, hydroxyapatite or dentine). Biofilms were subjected to treatment with NaOCl (0.025%, 0.1%, 0.5%, 2.5%) for 1 min, control groups included treatment with purified water. Biofilms were harvested and the number of surviving cells was determined by plate counting using general (monospecies biofilms) or selective (multispecies biofilms) media. A two-way ANOVA was used to explore the effect of the model parameters on biofilm eradication. Finally, the most physiologically relevant biofilm model (11-day-old multispecies biofilm grown anaerobically on dentine discs) was characterized by selective media plate counting, NaOCl susceptibility testing, scanning and transmission electron microscopy. RESULTS: There was no difference in NaOCl eradication between the anaerobically and aerobically grown E. faecalis biofilms. One-day-old biofilms of E. faecalis were more susceptible to most tested NaOCl concentrations than 11-day-old biofilms (p < .05). When grown in a multispecies biofilm, E. faecalis was significantly less susceptible to NaOCl treatment than in a monospecies biofilm (p < .05). E. faecalis in a multispecies biofilm grown in a MTP was more susceptible to NaOCl (0.025% and 0.1%) than when grown on hydroxyapatite or dentine. No difference in biofilm NaOCl susceptibility was seen between hydroxyapatite and dentine. The multispecies biofilm proved to be a reproducible model with high NaOCl resistance, complex structure and organization. CONCLUSION: The parameters biofilm age, biofilm composition and substrate had a significant influence on the NaOCl susceptibility of E. faecalis biofilms. Older biofilms, multispecies biofilms and biofilms grown on dentine and hydroxyapatite had reduced NaOCl susceptibility. These findings emphasize the importance of selecting relevant parameters when designing a laboratory biofilm model system for the evaluation of antimicrobial treatments.

Efficacy of different irrigation technique in simulated curved root canals.

The aim of this study was to assess the influence of the canal curvature on the efficacy of sonically, ultrasonically, and laser-activated irrigation in removing a biofilm-mimicking hydrogel (BMH) from simulated canal irregularities. Transparent resin blocks containing a curved root canal (40° or 60°) were used as test models. A 4-mm groove at 1 mm from the apex was filled with BMH. Five different irrigation procedures were performed (n=20): needle irrigation (NI), EndoActivator (EA), Eddy, ultrasonically activated irrigation (UAI) (Irrisafe), and laser-activated irrigation (LAI) using a pulsed erbium laser (PIPS approach). All protocols were executed for 3×20s. Images of the groove were taken before and after irrigation, and the percentage BMH removal was calculated using image analysis software. In the 40° canal curvature model, the highest BMH removal was observed for UAI (99.9%), yielding a significantly better removal than that of EA (57.2%) and NI (53.8%), but not of LAI (96.8%) and Eddy (99.4%). In the 60° canal curvature model, UAI removed 99.5%, which resulted in significantly greater hydrogel removal than all other groups (P < 0.05). The difference between LAI (82.5%) and Eddy (78.1%) was not statistically significant, but both were more effective than EA (13.5%) and NI (7.3%). Canal curvature negatively affects the cleaning efficacy of different irrigation methods. The effect was most pronounced for the sonic techniques, while this was not the case for UAI. This could be ascribed to the prebent ultrasonic tip. Despite the position of the laser tip at the orifice level, fluid streaming during LAI resulted in substantial BMH removal beyond the curve.

The efficacy of ultrasonic and PIPS (photon-induced acoustic streaming) irrigation to remove artificially placed dentine debris plugs out of an artificial and natural root model.

The aim was to validate an artificial resin 'root canal wall groove model' (RCWGM) mimicking the situation of natural roots with a groove of identical dimensions on debris removal out of these grooves, and to evaluate Erbium 'laser-activated irrigation' (LAI) with two conical tips at PIPS (photon-induced photoacoustic streaming) settings, with different activation times and different root canal positions on debris removal out of the grooves. A split RCWGM was used (resin blocks and roots of maxillary canines) with a canal size 40/0.06. The grooves in the apical third were filled with stained dentinal debris. Seventeen irrigation protocols (n = 20) were used: syringe-needle irrigation (3× 20 s), manual dynamic activation (1× 60 s), ultrasonically activated irrigation (UAI) with 25/25 Irrisafe (3× 20 s) and LAI (2940 nm Er:YAG) with X-Pulse or PIPS tips at PIPS settings (20 mJ, 50 µs, 20 Hz) and with the fibre (IN) or (OUT) the canal: IN during 1× 20 s, and OUT during 1× 20 s, 2× 20 s, 3× 20 s, 30 s, 2× 30 s and 1× 60 s. The quantity of remaining dentine debris in the groove was evaluated on a numerical scale. Statistical analysis was performed by means of proportional odds logistic regression, equivalence testing and Wald tests. The level of significance was set at 0.05. Resin models and the RCWGM with natural teeth can be called equivalent (log odds ratio 0.185). There were mostly no statistically significant differences for debris removal between UAI and LAI (p > 0.05) and between LAI with PIPS and X-Pulse (p > 0.05). Although not statistically different, the numbers of completely cleaned grooves were higher with LAI than with UAI for a 1-min activation, confirming findings from other studies. There is no difference in cleaning efficacy between X-Pulse and PIPS tips at PIPS settings.

Influence of lasing parameters on the cleaning efficacy of laser-activated irrigation with pulsed erbium lasers.

Laser-activated irrigation (LAI) using erbium lasers is an irrigant agitation technique with great potential for improved cleaning of the root canal system, as shown in many in vitro studies. However, lasing parameters for LAI vary considerably and their influence remains unclear. Therefore, this study sought to investigate the influence of pulse energy, pulse frequency, pulse length, irradiation time and fibre tip shape, position and diameter on the cleaning efficacy of LAI. Transparent resin blocks containing standardized root canals (apical diameter of 0.4 mm, 6% taper, 15 mm long, with a coronal reservoir) were used as the test model. A standardized groove in the apical part of each canal wall was packed with stained dentin debris. The canals were filled with irrigant, which was activated by an erbium: yttrium aluminium garnet (Er:YAG) laser (2940 nm, AT Fidelis, Fotona, Ljubljana, Slovenia). In each experiment, one laser parameter was varied, while the others remained constant. In this way, the influence of pulse energy (10-40 mJ), pulse length (50-1000 µs), frequency (5-30 Hz), irradiation time (5-40 s) and fibre tip shape (flat or conical), position (pulp chamber, canal entrance, next to groove) and diameter (300-600 µm) was determined by treating 20 canals per parameter. The amount of debris remaining in the groove after each LAI procedure was scored and compared among the different treatments. The parameters significantly (P < 0.05, Kruskal-Wallis) affecting debris removal from the groove were fibre tip position, pulse length, pulse energy, irradiation time and frequency. Fibre tip shape and diameter had no significant influence on the cleaning efficacy.

Efficacy of laser-based irrigant activation methods in removing debris from simulated root canal irregularities.

In root canal therapy, irrigating solutions are essential to assist in debridement and disinfection, but their spread and action is often restricted by canal anatomy. Hence, activation of irrigants is suggested to improve their distribution in the canal system, increasing irrigation effectiveness. Activation can be done with lasers, termed laser-activated irrigation (LAI). The purpose of this in vitro study was to compare the efficacy of different irrigant activation methods in removing debris from simulated root canal irregularities. Twenty-five straight human canine roots were embedded in resin, split, and their canals prepared to a standardized shape. A groove was cut in the wall of each canal and filled with dentin debris. Canals were filled with sodium hypochlorite and six irrigant activation procedures were tested: conventional needle irrigation (CI), manual-dynamic irrigation with a tapered gutta percha cone (manual-dynamic irrigation (MDI)), passive ultrasonic irrigation, LAI with 2,940-nm erbium-doped yttrium aluminum garnet (Er:YAG) laser with a plain fiber tip inside the canal (Er-flat), LAI with Er:YAG laser with a conical tip held at the canal entrance (Er-PIPS), and LAI with a 980-nm diode laser moving the fiber inside the canal (diode). The amount of remaining debris in the groove was scored and compared among the groups using non-parametric tests. Conventional irrigation removed significantly less debris than all other groups. The Er:YAG with plain fiber tip was more efficient than MDI, CI, diode, and Er:YAG laser with PIPS tip in removing debris from simulated root canal irregularities.

Optical properties of root canal irrigants in the 300-3,000-nm wavelength region.

In root canal therapy, irrigating solutions are essential to assist in debridement and disinfection. Their spread and action is often restricted by canal anatomy, requiring some form of activation. Lasers have been shown to be promising tools for this purpose (laser-activated irrigation (LAI)). For LAI to be effective, high absorption of radiation in the irrigant is essential. Although the absorption spectrum of water is well established, little is known about the optical properties of other irrigating solutions. Therefore, root canal irrigants (sodium hypochlorite (NaOCl), citric acid (CA), chlorhexidine (CHX), ethylenediaminetetraacetate (EDTA), water) were subjected to UV/Vis spectrophotometry in the 300-3,000-nm region using synthetic quartz cells with an optical path length of 1 mm. Transmission data were used to plot the transmission spectrum and calculate the absorption coefficient (α) of each irrigant. The transmission spectra of the tested solutions proved to follow the spectrum of pure water to a large extent. All tested solutions displayed absorption peaks around 1,450 nm (α ≈ 14 cm(-1)), 1,950 nm (α > 30 cm(-1)), and above 2,500 nm (α > 30 cm(-1)). NaOCl showed higher absorption than water in the UV region. Slightly higher absorption than water was noted for CHX (Corsodyl) around 513 nm and for CA between 1,600 and 1,800 nm and around 2,200 nm. The absorption in all tested solutions for wavelengths greater than 2,500 nm is very high, meaning a great potential for laser-activated irrigation. Other wavelengths eligible for LAI are located around 1,450 and 2,000 nm but require further investigation.

In vitro inactivation of endodontic pathogens with Nd:YAG and Er:YAG lasers.

Both Nd:YAG and Er:YAG lasers have been suggested as root canal disinfection aids. The aim of this in vitro study is to compare both wavelengths in terms of irradiation dose required for microbial inactivation, to quantify these irradiation doses and to investigate the influence of certain (laser) parameters on the antimicrobial efficacy. Agar plates containing a uniform layer of Enterococcus faecalis, Candida albicans or Propionibacterium acnes were mounted perpendicularly underneath the laser handpieces (5 mm spot). The Er:YAG laser was operated in single-pulse mode. Pulse energies of 40-400 mJ and pulse lengths of 100, 300, 600, and 1,000 µs were tested. After incubation at 37°C for 48 h, growth on the plates was scored. The pulse energy yielding complete absence of growth over the entire spot area was taken as the total inhibition threshold (TIT). TITs were determined for every species and pulse length. The Nd:YAG laser was operated with pulse trains because single pulses were ineffective. Output power was 15 W and frequency was 100 Hz. Spots were irradiated for 5-120 s. After incubation, the diameters of the inhibition zones were measured. For the Er:YAG laser, TITs varied between 100 and 210 mJ, and differed significantly between species and pulse lengths. Using Nd:YAG irradiation, TITs were around 5,300 J/cm(2) for C. albicans and 7,100 J/cm(2) for P. acnes. No inhibition was observed for E. faecalis. Er:YAG irradiation was superior to Nd:YAG in inactivating microorganisms on agar surfaces.