Atypical healing of an endodontic lesion following emergency treatment: a case report.

This case report examines the atypical healing of an endodontic lesion without standard endodontic treatment, influenced by the patient's failure to attend treatment appointments. A 50-year-old woman with no notable medical history presented with a deep carious lesion on her mandibular right first molar, accompanied by localized pain. Citing forgetfulness as a reason, the patient missed her initially scheduled root canal treatment, necessitating an emergency intervention. The emergency treatment included access cavity preparation, irrigation with 5.25% sodium hypochlorite solution, application of a modified triple antibiotic paste (equal parts penicillin G, metronidazole, and ciprofloxacin), and temporary restoration with amalgam. A large apical lesion was detected in immediate postoperative radiographs. However, the patient failed to return for definitive endodontic treatment, due to a lack of symptoms and time for treatment. Follow-up examinations 1 and 5 years after emergency treatment disclosed gradual healing of the lesion, culminating in the establishment of a normal periodontal ligament. This case underscores the potential efficacy of a modified triple antibiotic paste and highlights the importance of a well-sealed coronal restoration in promoting the healing of endodontic lesions, even in the absence of pulpectomy and conventional root canal therapy. Additional research is needed to understand the mechanisms behind such healing events.

Outcome of curcumin-based photodynamic therapy in endodontic microsurgery: A case report.

INTRODUCTION: Persistent apical periodontitis after root canal treatment may require surgical retreatment when non-surgical options are ineffective or impractical due to anatomical challenges or iatrogenic errors. Endodontic microsurgery (EMS) is a precise technique that aims to overcome extraradicular biofilm and root morphology issues. Photodynamic therapy (PDT) is an emerging supplementary disinfection approach that utilizes a photosensitizer agent and light to eliminate microorganisms through oxidative reactions. REPORT: A 60-year-old male with persistent apical periodontitis in a left maxillary first molar underwent non-surgical root canal retreatment followed by surgical reintervention due to anatomical complexities. During surgery, PDT was performed using a novel curcumin-based photosensitizer agent. After the procedure, the tooth was retrofilled with bioceramic cement, and photobiomodulation was applied to enhance tissue healing. One year post-surgery, the patient exhibited complete periradicular repair and remained asymptomatic. DISCUSSION: EMS is considered a last resort to salvage an endodontically treated tooth and has shown moderate success rates. PDT has demonstrated promise in improving periapical healing and reducing microorganisms. In this case, curcumin, diluted with 2 % chlorhexidine gel, served as an effective photosensitizer agent with antimicrobial properties. Moreover, performing photobiomodulation aided in cell recovery and reduced postoperative discomfort. CONCLUSION: The proposed EMS treatment protocol with PDT using curcumin yielded positive outcomes in this case report. Further randomized clinical trials are necessary to assess the efficacy of this approach in EMS. Additionally, further research on curcumin-based photosensitizer agents encapsulated in nanoparticles and enhanced antimicrobial agents is recommended to refine this treatment protocol for routine use.

A novel simplified approach for endodontic retrograde surgery in short single-rooted teeth.

BACKGROUND: High technical thresholds, long operative times, and the need for expensive and specialized equipment impede the widespread adoption of endodontic microsurgery in many developing countries. This study aimed to compare the effects of a simplified, cost-effective, and time-efficient surgical approach involving orthograde obturation using biological ceramic material greater than 6 mm combined with apicoectomy for single-rooted teeth with short lengths with those of the conventional and current standard methods. MATERIALS AND METHODS: Forty-five premolars equally categorized into three groups: conventional surgery group, standard surgery group, and modified surgery group. A µCT scan was used to calculate the volume of voids. A micro-leakage test and scanning electron microscope (SEM) were performed to assess the sealing effect. Additionally, four cases of chronic periapical periodontitis in the anterior region were selected, and the patients received either the modified approach or the standard surgery for endodontic microsurgery. RESULTS: The volumes of voids in the apical 0-3 mm of the modified group and the standard group were comparable. The micro-leakage test and SEM examination demonstrated closely bonded fillings in the dentinal walls in both the modified surgery group and standard surgery group. The outcomes of the preliminary application of this modified procedure on patients were successful at the time of the follow-up cutoff. CONCLUSIONS: The modified surgery group exhibited similar root canal filling and apical sealing abilities with the standard procedure for single-rooted teeth with short lengths (< 20 mm). The preliminary application of this modified surgical procedure achieved favorable results.

Dynamically guided transantral piezoelectric endodontic microsurgery: A case report with technical considerations.

AIM: Endodontic microsurgery (EMS) of maxillary molars may represent a complex challenge to the clinician due to the location of the roots and the proximity of the maxillary sinus floor. This report aimed to describe the simultaneous use of a computer-assisted dynamic navigation (C-ADN) system and piezoelectric bony-window osteotomy for the transantral microsurgical approach of a maxillary left first molar with adequate root canal filling and symptomatic apical periodontitis. SUMMARY: This case report highlights the importance of C-ADN to carry out a minimally invasive buccal surgical access to palatal roots affected by apical periodontitis and provides a practical example to help clinicians make treatment decisions based on the available evidence. Clinical and tomographic evaluations were performed before the surgical procedure and at 24-month follow-up. This case was treated using a C-ADN system fitted to a piezotome for the buccal approach of the buccal roots, maxillary sinus membrane lifting, and for transantral location, root-end resection, cavity preparation, and filling of the palatal root. The navigation system allowed to achieve an accurate apical canal terminus location and root-end filling of the three roots with a minimally invasive piezoelectric crypt approach. At the 24-month follow-up examination, the patient remains asymptomatic, with normal periapical structures, and regeneration of maxillary sinus walls. It was concluded that the combination of dynamic navigation with piezoelectric bony-window osteotomy offers enhanced accuracy, tissue preservation, diminished risk of iatrogenic complications, and could maximize success and survival rates in transantral EMS.

Immediate implant placement for chronic peri-apical periodontitis in the molar region: a randomised controlled trial.

The aim of this study was to evaluate the feasibility of immediate implantation for chronic peri-apical periodontitis in the molar region. Seventy-four molars were selected and allocated randomly to two groups. The experimental group (n = 38) received immediate implantation by flap surgery and the control group (n = 36) received delayed implantation. CBCT was performed immediately after surgery (T1) and 12 months after the permanent repair (T3). The implant survival rate at T3 was 100% in both groups. There was no significant difference in buccal or lingual vertical marginal bone loss between the groups (P = 0.515, P = 0.736). However, the buccal horizontal margin bone loss was significantly greater in the experimental group: 0.98 ± 0.34 mm vs 0.77 ± 0.27 mm in the control group (P = 0.003). In the experimental group, the highest point of buccal and lingual implant-bone contact increased at T3. The buccal and lingual jump gap widths were 3.21 ± 1.10 mm and 2.92 ± 1.01 mm at T1, and CBCT showed no jump gap around the implants at T3. The clinical outcomes showed immediate implantation to be feasible for chronic peri-apical periodontitis in the molar region.

Predictors of periapical bone healing associated with teeth having large periapical lesions following nonsurgical root canal treatment or retreatment: A cone beam computed tomography-based retrospective study.

AIM: Several factors influence the condition of the periapical tissues associated with root filled teeth. The primary objective of this study was to retrospectively evaluate the extent and speed of bone healing of large periapical lesions associated with nonsurgical root canal treatment or retreatment. The secondary objective was to analyse the relationship between the time to complete healing when analysed using cone beam computed tomography (CBCT) and other possible predictors that affect healing. METHODOLOGY: Seventy-nine patients were treated during the years 2013-2020 with large periapical lesions of endodontic origin (10-15 mm) as observed on intraoral periapical radiographs (IOPAR) were included. IOPAR and CBCT were available before treatment and during the follow-up (IOPAR every 6 months and CBCT every 12 months). The volume of periapical lesions was calculated by OsiriX Lite software. Variables such as initial volume of the lesion, age, gender, type of treatment or type of root canal filling were compared to identify the differences between healed and unhealed lesions. Pearson's Chi-square test was used for categorical variables, the t-test for age and the Wilcoxon test for initial volume of the lesion. The association between time to healing and the variables was assessed using univariate analysis and multivariate analysis. The Wilcoxon test was used to observe the association of healing time with categorical variables and the correlation index was measured with the quantitative variables. RESULTS: Of the 79 cases analysed, 60 lesions (76%) were completely healed as verified by CBCT in a mean healing time of 19 months, of which 60% healed fully between 12 and 18 months. Increase in age of patient and larger initial volume of the lesion were associated with a significantly longer healing time (p < .001). Gender, filling material and type of treatment did not have a significant effect on the healing process (p > .05). CONCLUSIONS: Clinicians should be aware that periapical lesions in older patients and larger areas of bone loss take longer to heal. CBCT monitoring of large periapical lesions is critical and it can help clinicians in the decision-making process.

Postoperative pain of single-visit endodontic treatment with gutta-percha versus MTA filling: a randomized superiority trial.

BACKGROUND: Postoperative pain has remained a challenge for clinicians. This randomized superiority trial compared the levels of postoperative pain following the use of gutta-percha (GP) and sealer or mineral trioxide aggregate (MTA) as root canal filling materials in teeth with asymptomatic apical periodontitis. METHODS: A total of 119 patients were initially evaluated in this two-arm, parallel-group, single-blind, superiority randomized trial. The inclusion criteria were participants aged 18-65 years with single-canal premolars diagnosed with asymptomatic apical periodontitis. The participants were finally divided into two groups using the permuted block randomization method. In the GP group (N = 46), the cleaned and shaped root canals were filled with gutta-percha and AH Plus sealer, while in the MTA group (N = 48), the cleaned and shaped root canals were filled with an MTA apical filling and a coronal gutta-percha and sealer. Patient pain level was measured 6, 12, 24, 48, and 72 h postoperatively using a 10-point visual analog scale (VAS). The data were analyzed by the chi-square, independent t, Friedman, and Mann-Whitney U tests. RESULTS: The mean of VAS scores decreased significantly over time in both groups (P < 0.001). The mean VAS scores were significantly lower in the MTA filling group than in the other group (P < 0.05). Female patients reported higher VAS scores at 6- and 12-hour periods in both groups (P < 0.05). CONCLUSION: MTA as a root canal filling material might be a valuable option for clinicians due to its low postoperative pain. TRIAL REGISTRATION: The trial protocol was registered at the Registry of Clinical Trials (IRCT20191104045331N1).

The effect of the irrigant activation protocol on postoperative pain in maxillary incisors with asymptomatic apical periodontitis: A three-arm randomized clinical trial.

OBJECTIVES: This study aimed to compare the effects of three irrigation activation systems (IAS) on postoperative pain (PP) in activating three final irrigants: sodium hypochlorite 5.25%, ethylenediaminetetraacetic acid 17%, and chlorhexidine 2%. MATERIALS AND METHODS: This parallel randomized clinical trial included referred patients with asymptomatic large-sized apical lesion incisors. A standard method was followed in the canal cleaning and shaping for all included patients in the study. Then, the patients were randomly assigned (1:1 allocation) into three groups: G1 (n = 20) with passive ultrasonic irrigation activation; G2 (n = 20) with XP-Endo Finisher file activation; and G3 (n = 20) with diode laser (810 nm) activation. PP was estimated in all groups using a visual analog scale after 1, 3, 7, and 14 days of treatment. Comparisons between the groups were made using the Kruskal-Wallis test, whereas the Mann-Whitney U test was used in the pairwise comparisons. RESULTS: Sixty patients were followed-up in this trial. There were significant differences between the groups in terms of PP After 1, 3, and 7 days of treatment (p = 0.002, p = 0.017, and p = 0.006, respectively). On the first day of treatment, G3 showed the lowest PP compared with G1 and G2 (p = 0.007 and p = 0.001, respectively). On the third day of treatment, G3 showed less PP compared with G2 (p = 0.005). On the seventh day of treatment, G2 showed the highest PP compared with G1 and G3 (p = 0.012 and p = 0.003, respectively). CONCLUSIONS: The XP-Endo Finisher file caused the highest PP level especially in the next day and 3 days of the treatment, whereas the diode laser had the lowest PP level during the first week of treatment. It is noteworthy that PP disappeared completely after 2 weeks of treatment with all three IASs. TRIAL REGISTRATION: The trial was registered in the ISRCTN registry (Trial ID: SRCTN99457940).

Well-being, postoperative pain and outcome after clinical application of a novel root canal irrigation fluid-RISA-in teeth with apical periodontitis: A first-in-human study.

AIM: The aim of the study was to assess the tolerance to the new root canal irrigation fluid RISA after root canal treatment (RCT) by evaluating the subject's postoperative well-being, postoperative pain (PP) and treatment outcome. METHODOLOGY: A single-arm prospective study with 16 subjects (17 teeth) diagnosed with asymptomatic apical periodontitis. Endodontic treatment in one session performed using RISA for root canal irrigation. Well-being was assessed on the same day and after 24 h by telephone. For pain intensity, a visual analogue scale was used at 0-5 days. Clinical and radiographic evaluations were performed at ≥12 months. Well-being, occurrence of PP and outcome were qualitatively reported. Friedman test for paired samples and Spearman correlation coefficient were used. Significance was set at p < .05. RESULTS: At the same day and after 24 h, 14/16 subjects felt 'good'. 9/16 presented intra- or extra-oral swelling. The frequency of PP ≥36 (weak) was 82.4%. On the same day, 1 and 2 days postoperatively, there was more pain compared with preoperative pain p < .05. At Day 3, PP equalled preoperative pain (p > .05). 62.5% of subjects needed analgesics Day 0-2. The recall rate was 94.1%, and resolution of apical periodontitis was observed in 87.5%. CONCLUSIONS: The well-being of subjects was good, and the overall PP intensity was low. However, postoperative intra- and extra-oral swelling occurred often. At the recall visit, the effectiveness of the RCT with RISA appeared high (87.5%). The encouraging outcome results plus the fact that RISA has a broader action range than NaOCl in vitro, justify further work on the RISA solution. To reduce postoperative swelling, it is advised to further investigate the optimal way of application of RISA in the laboratory before clinical application is recommended.

Comparison of intracanal ozone and low-level laser therapy on postoperative pain in vital teeth with symptomatic apical periodontitis:placebo-controlled randomize trial.

The aim of this study was to compare the effect of ozone and low-level-laser therapy (LLLT) on postoperative pain after root canal treatment in symptomatic apical periodontitis on vital teeth. Eighty patients were divided into four groups using a web program as follows: LLLT placebo (mock laser therapy), LLLT, Ozone placebo (mock ozonated water irrigation), and Ozone. Postoperative pain levels for 7 days after treatment and percussion pain levels at the 7th day were recorded on the visual analog scale. A regression analysis, Cochran's Q test, Chi-square test, Kruskal-Wallis tests were performed to analyze the data (P=.05). A regression analysis demonstrated that the most effective variables are "group" and "jaw" (P=0.01). Pain in the lower jaw is higher than the upper jaw. There was difference between the groups on postoperative pain at the days 1, 2, and 3; however, there was no significant difference on other days. LLLT and ozone groups had less postoperative pain and pain on percussion. Low-level laser and ozone therapy are useful methods on postoperative-pain in vital symptomatic teeth ,but they don't have superiority to each other.

Management of Apico-marginal Defects With Endodontic Microsurgery and Guided Tissue Regeneration: A Report of Thirteen Cases.

The loss of periodontal tissue support and vertical buccal bone loss in apico-marginal defects can often be mistaken for features indicative of vertical root fractures and this study reports thirteen cases with persistent symptomatic apical periodontitis, apico-marginal defects, and large periapical lesions that were managed with endodontic microsurgery in conjunction with bone grafts and barrier placements with a follow-up period of up to 9 years. At the recall sessions, all cases were asymptomatic with radiographical success with only 2 cases exhibiting residual apical radiolucency, but with evident reduction in the lesion size, indicative of healing. This study highlights the potential of utilizing endodontic microsurgery combined with guided tissue regeneration that proved effective in stimulating the regeneration of periodontal tissue in cases of apico-marginal defects that can lead to favourable long-term outcomes.

Immediate implant placement in single mandibular molar with chronic periapical periodontitis.

INTRODUCTION: The present study aims to assess and compare the clinical outcomes of immediate implant placement in the mandibular molar region with or without the presence of chronic periapical periodontitis. MATERIALS AND METHODS: Employing a case-control design, this study encompassed a cohort of patients necessitating implant surgery to supplant a single, failed mandibular molar. Participants exhibiting periapical lesions measuring between > 4 mm and < 8 mm were assigned to the test group, while those without periapical lesions to the control group. Subsequent to flap surgery and tooth extraction, extraction sockets were debrided thoroughly, and implants were immediately implanted (baseline). Permanent restorative procedures were carried out three months post-operation, with follow-up conducted one year post-surgery. During the study period, parameters including implant survival rate, Cone Beam Computer Tomography (CBCT) data, implant stability quotient (ISQ), insertional torque values (ITV), and potential complications were closely monitored. RESULTS: Throughout the yearlong observation period subsequent to implant placement, both groups exhibited a 100% implant survival rate. None of the participants experienced any complications. Both groups demonstrated significant decreases in the height and width of the alveolar bone (P < 0.05). However, there were no statistically discernible differences between corresponding areas in the two groups (P > 0.05). The differences in ITV between the test group (37.94 ± 2.12 N•cm) and the control group (38.55 ± 2.71 N•cm) were not statistically significant at baseline (P > 0.05). A significant rise in ISQ was noted within the same group between baseline and three months post-operation (P < 0.05), while no significant variations in ISQ changes were noted between the two groups (P > 0.05). CONCLUSION: Given the constraints of this investigation, the preliminary clinical outcomes of immediate implant placement in the mandibular molar region with chronic periapical periodontitis do not significantly differ from those observed in instances devoid of chronic periapical periodontitis.

Evaluating the efficacy of endodontic microsurgery for teeth with an undeveloped root apex and periapical periodontitis after nonsurgical treatment failure.

AIM: To determine the efficacy of endodontic microsurgery for teeth with an undeveloped root apex and periapical periodontitis caused by an abnormal central cusp fracture after failed nonsurgical treatment. METHODOLOGY: Eighty teeth in 78 patients were subjected to endodontic microsurgery. All patients were clinically and radiologically examined 1 year postoperatively. The data were statistically analyzed using SPSS 27.0 software. RESULTS: Of the 80 teeth in 78 patients, periapical lesions had disappeared in 77 teeth at 1-year postoperative follow-up, with a success rate of approximately 96.3% (77/80). The efficacy of endodontic microsurgery was not affected by sex, age, extent of periapical lesions, and presence of the sinus tract. Between-group differences were not statistically significant (P > 0.05). CONCLUSIONS: Endodontic microsurgery can be an effective alternative treatment option for teeth with an undeveloped root apex and periapical periodontitis caused by an abnormal central cusp fracture after nonsurgical treatment failure.

Root Canal Treatment of Oehlers Type III Dens Invaginatus in Maxillary Lateral Incisor and Remote Sinus Tract Using Dental Surgical Microscope and Cone-Beam Computed Tomography.

Dens invaginatus is a morphological abnormality of the tooth that results from a developmental anomaly during tooth formation, in which part of the enamel and dentin of the crown invaginates into the pulp cavity. This report describes a case of a maxillary lateral incisor with apical periodontitis apparently caused by Oehlers Type III dens invaginatus. The patient was a 69-year-old man who visited our clinic complaining of discomfort in the maxillary right lateral incisor. Cone-beam computed tomography (CBCT) revealed dens invaginatus of the maxillary lateral incisor and a sinus tract in the maxillary central incisor region, which was derived from apical periodontitis of the maxillary lateral incisor. The dens invaginatus was accompanied by a complex root canal morphology. Treatment, which was performed using a dental surgical microscope, had a favorable outcome. The patient remains in good condition at 1 year postoperatively.

Expression of chronic pain genes in apical periodontitis tissues.

AIM: To evaluate the expression of genes involved in chronic pain conditions in apical periodontitis (AP) tissues. METHODOLOGY: An electronic search was performed in Scopus and MEDLINE (via PubMed) databases to identify articles (n = 173) related to genes involved in chronic pain conditions. Full-text reviews of the selected articles allowed the prioritization of 16 genes to be investigated with regards to their expression in AP tissues. Periapical lesions (n = 42) were collected during surgical endodontic procedures and processed for mRNA extraction and investigation of target genes via RT-qPCR. Healthy periodontal ligament tissues obtained from third molar extractions were used as controls. Relative levels of target gene expression in AP and control tissues were normalized to GAPDH expression and compared using the 2-ΔΔCt method. Data analysis was performed using the Mann-Whitney U test with a statistical significance threshold set at p < .05. RESULTS: mRNA expression levels of MMP9, TIMP1, TNFA, CAMK4 and COMT were significantly increased in AP tissue samples compared with controls (p < .05). Positive correlations were observed between the expression of TIMP1 with COMT and CAMK4, TNFA with TIMP1 and CAMK4, COMT with CAMK4. CONCLUSIONS: This study confirms the upregulation of MMP9, TIMP1, TNFA in AP tissues and reports for the first time, the expression of CAMK4 and COMT as suggestive of their involvement in AP pathogenesis.

Irrigation - does it affect post-operative pain?

DESIGN: A randomised control trial involving eighty patients who were blindly allocated into four different groups for different disinfection and irrigation methods on lower permanent molars. The patients were treated by one experienced endodontist across two visits. The four methods of irrigation used were: 1. Conventional irrigation 2. Sonic irrigation activation system 3. Irradiation with a 980 nm diode laser and conventional irrigation 4. Irradiation with a 980 nm diode laser and sonic irrigation activation system Pain levels were then assessed postoperatively at 8 h, 24 h, 48 h and 7 days following access and chemomechanical preparation at the first visit. CASE SELECTION: Eighty patients who visited the Endodontic Department at Biruni University were included in the study. Those who were included were healthy adults, experiencing moderate to severe pain (self-scored from 4 to 10, based on a 0 to 10 pain scale) at the start of treatment and those who were given a dental diagnosis of 'symptomatic apical periodontitis' with a negative cold test in a mandibular molar. DATA ANALYSIS: Qualitative data was analysed using a chi-square test, Fisher's exact chi-square test and Fisher-Freeman-Halton exact test. The Kruskal-Wallis test and Willcoxon test were used to assess inter-group and intra-group parameters. RESULTS: The study found that patients in all groups experienced a statistically significant decrease in pain levels postoperatively. However, different irrigation methods resulted in no statistically significant differences in pain levels. There were also no statistically significant differences based on gender or age. Statistical significance was reached when p < 0.05. CONCLUSIONS: The use of sonic irrigation activation and irradiation with a 980 nm diode laser did not significantly reduce post-operative pain in adult mandibular molars undergoing endodontic treatment when compared to conventional irrigation methods.

Treatment outcome of surgical and non-surgical endodontic retreatment of teeth with apical periodontitis.

AIMS: To evaluate and compare the treatment outcome of root filled teeth with apical periodontitis treated either non-surgically or by endodontic microsurgery, and to assess the influence of an intra-radicular post, clinical and demographic factors. METHODOLOGY: Clinical and radiological data from 1157 patients with apical periodontitis in previously root filled teeth treated by postgraduate students at the Department of Endodontics, University of Oslo, between September 2010 and January 2020 with recall data at least 11 months from completion were studied. Surgical cases were scored using the Rud/Molven criteria and grouped into success, uncertain or failure at control. Non-surgical cases were scored with the periapical index (PAI) and similarly grouped into success, uncertain or failure at control. Chi-square analyses were used for comparison of subgroups of teeth treated and logistic regression analyses for assessment of the influence of clinical variables. RESULTS: Non-surgical retreatment was performed on 351 teeth and 107 teeth were treated with endodontic microsurgery, with overall success rates of 65.5% and 77.6%, respectively. The difference was statistically significant. Teeth with an intra-radicular post treated non-surgically (n = 30) were successful in 73.3% of cases, whereas teeth with intra-radicular post treated with endodontic microsurgery (n = 30) had a lower, 66.7% success rate. The distribution of tooth groups (anterior, premolar and molar) differed significantly between surgical and non-surgical cases, with maxillary anterior and premolar teeth more often treated surgically. Non-surgical retreatment cases were significantly influenced by patients' age (older patients had poorer outcome) and pre-operative PAI score (negatively correlated with outcome). Surgical cases were not significantly influenced by the factors studied here. CONCLUSIONS: The tooth type differed significantly for teeth treated by surgical versus non-surgical methods. Microsurgical treatment with apicectomy and retrograde filling showed significantly better treatment results than non-surgical retreatment of teeth with apical periodontitis, whereas treatment outcome in teeth with posts after non-surgical treatment tended to be better than after surgical treatment. Outcome of non-surgical retreatment was negatively influenced by older age and higher pre-operative PAI score.

Suspected Endodontic Failure in a Patient with Cleidocranial Dysplasia: A Case Report.

A patient's medical history and related dental manifestations can significantly contribute to confounding signs and symptoms leading to a diagnostic challenge. An 18-year-old female patient presented with persistent radiographic radiolucency associated with the apex of a previously treated tooth (tooth 9); asymptomatic apical periodontitis and endodontic failure were suspected. This report presents how a patient's condition of cleidocranial dysplasia had a profound effect on her dental history, which included the presence of multiple supernumerary teeth. Extensive surgical intervention during the patient's childhood was required to remove the supernumerary teeth, which resulted in an endodontic misdiagnosis in her adult life. After clinical and radiographic examination, the patient was diagnosed with a periapical scar. Periapical fibrous scars have a prevalence of between 2.5% and 12% and are a rare healing process with fibrous tissue after surgical and nonsurgical interventions. This report describes the diagnosis and pathophysiology of fibrous scars, including their risk factors and long-term monitoring approaches.

Influence of inflammation on bleeding and wound healing following surgical extraction of impacted lower third molars.

OBJECTIVE: This study aimed to investigate the effect of inflammatory states following impacted lower third molar (ILTM) surgery regarding postoperative bleeding and wound healing. METHODS: The study included patients who underwent extraction of ILTMs associated with or without inflammatory conditions. Post-extraction bleeding and wound healing were assessed. In addition, mean grey values (MGVs) of alveolar bone and bone height using an orthopantomography radiograph were analyzed. RESULTS: A total of 376 patients were enrolled; 171 pericoronitis, 51 pulpitis, 44 chronic periapical periodontitis, 36 chronic periodontitis, and 74 control. The bleeding score in the control group was significantly lower than in the periapical periodontitis and periodontitis groups. Excellent wound healing for control, pericoronitis, pulpitis, periapical periodontitis, and periodontitis groups was (78.38%, 35.67%, 70.59%, 70.45%, and 33.33%, respectively). Patients with pericoronitis and periodontitis had significantly poorer wound healing (P < 0.01). The MGV in periapical periodontitis and periodontitis was considerably lower than in the control group. CONCLUSIONS: The inflammatory conditions associated with ILTMs increase the risk of bleeding. So suturing with the placement of local hemostatic agents over a pressure pack alone is recommended. The poorest wound healing was in localized gingival inflammation. Furthermore, MGV was affected by age and was lower with periapical periodontitis.