Iranian Endodontic Journal

Introduction: This review evaluates the effectiveness of treatment modalities for immature teeth with pulp necrosis, focusing on calcium hydroxide (CH) and mineral trioxide aggregate (MTA) apexification, as well as regenerative endodontic treatments (RETs). Recent advancements and clinical outcomes are highlighted. Materials and Methods: A comprehensive search of MEDLINE (PubMed), Embase, Cochrane Library, Scopus, and grey literature was conducted from inception to July 2024. Systematic reviews and meta-analyses (SR/MAs) assessing apexification and RET outcomes in immature teeth with pulp necrosis were included. Studies were selected based on predefined criteria, and data on study design, interventions, and outcomes were extracted. Methodological quality was evaluated using the AMSTAR-2 tool. Results: 31 SR/MAs were included. The quality ranged from critically low to low, except one rated as high. MTA apexification was more effective than CH for faster apical barrier formation, though overall success rates were similar. MTA is preferred for its efficiency, but standardized protocols are needed, and tooth discoloration was noted as a potential complication. RET generally outperforms apexification in root maturation, with platelet concentrates like platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) showing promising results; PRP was associated with greater root length, while PRF showed superior apical healing. Variability in RET outcomes was noted due to the lack of standardized protocols. Comparative studies of RET versus apexification showed no significant differences in survival or overall success rates. RET often provides better apical closure and root development, though results vary. Both approaches are viable, but more research with standardized protocols and larger samples is needed to establish definitive clinical advantages. Conclusions: MTA apexification and RET are viable alternatives to CH apexification, with RET showing greater potential for root development and apical healing. Future research should focus on developing standardized protocols and uniform RET guidelines, and evaluating long-term outcomes to establish efficacy and safety.

This scoping review aimed to assess immunohistochemical markers associated with the physiopathogenesis of Persistent Apical Periodontitis. The protocol was adapted from the Joanna Briggs Institute Reviewer's Manual (2017) and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for Scoping Reviews. A total of 239 articles were considered potentially eligible, and their full texts read by two reviewers. Six articles were included. The included articles were published between 1999 and 2017. A total of 12 biomarkers were identified, forkhead box P3, cluster of differentiation (CD)3, CD8, CD450, CD68, transforming growth factor alpha, transforming growth factor-beta1, matrix metalloproteinase-9, receptor activator of nuclear factor kappa beta ligand, osteoprotegerin, CD90 and sex-determining region Y-box 2; categorized according to their applicability. Among the biomarkers identified, receptor activator of nuclear factor kappa beta ligand and osteoprotegerinare were related to bone remodeling in apical periodontitis and may also be associated with persistent apical periodontitis.

Introduction: Endodontic therapy has been regarded as a safe treatment option with highly promising results in preserving natural teeth. Numerous factors may influence the longevity of endodontically treated teeth (ETT), thus altering their success/survival rate. This study aimed to determine the survival and success rates of endodontically treated premolars and molars with different complex restorative/prosthodontic treatments. Materials and Methods: A total of 190 patients with an ETT were included, who had received final coronal restoration up to 14 days after the temporary one and at least one year prior to the enrollment. The investigator evaluated the quality of endodontic filling, coronal restoration, mobility, and proximal contacts. Data were analyzed with multiple binary logistic regression and the Chi-Square test. Results: The average duration of follow-up was 28.6±11.9 months. Overall, 89.4% (170/190) of the teeth survived. The overall success rate for the investigated teeth was 70.5% (134/190). Success rates of 100% for crown, 95.7% for post and core crown (PCC), and 94.7% for amalgam build-up with post were achieved. However, the success rates were 75%, 52.5%, and 50% for amalgam build-up, composite build-up, and PCC with crown lengthening, respectively. The Chi-square test revealed that there was a significant difference between the different restorations in terms of success (P<0.001). Multiple binary logistic regression models revealed that coronal leakage (P=0.048), obturation void (P=0.037), obturation length (P=0.020), mobility (P=0.002), type of the restoration (P<0.001), and proximal contact (P<0.001) were significant predictors for success. However, apical lucency, root length, marginal caries, tooth type, and post did not appear to be significant indicators of success (P>0.05). Conclusions: ETT with minimal mobility, exhibiting underfilled obturations without visible voids, and having received crown/PCC/amalgam build-up with a post, along with the presence of both proximal contacts, tend to exhibit a significantly high success rate.

Introduction: In this study, the cleaning ability of a stainless-steel rotary instrument called Gentlefile, was compared with three nickel-titanium rotary instruments. Materials and Methods: In this in vitro study, forty mandibular single-rooted premolars were randomly assorted into four groups: Gentlefile, ProTper Universal, RaCe files, and XP-Endo Finisher/ProTaper Universal system (n=10). Final instrumentation was done using the aforementioned files with 5.25% sodium hypochlorite and normal saline for root canal irrigation. Debris and smear layers were observed by the scanning electron microscope on the canal walls in the coronal, middle, and apical third of the root level, through a 4-point scoring system. The chi-square test and Kruskal-Wallis were used for data analysis. Results: The Gentlefile demonstrated a promising outcome in smear layer clearance and debris removal compared with the other three rotary systems (P<0.05), specifically at the apical third of the root canal. Based on chi-square test results, there was a significant relationship between root canal cleaning (three levels of cleanliness) in ProTaper Universal (P=0.004) and Gentlefile (P=0.04) groups. Neither of the investigated systems achieved complete cleanliness. Conclusion: The Gentlefile rotary system can be capable of cleaning the apical third of root canals more than the other three groups including Protaper Universal, RaCe, and XP-Endo Finisher.

Introduction: Calcium silicate-based sealers are an alternative to be used into root canal, mainly to their biological properties. However, some biological parameters need to be determined in an in vivo animal research model. So, the aim of the present study was to evaluate in vivo the tissue biocompatibility of a calcium silicate-based sealer (EndoSequence BC Sealer) and an epoxy resin-based sealer (AH-Plus). Materials and Methods: Polyethylene tubes were filled with freshly mixed sealers and implanted in connective subcutaneous tissue of 25 rats (5/euthanasia day) (Rattus norvegicus albinus). Empty tubes were used as controls and no tubes as sham. Histopathological (hematoxylin eosin) and histochemical (Picrosirius red) examinations were conducted at 3, 7, 15, 30 and 60 days (five rats/day) after the implantation procedure (n=5/group). The type/intensity of inflammation and collagenesis was analyzed statistically with Friedman or Kruskal-Wallis/Dunn tests (P<0.05). Results: The profile of inflammation induced by AH-Plus (Median=2, Range=2-3) was significantly greater than that by Endosequence BC Sealer (Median=1, Range=1-1) during the 15-day experimentation period (P=0.018). After 30 days, both materials produced similar tissue reaction (P>0.05). AH-Plus and Endosequence BC Sealer (Median=2, Range=1-2) induced a high level of fibrosis after 60-day than control (Median=1, Range=1-1) and sham (Median=0, Range=0-0) groups (P<0.001) of fibrosis based in type I collagen increase (P=0.025 and P=0.021, respectively). Tissue necrosis was not observed and the bioceramic sealer showed significant signs of endocytosed (Median=1, Range=1-1) material after 7 days than other groups (Median=0, Range=0-0) (P<0.05). The calcium silicate-based sealer induced tissue repair faster than the epoxy resin-based sealer tested. However, both materials showed adequate biocompatibility and tolerance by subcutaneous tissues, with few differences in inflammatory profiles, formation of granulation tissue, and collagenesis. Conclusions: It may be concluded that calcium silicate-based sealer (EndoSequence BC Sealer) and an epoxy resin-based sealer (AH-Plus) presented suitable biocompatibility.

The patients with unusual symptoms present a diagnostic challenge for clinicians and may lead to misdiagnoses and inappropriate or unnecessary treatments. Endodontic diseases can present with a variety of symptoms, and it is possible for odontogenic pain to resemble non-odontogenic pain, which can complicate treatment due to the distinct management plans of the two conditions. This report details the successful management of vague pain, and popping sensations in the left maxilla triggered by cold exposure. Previous clinicians were unable to identify the pain's origin, leading to unnecessary treatments. A clinical examination, and cone-beam computed tomography evaluation revealed the presence of a missed second mesiobuccal root canal. The canal was located using an operating microscope and ultrasonics. Non-surgical endodontic retreatment was completed in two visits, successfully. This report highlights the critical importance of identifying the diverse symptoms that may arise from endodontic origin, as these can complicate clinical diagnosis.

Internal tooth resorption is a subtle proceeding typically occurring in the tooth dictating past trauma, chronic pulpal inflammation, or caries-related issues. It is frequently observed Front teeth are susceptible to injury because they are more vulnerable but can also affect posterior teeth, often due to pulp involvement in cavities. Timely detection, addressing the underlying cause, and Effective care of the impacted root are essential for achieving a favorable treatment result. This case report illustrates the handling of a resorptive issue in the lower part of the tooth, managed through non-surgical means employing the thermoplasticized gutta-percha technique.

Invasive cervical resorption (ICR) is an aggressive pathological condition that can affect any permanent tooth. This process is characterized by replacement of the tooth structure with granulomatous fibrovascular or fibro-osseous tissue. Despite its asymptomatic nature, ICR can lead to tooth loss. This study reports a case of ICR in a 15-year-old boy with a history of dental trauma. The patient had a diagnosis of ICR in tooth #21. After considering the risks of an external surgical approach and exclusive endodontic treatment, intentional re-implantation combined with extraoral composite resin restoration and endodontic treatment was proposed. The procedure consisted of atraumatic tooth extraction, removal of granulomatous tissue, restoration of the cavity with composite resin, re-implantation of the tooth in the alveolus, and endodontic treatment. This approach resulted in satisfactory repair of the resorptive lesion observed in over 3 years of follow-up. This case highlights intentional re-implantation combined with appropriate endodontic treatment as a viable treatment option for ICR.

External cervical resorption is a condition that leads to the loss of hard dental tissues, including enamel, cementum, and dentin. Although it is an aggressive condition, its causes are not yet fully understood. The treatment of resorptions depends on their extent, location and the material used. When managing these lesions, the position of the bone crest and the ability of the periodontal tissue to adhere to the material after setting must be considered. This case report aims to demonstrate a clinical case of external cervical resorption which was treated by a proposed protocol that uses different dentin substitute restorative materials depending on the location of the resorptive area in relation to the bone crest. The success of this treatment depended on the correct use of materials and adequate tissue management. The combination of different materials has shown promising results in treating resorptions in both supra- and infra-osseous areas.

Pulp canal calcification (PCC) is common in patients with dentinogenesis imperfecta (DGI). We present endodontic management of multiple anterior and posterior teeth with PCCs in a patient with DGI type II using guided endodontics. A 26-year-old female patient was diagnosed with DGI type II. Clinical examination revealed palatal cusp fracture in tooth #13, microcracks in tooth #14, and a sinus tract in the maxillary right buccal vestibule related to tooth #13. Periapical radiographs revealed PCCs in all teeth, and periapical radiolucencies in several teeth. Due to difficult negotiation of canal orifices, guided endodontic approach was planned. Cone-beam computed tomography (CBCT) was requested and obtained. Intraoral scanning was performed, and CBCT and intraoral scanning data were superimposed. A template was designed and 3D printed. The root canal orifices were successfully negotiated and endodontic treatments were successfully accomplished. At the 1-year follow-up, the endodontically treated teeth were asymptomatic, and periapical lesions were healing.