Characterizing the Root Canal Configuration of Mandibular Incisors in a Western Saudi Arabian Sub-population Using Cone Beam Computed Tomography.

Aim This study aimed to explore the morphology and complexity of mandibular anterior teeth in a Western Saudi Arabian sub-population using cone beam computed tomography (CBCT). Methodology CBCT scans from 818 patients were evaluated, and 3193 mandibular anterior teeth were analyzed for the number of roots, canal, canal configurations, separation level, bilateral symmetry, and gender associations. Results The results showed that all examined central and lateral incisors had a single root, and the majority exhibited a single canal. The prevalence of two canals in mandibular central and lateral incisors was 20.1% and 23.2%, respectively, resulting in an overall prevalence of 21.7% for two root canals in mandibular anterior teeth. The separation level of the two canals was predominantly located in the middle third of the root. Type I canal configuration was the most common, followed by type III. A high degree of bilateral symmetry in the number of canals and canal configurations was noted. Conclusion The findings contribute to the understanding of root canal anatomy in the Saudi population and provide valuable information for endodontic treatment planning.

Outcomes of endodontic microsurgery using different calcium silicate-based retrograde filling materials: a cohort retrospective cone-beam computed tomographic analysis.

PURPOSE: To evaluate the outcomes of endodontic microsurgery (EMS) using mineral trioxide aggregate (MTA; Dentsply Sirona, Charlotte, NC, USA), EndoSequence root repair material (RRM putty; Brasseler, Savannah, GA), and injectable Bioceramic (BC) sealer (Brasseler USA) followed by the application of RRM putty (lid technique) as root-end filling materials. METHODS: One hundred and ten patients who underwent EMS between 2016 and 2020 at King Abdulaziz University Dental Hospital were recruited for clinical and radiographic follow-up after a minimum of 1 year. Radiographic assessment was performed using periapical radiographs (PAs) and cone-beam computed tomography (CBCT). Volumetric analysis of periapical radiolucencies (PARLs) was performed using Amira software. RESULTS: Seventy-nine patients (103 teeth: MTA group, n = 28; RRM putty, n = 41; lid technique, n = 34), attended the follow-up visit, with an average follow-up period of 24 months (recall rate = 74.5%). Of the 103 teeth, 40 were anteriors, 24 were premolars, and 39 were molars. All three groups of retrograde filling materials (MTA, RRM putty, and lid technique) showed high success rates on both PA (85.7, 85.4, 94.1%, respectively) and CBCT imaging (67.9, 75.6, 88.2%, respectively), without any significant difference among the success rates of different materials. Overall, a slight agreement was noted between the PA and CBCT outcomes, with a statistically significant difference (P = 0.029). None of the patient-, tooth-, or treatment-related factors significantly influenced the outcomes of EMS. Adequate density of root canal filling material was significantly associated with a high percentage of completely healed cases on CBCT (P = 0.044). PARL volumes were reduced significantly over 1-4 years follow-up after EMS (P < 0.001) CONCLUSIONS: EMS showed high success rates on both PA and CBCT when MTA, RRM putty or lid technique were used as retrograde filling materials. CBCT imaging is more precise than PA in detecting the healing outcomes of EMS.

Pulpal and periapical tissue response after direct pulp capping with endosequence root repair material and low-level laser application.

BACKGROUND: The study aims to investigate the pulp and periapical reaction and healing after capping with EndoSequence Root Repair Material (ERRM) combined with low-level laser application. METHODS: In 6 rabbits, pulps were exposed via class V, half of the samples received a low-level diode laser at 980 nm. Thereafter, cavities were capped with regular-set ERRM. The specimens were processed for histomorphological examination after 2 weeks and two months. RESULTS: After 2 weeks, images show mild inflammation and organized odontoblasts in lased group. The non-lased group shows more severe inflammation. The predentin thickness was thicker in the lased group with statistical significance (p < 0.05). After 2 months, inflammatory cells were sparse in both lased and non-lased groups. In the periapical area, group one showed dilated blood vessels and thick fibrous connective tissues. In group two, there were more numerous maturations of PDL fibers with scattered inflammatory cells and congested blood vessel. CONCLUSIONS: Using low-level laser therapy in combination with ERRM for pulp capping shortens the inflammatory phase and enhances healing.

Prevalence and Pattern of Idiopathic Osteosclerosis and Condensing Osteitis in a Saudi Subpopulation.

Background This study aims to investigate the prevalence and pattern of idiopathic osteosclerosis (IO) and condensing osteitis (CO) in the jaws of a Saudi Arabian subpopulation with regards to gender, age, shape, localization, and tooth relationship. Methodology Digital panoramic and periapical radiographs with clinical data of 1,000 patients at King Abdulaziz University Dental Hospital were analyzed to determine the incidence of IO and CO lesions in relation to age, gender, location in the jaws, and dental status of the associated tooth. Descriptive statistics and chi-square tests were used for data analysis. Results Out of the 752 patients (495 females, 257 males), IO was identified in 66 (8.8%) patients, while 44 (5.9%) patients had CO. IO occurred more in females (68.2%) than males (31.8%). CO had a statistically significant higher rate of occurrence in females (81.8%) than males (18.2%) (P ≤ 0.05). IO and CO lesions were observed to be higher in individuals in their third decade, and 100% were in the mandibular molar area. Almost half of the identified IO (48.5%) had a rounded shape radiopacity, while CO mostly appeared irregular (63.6%). Conclusions The prevalence of IO and CO in the studied Saudi subpopulation was low. Both lesions were more frequent in females in their third decade and were primarily found in the mandibular molar region.

Characterization of the differential efficacy of austenitic vs martensitic NiTi rotary files in non-surgical root canal retreatment: a micro-CT analysis.

Aim: Our study aims to characterize the differential efficacy of martensitic and austenitic files in root canal retreatment regarding defiling ability, debris management and morphometric features. Materials and methods: A total of 10 human premolar teeth with two separate fully formed roots were selected, prepared with BioRace system (BR) up to a size BR2 (0.04/25). Root canals were filled and then divided according to the file type into two groups (n = 10). Two geometrically identical files have been used with the only difference between them is heat treatment; One Curve (OC) martensitic and One Shape (OS) austenitic. Preoperative and postoperative Micro-CT scans were done for all the samples, and the percent volume of residual filling materials was calculated. Canals reshaping and remaining debris in the canals were assessed by calculating the volume of the canals before and after retreatment using Micro-CT software. Results: The percentages of removed filling materials were similar between both groups (97.2% OC vs 97.8% OS). OS was significantly faster than OC (P < 0.05). Retreatment procedure did not significantly change volume, structure model index, surface area, and canal curvature. OS group transported the canals more than OC at the apical third (P < 0.05). There were no significant differences between both groups concerning un-instrumented surface area and accumulated hard tissue debris (AHTD) (P > 0.05). Conclusion: Under the circumstances of this study, neither file systems could completely remove the filling materials. However, OC resulted in less transportation than OS in the apical one third (P < 0.05). Also, OC resulted less AHTD than OS but with no statistical difference.

Micro-cleanliness of Hard Tissue Debris After Advanced Irrigation and Comparison Between EndoVac and XP-endo Finisher: A Microcomputed Tomographic Study.

INTRODUCTION: Conventional irrigation techniques do not remove debris adequately. The remaining tissue debris cause infection inside the root canal and may also affect the seal of the root canal. The study aimed to compare the ability of EndoVac (EV) with XP-endo finisher (XPF) in debris removal using micro-CT analysis. MATERIALS AND METHODS: We used 12 lower first permanent molar human teeth for this study. The root canals were instrumented using a small TF adaptive system. Then, the volume of debris was calculated. Teeth were divided into two groups, according to advanced irrigation methods, with six teeth per group: EV group and XPF group. The volume of debris was calculated again. The paired-sample t-test was used to compare the volume of the debris before and after the use of advanced irrigation methods with the statistical significance of P < 0.05. The percentage of debris reduction was also calculated. RESULTS: Both EV and XPF showed a significant decrease of debris in the mesial canals (P < 0.05), whereas EV only showed a significant reduction of debris in the distal canals. CONCLUSION: Both EV and XPF were able to significantly reduce debris after instrumentation in the mesial canals of lower first mandibular molars. CLINICAL SIGNIFICANCE: The study provides insight into the recent advanced methods used in debris removal and canal disinfection.

Assessment of Mesiobuccal Canal Configuration, Prevalence and Inter-Orifice Distance at Different Root Thirds of Maxillary First Molars: A CBCT Study.

AIM: The aims of this study were to assess the prevalence and configuration of the second mesiobuccal (MB2) canal in the mesiobuccal MB root of permanent maxillary first molars at different root levels in a Saudi sub-population using cone­beam computed tomography (CBCT) and to measure the inter-orifice distance between MB & MB2 at the pulpal floor level. MATERIALS AND METHODS: This retrospective study was carried out on CBCT images of Saudi patients seen at King Abdul Aziz University. A total of 106 maxillary first molars were evaluated using a specialized software program (iCAT CBCT software). The prevalence of MB2, canal configuration and location of joining (apical-middle-coronal), if present was calculated. Also, the inter-orifice distance between both canals was measured at the level of the pulpal floor. Chi­square and one-way analysis of variance (ANOVA) were used. RESULTS: The MB2 canal was found in 92 (86.8%) maxillary first molar teeth. The MB and MB2 canals were joined in 61 (58%) cases, where the location of joining was 14 (23%), 17 (27%), and 31 (50%) in the coronal, middle, and apical third, respectively. The mean inter-orifice distance between both canals at the level of the pulpal floor was 2.52±0.76 mm. CONCLUSION: The prevalence of MB2 canal in this Saudi sub-population was high. The prevalence decreased as the root canal approached the apical third. There was no correlation between the average distance and occurrence of canal joining. CBCT is useful in detecting and mapping the mesiobuccal root canal system, with a likelihood of enhancing the quality of root canal treatment.

Efficacy of the Rotary Instrument XP-Endo Finisher in the Removal of Calcium Hydroxide Intracanal Medicament in Combination with Different Irrigation Techniques: A Microtomographic Study.

OBJECTIVES: This study aims to evaluate the efficacy of the rotary instrument XP-endo Finisher for the removal of Ca(OH)2 aided by different irrigation regimens. METHODS: Sixteen double-rooted upper premolar human teeth were selected for the study. Thirty-two canals were prepared using a ProTaper Next rotary system up to X3. Then, the canals were filled with Ca(OH)2. The volume of Ca(OH)2 inside the canals was measured by microcomputed tomography (micro-CT). After that, the teeth were randomly allocated into two experimental groups, i.e., A and B (n = 16 canals). In group A, Ca(OH)2 was removed using the master apical file (X3). In group B, Ca(OH)2 was removed using a XP-endo finisher. In half of both groups (n = 8), syringe irrigation (SI) was used, while passive ultrasonic irrigation (PUI) was used for the other half. After removal, the remaining volume of Ca(OH)2 was measured. All data were statistically analyzed using two-way ANOVA with Tukey's post hoc test. RESULTS: The percentages of remaining Ca(OH)2 in the apical thirds of all canals were significantly higher as compared with the middle and coronal thirds in all groups (p < 0.05). There was no significant difference between different files and techniques (p > 0.05). CLINICAL SIGNIFICANCE: This study presents a new method for the removal of Ca(OH)2 from root canals.

Dental Mesenchymal Stem Cells: Dental Pulp Stem Cells, Periodontal Ligament Stem Cells, Apical Papilla Stem Cells, and Primary Teeth Stem Cells-Isolation, Characterization, and Expansion for Tissue Engineering.

Dental stem cells (DSCs) have been shown to possess great potential for multiple biomedical applications, especially for dental tissue regeneration. They are a special type of subpopulation of mesenchymal stem/stromal cells (MSCs) and present subtle differences from other types of MSCs. Therefore, it requires a specialized expertise to isolate, culture, and characterize these cells in vitro and in vivo. The purpose of this chapter is to share our experience in studying these cells. We will describe in detail laboratory protocols outlining how the cells are isolated, cultured, expanded, and characterized using various in vitro cellular and biochemical analyses, as well as an in vivo study model using immunocompromised mice to observe tissue regeneration after transplantation of these DSCs.

Differential Properties of Human ALP+ Periodontal Ligament Stem Cells vs Their ALP- Counterparts.

Characterizing subpopulations of stem cells is important to understand stem cell properties. Tissue-nonspecific alkaline phosphatase (ALP) is associated with mineral tissue forming cells as well as stem cells. Information regarding ALP subpopulation of human periodontal ligament stem cells (hPDLSCs) is limited. In the present study, we examined ALP+ and ALP- hPDLSC subpopulations, their surface markers STRO-1 and CD146, and the expression of stemness genes at various cell passages. We found that ALP+ subpopulation had higher levels of STRO-1 (30.6 ± 5.6%) and CD146 (90.4 ± 3.3%) compared to ALP- (STRO-1: 0.5 ± 0.1%; CD146: 75.3 ± 7.2%). ALP+ cells expressed significantly higher levels of stemness associated genes, NANOG, OCT4 and SOX than ALP- cells at low cell passages of 2-3 (p<0.05). ALP+ and ALP- cells had similar osteogenic, chondrogenic and neurogenic potential while ALP-, not ALP+ cells, lacked adipogenic potential. Upon continuous culturing and passaging, ALP+ continued to express higher stemness genes and STRO-1 and CD146 than ALP- cells at ≥passage 19. Under conditions (over-confluence and vitamin C treatment) when ALP+ subpopulation was increased, the stemness gene levels of ALP+ was no longer significantly higher than those in ALP- cells. In conclusion, ALP+ hPDLSCs possess differential properties from their ALP- counterparts.

Challenges of stem cell-based pulp and dentin regeneration: a clinical perspective.

There are two types of approaches to regenerate tissues: cell-based and cell-free. The former approach is to introduce exogenous cells into the host to regenerate tissues, and the latter is to use materials other than cells in an attempt to regenerate tissues. There has been a significant advancement in stem cell-based pulp and dentin regeneration research in the past few years. Studies in small and large animals have demonstrated that pulp/dentin-like tissues can be regenerated partially or completely in the root canal space with apical openings of 0.7-3.0 mm using dental pulp stem cells, including stem cells from apical papilla (SCAP) and subpopulations of pulp stem cells. Bone marrow mesenchymal stem cells (BMMSCs) and adipose tissue-derived MSCs (ADMSCs) have also been shown to regenerate pulp-like tissue. In contrast, the cell-free approach has not produced convincing evidence on pulp regeneration. However, one crucial concept has not been considered nor defined in the field of pulp/dentin regeneration and that is the critical size defect of dentin and pulp. Without such consideration and definition, it is difficult to predict or anticipate the extent of cell-free pulp regeneration that would occur. By reasoning, cell-free therapy is unlikely to regenerate an organ/tissue after total loss. Similarly, after a total loss of pulp, it is unlikely to regenerate without using exogenously introduced cells. A cell homing approach may provide a limited amount of tissue regeneration. Although stem cell-based pulp/dentin regeneration has shown great promise, clinical trials are difficult to launch at present. This article will address several issues that challenge and hinder the clinical applications of pulp/dentin regeneration which need to be overcome before stem cell-based pulp/dentin regeneration can occur in the clinic.

Small molecules affect human dental pulp stem cell properties via multiple signaling pathways.

One fundamental issue regarding stem cells for regenerative medicine is the maintenance of stem cell stemness. The purpose of the study was to test whether small molecules can enhance stem cell properties of mesenchymal stem cells (MSCs) derived from human dental pulp (hDPSCs), which have potential for multiple clinical applications. We identified the effects of small molecules (Pluripotin (SC1), 6-bromoindirubin-3-oxime and rapamycin) on the maintenance of hDPSC properties in vitro and the mechanisms involved in exerting the effects. Primary cultures of hDPSCs were exposed to optimal concentrations of these small molecules. Treated hDPSCs were analyzed for their proliferation, the expression levels of pluripotent and MSC markers, differentiation capacities, and intracellular signaling activations. We found that small molecule treatments decreased cell proliferation and increased the expression of STRO-1, NANOG, OCT4, and SOX2, while diminishing cell differentiation into odonto/osteogenic, adipogenic, and neurogenic lineages in vitro. These effects involved Ras-GAP-, ERK1/2-, and mTOR-signaling pathways, which may preserve the cell self-renewal capacity, while suppressing differentiation. We conclude that small molecules appear to enhance the immature state of hDPSCs in culture, which may be used as a strategy for adult stem cell maintenance and extend their capacity for regenerative applications.

Cells isolated from inflamed periapical tissue express mesenchymal stem cell markers and are highly osteogenic.

INTRODUCTION: We previously reported the presence of mesenchymal stem/progenitor cells (MSCs) in inflamed pulp tissue. Here we asked whether MSCs also exist in inflamed periapical tissues resulting from endodontic infection. The objectives of this study were to detect the expression of MSC markers in periapical inflammatory tissues and to characterize isolated cells from these tissues. METHODS: Human periapical inflammatory tissues were collected and processed to detect MSC marker expression by immunohistochemistry. Cells were isolated and tested for cell surface marker expression by using flow cytometry and examined for multiple differentiation potential into osteogenic and adipogenic pathways. In vivo formation of mineralized tissues was assessed in a mouse model. RESULTS: Immunohistochemistry showed positive staining for MSC markers STRO-1, CD90, and CD146. Isolated cells at passage 0 appeared as typical fibroblastic cells, and a few cells formed colony-forming unit-fibroblasts (CFU-Fs). After passaging, the CFU-F forming ability diminished dramatically, and the population doubling was up to 26. Flow cytometry data showed that these cells at passage 2 expressed low levels of STRO-1 and CD146 and moderate to high levels of CD90, CD73, and CD105. At passage 6, the levels of these markers decreased. When incubated in specific differentiation medium, cells demonstrated a strong osteogenic but weak adipogenic capacity. After in vivo cell transplantation, mineralized tissues formed in immunocompromised mice. CONCLUSIONS: Human periapical inflammatory tissues expressed MSC markers, suggesting the presence of MSCs. Isolated cells exhibited typical mesenchymal cell immunophenotype with a capacity to form mineralized matrix in vitro and in vivo.