Treatment outcomes of pulpotomy versus pulpectomy in vital primary molars diagnosed with symptomatic irreversible pulpitis: protocol for a non-inferiority randomised controlled trial.

BACKGROUND: Pulpectomy continues to be the standard treatment recommendation for management of vital primary molars diagnosed with symptomatic irreversible pulpitis. The recent decade has seen a paradigm shift in the treatment concepts of how vital mature permanent molars diagnosed with irreversible pulpitis can be more conservatively managed using vital pulp therapy techniques like pulpotomy. However, despite emerging evidence indicating similarities between primary and permanent tooth pulp response to dental caries, there is limited research on whether pulpotomy can be similarly used as a definitive treatment modality for vital primary teeth with irreversible pulpitis. This randomised controlled trial (RCT) aims to compare the treatment effectiveness of pulpotomy versus pulpectomy in management of vital primary molars diagnosed with symptomatic irreversible pulpitis over a two-year period. METHODS/DESIGN: This clinical study is a parallel, two-armed, open label, non-inferiority RCT with a 1:1 allocation ratio between the experimental intervention arm (pulpotomy) and the active comparator arm (pulpectomy). Healthy cooperative children, between 4-9 years of age, who have painful primary molars with clinical symptoms typical of irreversible pulpitis will be recruited after obtaining informed consent from their parents/legal guardians. 50 vital primary molars clinically diagnosed with symptomatic irreversible pulpitis will be randomly distributed between the two treatment arms. The primary outcomes that will be assessed are clinical and radiographic success after six-months, one-year and two-years of the trial interventions. The influence of baseline pre-operative variables (age; gender; tooth type; site of caries; pre-operative furcal radiolucency; pre-operative pain intensity) and intra-operative factors (time taken to achieve haemostasis) on treatment outcomes will also be assessed. The secondary outcome evaluated will be the immediate (24 h and 7 d) post-operative pain relief afforded by the two treatment interventions. DISCUSSION: This trial seeks to provide evidence on whether pulpotomy treatment can be no worse than the standard pulpectomy treatment for the management of symptomatic irreversible pulpitis in vital primary molars. TRIAL REGISTRATION: ClinicalTrials.gov (NCT06183203). Registered on 30 January 2024.

Managing failed vital pulp therapies in mature permanent teeth in a retrospective cohort study, with success and survival rates of managing protocols.

Despite advancements in vital pulp therapy (VPT), a subset of cases fails to achieve desired outcomes. This study based on a previous large-scale cohort study involving 1257 VPT-treated teeth, aiming to describe the demographic data and clinical characteristics of all failed cases and their management protocols. Clinical records/images of 105 failed cases treated by a single endodontist (2011-2022) were examined, including 10 extracted teeth. Asymptomatic cases with PDL widening received no intervention, while others underwent management protocols, including (selective) RCT and (tampon) re-VPT. These retreatments were assessed for success (defined as radiographic evidence of healing) and survival (characterized by the retention/function of the treated tooth) using Kaplan-Meier analysis. While 51.4% of all initial failures were diagnosed due to symptoms, 48.6% were symptom-free. Notably, failed cases with symptomatic irreversible pulpitis, and apical periodontitis/widened PDL before initial treatment significantly outnumbered asymptomatic cases and normal PDL, respectively (P = 0.001). Moreover, most of the initial failures were observed in teeth with composite resin rather than amalgam restorations (P = 0.002). The success and survival rates for the management protocols were 91.78% and 95.79%, respectively, over an average follow-up period of 36.94 (± 23.30) months. RCT and re-VPT procedures provide successful outcomes for managing unsuccessful VPTs.

Clinical influencing factors of vital pulp therapy on pulpitis permanent teeth with 2 calcium silicate-based materials: A randomized clinical trial.

BACKGROUND: Compared with traditional root canal therapy (RCT), vital pulp therapy (VPT) is a personalized and minimally invasive method for the treatment of pulpitis caused by dental caries. However, there are still no clear guidelines for VPT because high-quality randomized clinical trials are scarce. This prospective cohort study evaluated the clinical efficacy of VPT with the light-curable calcium silicate-based material TheraCal LC (TH) and bioceramic material iRoot BP Plus (BP) in reversible and irreversible pulpitis permanent teeth with carious exposures. METHODS: 115 teeth with reversible or irreversible pulpitis caused by deep care were randomly divided into 2 groups. TheraCal LC and iRoot BP Plus were used for the pulp capping. Direct pulp capping (DPC), partial pulpotomy (PP) and full pulpotomy (FP) were performed based on observation of the exposed pulp. Postoperative discomforts were enquired and recorded via follow-up phone calls. Clinical and radiographic evaluations were performed 3, 6, and 12 months postoperatively. RESULTS: The overall clinical success rate in the first year was 90.4% (47/52) in both groups. The TH group required less operating time, showed lower levels of pain, and had shorter pain duration post-operative (P < .001). According to the binary logistic regression model, preoperative pain duration was significantly correlated with the prognosis of VPT (P = .011). CONCLUSION: VPT with TheraCal LC and iRoot BP Plus in pulpitis permanent carious teeth both achieved good clinical outcomes, and TheraCal LC can be easily operated for clinical use. Preoperative pain duration of the affected tooth might have a significant correlation with the prognosis of VPT.

Effect of submucosal cryotherapy compared with steroids and NSAIDs injections on Substance P and Interleukin 6 pulpal release in experimentally induced pulpal inflammation in rabbits.

OBJECTIVE: To compare the effect of submucosal cryotherapy using cold saline to dexamethasone sodium phosphate and diclofenac sodium injections on substance P and interleukin 6 release in experimentally induced pulpal inflammation in rabbits' molar teeth. METHODOLOGY: Fifteen rabbits were randomly classified into 3 groups according to the submucosal injection given: cold saline, dexamethasone sodium phosphate, and diclofenac sodium. A split-mouth design was adopted, the right mandibular molars were experimental, and the left molars served as the control without injections. Intentional pulp exposures were created and left for 6 hours to induce pulpitis. Pulpal tissue was extracted and examined for SP and IL-6 levels using ELISA. Within each group, the level of cytokines released was measured for both control and experimental groups for intragroup comparison to determine the effect of injection. The percentage reduction of each mediator was calculated compared with the control side for intergroup comparison then the correlation between SP and IL-6 levels was analyzed using Spearman's rank order correlation coefficient. Statistical analysis was performed, and the significance level was set at p<0.05. RESULTS: Submucosal cryotherapy, dexamethasone sodium phosphate, and diclofenac sodium significantly reduced SP and IL-6 pulpal release. Submucosal cryotherapy significantly reduced SP more than and IL-6 more than dexamethasone sodium phosphate and diclofenac sodium. Pulpal reduction of SP and IL-6 showed a strong positive significant correlation. CONCLUSIONS: Submucosal cryotherapy reduces the pulpal release of SP and IL-6 and could be tested as an alternative to premedication to potentiate the effect of anesthesia and control postoperative endodontic pain.

Novel cryotherapy technique for pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis- a randomized controlled trial.

OBJECTIVES: To assess the effect of cryotherapy on haemostasis, post-operative pain, and the outcome of full pulpotomy performed in mature permanent teeth with symptomatic irreversible pulpitis. MATERIALS AND METHODS: The study included sixty mature permanent mandibular molar teeth with symptomatic irreversible pulpitis and no periapical rarefaction. After coronal pulp tissue amputation, teeth were randomly allocated to one of two groups (n = 30 each). In group I (conventional pulpotomy), a sterile cotton pellet moistened with 2.5% NaOCl was used for haemostasis. In group II (cryotherapy), the pulp chamber was continuously lavaged with 2.50C normal saline solution for haemostasis using an indigenous portable cryotherapy irrigation unit. Following haemostasis, the pulp was capped with mineral trioxide aggregate and the tooth was restored with resin composite. The time taken to achieve haemostasis was recorded. Preoperative and 24, 48 and 72 h postoperative pain was measured using the Numerical Rating Scale. The pulpotomy outcome was assessed at the 12-month follow-up. Data were analyzed using Fischer's exact test, two-sample t-test, two-sample Wilcoxon rank-sum test, Friedman Test, and Wilcoxon Signed Rank Test. RESULTS: The cryotherapy group achieved haemostasis in less time (p < 0.05). There was a significant pain reduction at 24 and 48 h in the cryotherapy group when compared with the conventional pulpotomy group (P < 0.005). The overall success rate of pulpotomy after 12 months was 88% (n = 22) in both study groups(p < 0.05). CONCLUSIONS: Cryotherapy application reduces postoperative pain and has no adverse effect on the outcome of pulpotomy in permanent teeth with symptomatic irreversible pulpitis. CLINICAL RELEVANCE: The cryotherapy can be incorporated in pulpotomy protocol as an adjunct to minimize post-operative pain.

Post-endodontic pain in curved canals prepared with different rotary instrumentation techniques: A randomized controlled trial.

BACKGROUND: Curved root canals are associated with the highest number of procedural errors during endodontic instrumentation. Recently, numerous rotary instruments have been developed, with both manual and automated mechanisms, to facilitate endodontic treatment and manage the complications related to it. OBJECTIVES: The aim of the study was to assess post-endodontic pain after using the HyFlex® EDM OneFile (HEDM), WaveOne® Gold (WOG) and XP-endo® Shaper (XPS) systems in the preparation of curved canals in patients with asymptomatic irreversible pulpitis. MATERIAL AND METHODS: A total of 45 molars with curved canals and asymptomatic irreversible pulpitis were randomly divided into 3 equal groups based on the instrumentation used: HEDM (group A); WOG (group B); and XPS (group C). All teeth were prepared according to the manufacturers' instructions. Postendodontic pain was assessed using the visual analog scale (VAS) at 6, 12, 18, 24, 48, and 72 h after root canal instrumentation. The data was analyzed using the one-way analysis of variance (ANOVA) and the paired-samples t test with the Bonferroni correction, with a p-value of 0.05 set for statistical significance. RESULTS: The highest levels of post-endodontic pain were recorded at 6 h after treatment. Then, the values gradually decreased until the pain nearly vanished after 72 h. No statistically significant differences were observed in the VAS scores between groups A and B. At the same time, group C showed the lowest VAS scores at all follow-up time points. CONCLUSIONS: The use of the XPS system resulted in the lowest pain scores at all follow-ups. The HEDM and WOG groups showed no differences in the pain scores throughout the whole follow-up period.

[Research progress in autophagy in the development of pulp inflammation and dental pulp injury reparation and regeneration].

Pulpitis is an infectious disease characterized by persistent inflammation of dental pulp and severe pain of patients, root canal treatment increases the risk of tooth fracture, discoloration and reinfection. Therefore, pulp injury repair and pulp regeneration become the new targets of pulpitis treatment. Autophagy is considered as an important defense and protective mechanism, thus plays an important role in preventing the host from excessive inflammatory reaction. There are few reports on the regulative mechanisms and therapeutic strategies of autophagy on pulp inflammation progression, therefore, this paper reviewed the role of autophagy on the progression of pulpitis, also reviewed the research progress of autophagy on dental pulp injury repair and regeneration, aiming to provide theoretical support for further research and clinical application.

Interleukin-8 (IL-8) levels in gingival crevicular fluid during root canal treatment of molar teeth with symptomatic irreversible pulpitis: impact of varying sodium hypochlorite concentrations.

BACKGROUND: The aim of this study was to evaluate the effect of the use of different NaOCl concentrations (1%, 2.5%, and 5.25%) during root canal treatment of molar teeth with symptomatic irreversible pulpitis on the change of the IL-8 level in gingival crevicular fluid (GFC). METHODS: GCF sampling was performed on experimental tooth with irreversible pulpitis before and after treatment and also contralateral healthy tooth of 54 patients. The patients were divided into three groups according to concentration of NaOCl solution (n = 18); 1%, 2.5%, and 5.25% NaOCl solution. GCF sampling from experimental teeth was repeated one week after root canal treatment. Statistical analysis was performed using Mann-Whitney U, Wilcoxon test, one-way ANOVA and Pearson correlation analysis. RESULTS: There was a significant correlation between IL-8 levels in GCF samples taken from teeth with pulpitis before treatment and from healthy contralateral teeth (p = .000). Furthermore, the pretreatment IL-8 level was significantly higher than the posttreatment IL-8 level(p < .05). The effect of the NaOCl concentration on the change in IL-8 level betweeen pre and post treatment was not found statistically significant (p > .05). CONCLUSIONS: The use of NaOCl during root canal treatment can effectively reduce the levels of IL-8 in GCF and improve clinical outcomes. TRIAL REGISTRATION: This study was registred in the Institutional Review Board and the Ethics Committee of the University (No:11) on 15/12/2021.

Comparative evaluation of cervical pulpotomy and pulpectomy for primary molars with irreversible pulpitis: a multicentre randomised controlled trial.

PURPOSE: The objective of this multicentre randomised controlled trial was to compare the clinical/radiographic outcomes of cervical pulpotomy using calcium-enriched mixture cement (PCEM) and pulpectomy using Metapex (PM) in primary molars with irreversible pulpitis (IP). METHODS: A total of 134 primary molars from 94 children were randomly assigned to two intervention groups: the PCEM group (n = 74) and the PM group (n = 60). Baseline characteristics including age/gender/molar type/tooth type/jaw were recorded. The primary outcome measures were clinical/radiographic success rates assessed at the first and second follow-up appointments. Secondary outcomes included reasons for clinical/radiographic failures. Multiple logistic regression analysis was performed to determine the impact of various factors on the success rates. RESULTS: The mean age of the participants in both groups was similar (PCEM group: 5.4 years, PM group: 5.5 years). Gender distribution, molar type, tooth type, jaw, and number of practitioners were comparable between the groups. The clinical success rate at the first follow-up was 98.6% in the PCEM group and 96.4% in the PM group. At the second follow-up, the clinical success rate was 97.1% in the PCEM group and 91.1% in the PM group. The radiographic success rates at the first and second follow-up were 98.6% and 96.4% in the PCEM group and 96.4% and 91.1% in the PM group, respectively. Multiple logistic regression analysis did not reveal any significant association between the success rates and age/gender/molar type/jaw, or treatment groups (P > 0.05). CONCLUSION: In primary molars with IP, both simple/conservative cervical pulpotomy using calcium-enriched mixture cement and pulpectomy using Metapex demonstrated high clinical/radiographic success rates. No significant differences were observed between the two treatment modalities. These findings suggest that both techniques can be considered effective treatment options for managing primary molars with IP. TRIAL REGISTRATION NUMBER: Trial registration number: IRCT20201226049838N1, retrospectively registered on 12 January 2021.

Prognostic factors associated with pulp status in patients with cracked teeth treated with occlusal veneer: A 6- through 24-month prospective clinical study.

BACKGROUND: The authors evaluated the prognostic factors associated with pulp status in patients with cracked teeth (CT) treated with occlusal veneer. METHODS: An analysis of 80 CT (71 patients) with 1 or more crack lines (CLs) and normal pulp vitality or reversible pulpitis was performed. All patients received occlusal veneer and their demographic and clinical data were recorded. Pulp status and clinical features were recorded at 1 week and posttreatment at 1, 2, 3, 6, 12, 18, and 24 months. RESULTS: Maxillary first molars were commonly involved (30 [38%]). The number of CLs on the finish line ranged from 1 through 7 and most had 3 CLs (24 [30%]). The number of CLs through preparation on the finish line ranged from 0 through 4, and 2 CLs (42 [53%]) were the most prevalent. During follow-up, 5 of 80 CT progressed to pulp disease, resulting in a success rate of 93.8%. Results of the Cox model and Kaplan-Meier analysis showed that probing depth greater than 6 mm, widening periodontal ligament of apical area, more than 4 CLs on finish line, and more than 2 CLs through preparation on the finish line were risk factors associated with pulp status (P < .05). CONCLUSIONS: Occlusal veneer can protect CT without preventive root canal therapy. PRACTICAL IMPLICATIONS: The success rate and risk factors of pulp disease in CT restored with occlusal veneer are reported.

Efficacy of pulpotomy in managing irreversible pulpitis in mature permanent teeth: A systematic review and meta-analysis.

OBJECTIVES: This paper evaluated the success rates of pulpotomy, compared its efficacy with non-surgical root canal treatment (NSRCT), evaluated different pulpotomy techniques, and analyzed the effectiveness of contemporary bioactive materials in managing irreversible pulpitis in mature permanent teeth. DATA SOURCES: A comprehensive literature search was conducted across multiple databases including PubMed, Web of Science, Scopus, and the Cochrane Library. Search was conducted from the inception of each database to the present, adhering to PRISMA 2020 guidelines. STUDY SELECTION: Studies were selected through a multi-step screening process, focusing on adult populations, randomized controlled trials, and single-arm trials. DATA: Fifteen randomized controlled trials and eight single-arm trials were included. For a follow-up period of more than 24 months, pooled clinical success rate of pulpotomy was 92.9 % (95 %CI;82.1-99.0 %), whereas pooled radiographic success rate was 78.5 % (95 %CI;66.7-88.4 %). Meta-analyses showed that there was no significant difference in success rates between pulpotomy and NSRCT, between full and partial pulpotomy techniques, or between Mineral Trioxide Aggregate pulpotomy and Calcium Enriched Mixture pulpotomy. The results indicated comparable efficacy across these variables. CONCLUSIONS: The study highlights the potential of less invasive treatments. Pulpotomy may be a viable alternative to NSRCT for managing irreversible pulpitis in mature permanent teeth. Limitations such as the low quality of some single-arm trials and the high risk of bias in some randomized controlled trials highlight the need for further research to standardize methodologies and broaden literature inclusion for a more comprehensive understanding of the efficacy of pulpotomy, considering the high success rates reported. Clinical Significance This quantitative systematic review recognizes the potential of full or partial pulpotomy as a viable treatment alternative to root canal therapy for managing irreversible pulpitis in mature permanent teeth. Future studies should aim for standardized protocols to validate these findings and improve patient treatment outcomes.

Vital pulp therapy-Factors influencing decision-making for permanent mature teeth with irreversible pulpitis: A systematic review.

BACKGROUND: There is an increased tendency towards adopting minimally invasive interventions in dentistry, supported by advancement in materials and techniques. However, the decision-making process in choosing conservative or invasive treatments is influenced by several factors, particularly in permanent teeth with irreversible pulpitis. OBJECTIVES: The objective of the study was to systematically review the literature regarding factors that influence decision-making for vital pulp therapy (VPT) as definitive treatment option in permanent mature teeth diagnosed with irreversible pulpitis. METHODS: Two independent reviewers searched five electronic databases (PubMed, Embase, Web of Science, Scopus and Cochrane Library). Grey literature was searched through Google Scholar and contact with experts. Defined search keys were applied, and all peer-reviewed literature published with no language nor publication date limits were included. The All studies investigating the factors influencing treatment decision-making in mature permanent teeth with irreversible pulpitis were included. The quality of included studies was assessed by two independent reviewers using the Joanna Briggs Institute quality assessment tool. RESULTS: Six articles were included in the review. All included studies used questionnaires to characterize clinician preferences and attitudes in choosing treatment options for mature permanent teeth with irreversible pulpitis. The available evidence suggests that dentist-related factors have a significant influence on the chosen treatment in teeth with irreversible pulpitis, with speciality training and years of experience influencing the choice of VPT over other treatment options. COVID-19 reportedly swayed the dentists' decision to favour VPT. Only one article studied the influence of patient-related factors, such as age and presence of spontaneous pain on decision-making. Of note, a history of cardiovascular disease moved dentists towards prescribing VPT. DISCUSSION: Collectively, the included studies demonstrated an overriding influence of dentist-related factors on choosing among treatment options for painful teeth diagnosed with irreversible pulpitis. Patient-related factors were acknowledged but there are also potential factors such as socio-economic constraints that were not included in the component studies. CONCLUSION: In teeth with irreversible pulpitis clinicians educational background influence the decision towards a specific treatment option. Further data, preferably derived from clinical records, is necessary in future investigations to explore the effect of other important factors related to both dentists and patients. REGISTRATION: PROSPERO database (CRD42022339653).

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.

Vital Pulp Therapy of Young First Permanent Molars: A Retrospective Study on Radiographic Findings 24 Months Post-treatment.

PURPOSE: With success rates comparable to that of root canal treatment, vital pulp therapy (VPT) has gained clinical interest and has been used in the management of young permanent teeth with inflamed pulps. The aim of the present study was to retrospectively evaluate the radiographic success of VPT in young first permanent molars 24 months post-treatment and correlate findings with tooth and treatment-related characteristics. MATERIALS AND METHODS: Dental records of all patients with first permanent molars which received VPT in the Department of Paediatric Dentistry (National and Kapodistrian University of Athens) were retrieved. Demographic characteristics and data regarding the treatment performed were recorded. Patients' radiographs were evaluated at 6, 12 and 24 months post-treatment by two qualified paediatric dentists blinded regarding the treatment performed. Radiographic success, reasons for failure and continuation of root development were evaluated. Differences were tested using the Χ2 and Student's t-test, and possible correlations were determined by calculating the odds ratio. RESULTS: Overall radiographic success rate at 24 months was 77%, ranging between 50% for direct pulp capping and 92% for full pulpotomy. Differences were not statistically significant. Continuation of root development was recorded in almost 1/3 of the teeth and completion in almost 1/5. No statistically significant association was recorded between the outcome and any tooth and treatment-related variables. CONCLUSION: VPT seems to be a reliable option in the long term for the treatment of deep carious lesions in young permanent molars.

Effect of 810 nm Diode Laser Irradiation on the Time of Initiation and Depth of Anesthesia for Endodontic Treatment of Mandibular First Molars with Symptomatic Irreversible Pulpitis: A Clinical Trial.

Objective: In endodontic treatments, performing appropriate anesthesia in patients with irreversible pulpitis in mandibular molars may result in pain and severe problems. The irradiation of low-level lasers could be effective in this regard due to its anti-inflammatory and regenerative properties. This study aimed to assess the effect of 810 nm diode laser on the time of initiation and depth of anesthesia for endodontic treatment of mandibular first molars with symptomatic irreversible pulpitis. Materials and methods: This randomized controlled clinical trial evaluated 60 patients requiring endodontic treatment of mandibular first molars with symptomatic irreversible pulpitis and pain score ≥114 according to the Heft-Parker visual analog scale (HP-VAS). The teeth were randomized into two groups of diode laser and control. In the diode laser group, 810 nm diode laser with 300 mW power and 15 J/cm2 energy density was irradiated to the buccal surface of tooth crowns for 20 sec at 2 mm distance immediately before anesthesia administration. Laser in off mode was used in the control group. Inferior alveolar nerve block was then performed using 2% lidocaine with 1:80,000 epinephrine. After anesthetic injection, the mandibular first molar and canine teeth (control) were tested by an electric pulp tester every 2 min. Two consecutive negative responses to 80 mA indicated the initiation of anesthesia. HP-VAS forms were filled out by patients to assess their level of pain during the procedure. Data were analyzed by the Student's t and Chi-square tests, and analysis of variance (α = 0.05). Results: No remarkable difference was noted between the laser group and control groups in pain severity or anesthesia onset (p > 0.05). Conclusions: Low-level (810 nm) diode laser did not affect the time of initiation or depth of anesthesia in endodontic treatment of mandibular first molars with symptomatic irreversible pulpitis. Clinical trials registration: Iranian Registry of Clinical Trials (IRCT20181222042076N1).

Treatment of pulpal and apical disease: The European Society of Endodontology (ESE) S3-level clinical practice guideline.

BACKGROUND: The ESE previously published quality guidelines for endodontic treatment in 2006; however, there have been significant changes since not only in clinical endodontics but also in consensus and guideline development processes. In the development of the inaugural S3-level clinical practice guidelines (CPG), a comprehensive systematic and methodologically robust guideline consultation process was followed in order to produce evidence-based recommendations for the management of patients presenting with pulpal and apical disease. AIM: To develop an S3-level CPG for the treatment of pulpal and apical disease, focusing on diagnosis and the implementation of the treatment approaches required to manage patients presenting with pulpitis and apical periodontitis (AP) with the ultimate goal of preventing tooth loss. METHODS: This S3-level CPG was developed by the ESE, with the assistance of independent methodological guidance provided by the Association of Scientific Medical Societies in Germany and utilizing the GRADE process. A robust, rigorous and transparent process included the analysis of relevant comparative research in 14 specifically commissioned systematic reviews, prior to evaluation of the quality and strength of evidence, the formulation of specific evidence and expert-based recommendations in a structured consensus process with leading endodontic experts and a broad base of external stakeholders. RESULTS: The S3-level CPG for the treatment of pulpal and apical disease describes in a series of clinical recommendations the effectiveness of diagnosing pulpitis and AP, prior to investigating the effectiveness of endodontic treatments in managing those diseases. Therapeutic strategies include the effectiveness of deep caries management in cases with, and without, spontaneous pain and pulp exposure, vital versus nonvital teeth, the effectiveness of root canal instrumentation, irrigation, dressing, root canal filling materials and adjunct intracanal procedures in the management of AP. Prior to treatment planning, the critical importance of history and case evaluation, aseptic techniques, appropriate training and re-evaluations during and after treatment is stressed. CONCLUSION: The first S3-level CPG in endodontics informs clinical practice, health systems, policymakers, other stakeholders and patients on the available and most effective treatments to manage patients with pulpitis and AP in order to preserve teeth over a patient's lifetime, according to the best comparative evidence currently available.

Effect of Photobiomodulation on the Depth of Local Anesthesia during Endodontic Treatment of Teeth with Symptomatic Irreversible Pulpitis.

AIM: To determine whether photobiomodulation (PBM) therapy could increase the depth of analgesia during endodontic therapy of teeth affected with symptomatic irreversible pulpitis. MATERIALS AND METHODS: Forty-nine patients with symptomatic irreversible pulpitis were randomized into two groups. In the laser group, before administering anesthesia, the lower molars' crowns were continuously treated with a diode laser (980 nm) for 20 s with a low-level laser tip in the buccal aspect close to the gingival margin. While the teeth of the second group who was blinded to the type of treatment received placebo treatment wherein the laser device was switched off. The visual analogue scale (VAS) was used to assess pain in both groups before the endodontic procedure, during dentin cutting, and at dropping pulp, wherein, the success was defined as no or mild pain. The Chi-square and independent sample t-tests were used to assess the data. RESULTS: During dentin cutting and pulp dropping, the group receiving the laser therapy presented with less mean pain score than the placebo group which was statistically significant. Additionally, it was observed that the need for supplementary injection was less frequent in the laser-treated group than in the placebo group (p = 0.01). CONCLUSION: The irradiation by diode laser (980 nm) prior to administration of local anesthesia appears to be useful in minimizing discomfort and additional injection during root canal therapy (RCT). CLINICAL SIGNIFICANCE: Pain management is essential for providing the best possible treatment to patients before, during, and after endodontic therapy. Adequate pain control during treatment also aids in reducing postoperative discomfort. This implies the need for additional methods to reduce discomfort during endodontic treatment; hence, adjuncts are crucial to achieving this goal. Photobiomodulation may be used as an adjuvant to reduce discomfort and supplementary injections during RCT.

Clinical correlation of salivary alpha-amylase levels with pain intensity in patients undergoing emergency endodontic treatment.

BACKGROUND: Pain is usually subjective and thus it is challenging to describe its characteristics such as nature, intensity, and origin. Non-invasive methods such as assessing salivary alpha-amylase (SAA) may aid the practitioner to evaluate the pain intensity. Hence, the current study aimed to correlate the levels of SAA with the pain intensity in patients presenting with varied endodontic pain levels. METHODS: Sixty patients who presented with varied intensities of endodontic pain were selected for the present study out of which seven patients were excluded/dropped, leaving a total sample of fifty-five patients for assessment. Mandibular molar with symptomatic irreversible pulpitis without periapical pathology were included in the study. A 5ml of un-stimulated was obtained from the patients, following which the local anesthesia was administered. Root canal treatment was then performed and the pain scores at pre-operative and post-operative were recorded. Additionally, salivary samples were collected after emergency endodontic treatment and sent for sialochemical analysis. IBM.SPSS statistics software 23.0 was employed to assess the obtained data. RESULTS: A statistically significant drop in the pain score (P < 0.001) and SAA levels (P < 0.001) were observed post-operatively in the contract to pre-operative state. A strong positive correlation was reported between SAA levels and pain scores in patients undergoing emergency endodontic treatment at both time intervals namely pre-operative (P < 0.001) and post-operative (P < 0.001). CONCLUSION: The results of this preliminary showed a strong association between the pain score and SAA levels in patients undergoing an emergency endodontic treatment.

Molecular biomarkers for objective assessment of symptomatic pulpitis: A systematic review and meta-analysis.

BACKGROUND: Inflammatory biomarkers are potentially useful targets for pulpal diagnostic tests that can identify pulp status and predict vital pulp treatment (VPT) outcome, however, their accuracy is unknown. OBJECTIVES: (1) Calculate sensitivity, specificity and diagnostic odds ratio (DOR) of previously investigated pulpitic biomarkers; (2) Determine if biomarker levels discriminate between clinical diagnoses of pulpitis based on the presence or absence of spontaneous pain (3) Evaluate if biomarker level can predict VPT outcome. METHODS: Searches: PubMed/MEDLINE, Ovid SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase, Web of Science and Scopus in May 2023. INCLUSION: prospective and retrospective observational studies and randomized trials. Participants were humans with vital permanent teeth and a well-defined pulpal diagnosis. EXCLUSION: deciduous teeth, in vitro and animal studies. Risk of bias was assessed with modified-Downs and Black quality assessment checklist. Meta-analysis was performed using bivariate random effect model in Meta-DiSc 2.0 and RevMan and the quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Fifty-six studies were selected, reporting >70 individual biomolecules investigating pulpal health and disease at the gene and protein level. Most studies were of low and fair quality. Among the biomolecules investigated, IL-8 and IL-6 demonstrated a level of diagnostic accuracy with high sensitivity, specificity and DOR to discriminate between healthy pulps and those exhibiting spontaneous pain suggestive of IRP (low-certainty evidence). However, none was shown to have high DOR and the ability to discriminate between pulpitic states (very low certainty evidence). Limited data suggests high levels of matrix metalloproteinase 9 correlate with poorer outcomes of full pulpotomy. DISCUSSION: The inability of identified molecular inflammatory markers to discriminate between dental pulps with spontaneous and non-spontaneous pain should shift the focus to improved study quality or the pursuit of other molecules potentially associated with healing and repair. CONCLUSIONS: Low-quality evidence suggests IL-8 and IL-6 demonstrated level of diagnostic accuracy to discriminate between healthy pulps and those exhibiting spontaneous pain. There is a need for standardized biomarker diagnostic and prognostic studies focusing on solutions that can accurately determine the degree of pulp inflammation. REGISTRATION: PROSPERO CRD42021259305.