Expert consensus on odontogenic maxillary sinusitis multi-disciplinary treatment.

ABSTARCT: Odontogenic maxillary sinusitis (OMS) is a subtype of maxillary sinusitis (MS). It is actually inflammation of the maxillary sinus that secondary to adjacent infectious maxillary dental lesion. Due to the lack of unique clinical features, OMS is difficult to distinguish from other types of rhinosinusitis. Besides, the characteristic infectious pathogeny of OMS makes it is resistant to conventional therapies of rhinosinusitis. Its current diagnosis and treatment are thus facing great difficulties. The multi-disciplinary cooperation between otolaryngologists and dentists is absolutely urgent to settle these questions and to acquire standardized diagnostic and treatment regimen for OMS. However, this disease has actually received little attention and has been underrepresented by relatively low publication volume and quality. Based on systematically reviewed literature and practical experiences of expert members, our consensus focuses on characteristics, symptoms, classification and diagnosis of OMS, and further put forward multi-disciplinary treatment decisions for OMS, as well as the common treatment complications and relative managements. This consensus aims to increase attention to OMS, and optimize the clinical diagnosis and decision-making of OMS, which finally provides evidence-based options for OMS clinical management.

Experts consensus on the procedure of dental operative microscope in endodontics and operative dentistry.

The dental operative microscope has been widely employed in the field of dentistry, particularly in endodontics and operative dentistry, resulting in significant advancements in the effectiveness of root canal therapy, endodontic surgery, and dental restoration. However, the improper use of this microscope continues to be common in clinical settings, primarily due to operators' insufficient understanding and proficiency in both the features and established operating procedures of this equipment. In October 2019, Professor Jingping Liang, Vice Chairman of the Society of Cariology and Endodontology, Chinese Stomatological Association, organized a consensus meeting with Chinese experts in endodontics and operative dentistry. The objective of this meeting was to establish a standard operation procedure for the dental operative microscope. Subsequently, a consensus was reached and officially issued. Over the span of about four years, the content of this consensus has been further developed and improved through practical experience.

Expert consensus on regenerative endodontic procedures.

Regenerative endodontic procedures (REPs) is a biologic-based treatment modality for immature permanent teeth diagnosed with pulp necrosis. The ultimate objective of REPs is to regenerate the pulp-dentin complex, extend the tooth longevity and restore the normal function. Scientific evidence has demonstrated the efficacy of REPs in promotion of root development through case reports, case series, cohort studies, and randomized controlled studies. However, variations in clinical protocols for REPs exist due to the empirical nature of the original protocols and rapid advancements in the research field of regenerative endodontics. The heterogeneity in protocols may cause confusion among dental practitioners, thus guidelines and considerations of REPs should be explicated. This expert consensus mainly discusses the biological foundation, the available clinical protocols and current status of REPs in treating immature teeth with pulp necrosis, as well as the main complications of this treatment, aiming at refining the clinical management of REPs in accordance with the progress of basic researches and clinical studies, suggesting REPs may become a more consistently evidence-based option in dental treatment.

Intentional Replantation with a 2-segment Restoration Method to Treat Severe Palatogingival Grooves in the Maxillary Lateral Incisor: A Report of 3 Cases.

The palatogingival groove is a developmental anomaly that typically starts near the cingulum of the maxillary incisors and extends along the roots at varying lengths and depths. Severe grooves that extend to the root apex often lead to complex combined periodontal-endodontic lesions. There are various therapeutic options available for these cases; however, the prognosis is unfavorable. Here, we report the successful surgical treatment of 3 cases of maxillary lateral incisors with severe palatogingival grooves using intentional replantation with a 2-segment restoration method. The teeth were gently extracted, resulting in minimal damage to the periodontal ligament. Under a dental operating microscope, 3 mm of the root end was resected. The palatogingival groove was removed, and root-end preparation was performed with a #700 fissure bur. The groove cavity was connected with root-end cavity to form a class II cavity. The cavity was then filled using a 2-segment restoration method (ie, dividing the cavity into 2 parts by the cementoenamel junction, the coronal portion was filled with a flowable composite while the radicular portion, including the root-end cavity, was filled with bioceramics). The tooth was then replanted into its alveolar bone and splinted with a flexible splint for 7 days. The sinus tract was closed at the 1-week postoperative visit. During subsequent recalls, the teeth showed almost complete periapical healing. In summary, intentional replantation with a 2-segment restoration method is a viable treatment modality for single-rooted teeth with a severe palatogingival groove that extends to the root apex.

A Cone-beam Computed Tomographic Study of Apical Surgery-related Morphological Characteristics of the Distolingual Root in 3-rooted Mandibular First Molars in a Chinese Population.

INTRODUCTION: Apical surgery on the separate distolingual (DL) root of a 3-rooted mandibular first molar is thought to be difficult because DL roots are always severely curved, small, and shorter than distobuccal (DB) roots, and they are located far from the buccal cortical bone. The purpose of this study was to use cone-beam computed tomographic images to investigate the apical surgery-related morphological characteristics of DL roots in a Chinese population. METHODS: The screening process identified 83 subjects with 128 mandibular first molars with separate DL roots. The degree of root canal curvature was measured in the mesiodistal (MD) and buccolingual (BL) planes using the Schneider method. Distances were measured from the DL root apex to the buccal cortical bone, to the buccal cortical bone opposite the DB root apex, and to the buccal cortical bone opposite the mesiobuccal (MB) root apex. The lengths of the remaining DB, MB, and DL roots were measured after resection of 3 mm of the DL apical root. Angulations of the DL root canal were determined before and after DL apical root resection. RESULTS: The teeth were classified into 3 types: type I, straight in the MD and BL planes; type II, straight in the MD plane and curved in the BL plane; and type III, curved in the MD and BL planes. Only 5 molars (3.9%) were classified as type I, whereas 52 (40.6%) molars were type II and 71 (55.5%) molars were type III. The type I DL root has a significantly shorter length and longer distance from the DL root apex to the buccal cortical bone than type II and III roots (P < .05). The distance from the DL root apex to the buccal cortical bone opposite the MB root apex is significantly longer than the distance to the buccal cortical bone opposite the DB root apex in types I and II (P < .05), whereas the distance is nearly equal for type III. The angulations for root-end preparation of types II and III DL roots vary from 57.5° to 129.1° and from 55.8° to 128.1°, respectively. CONCLUSIONS: A new classification was proposed for DL roots in 3-rooted mandibular first molars based on the root canal curvature. Type I is unsuitable for apical surgery. Access to the type II DL root apex should be through the DB root apex, whereas access to the type III DL root apex through the MB root apex is more feasible. Apical surgery on types II and III DL roots may be accomplished when the depth of the root-end preparation is reasonably reduced, and fine and personalized angulated ultrasonic retro tips are used.

Healing after root-end microsurgery by using mineral trioxide aggregate and a new calcium silicate-based bioceramic material as root-end filling materials in dogs.

INTRODUCTION: The purpose of this study was to compare healing after root-end surgery by using grey mineral trioxide aggregate (MTA) and EndoSequence Root Repair Material (RRM) as root-end filling material in an animal model. METHODS: Apical periodontitis was induced in 55 mandibular premolars of 4 healthy beagle dogs. After 6 weeks, root-end surgeries were performed by using modern microsurgical techniques. Two different root-end filling materials were used, grey MTA and RRM. Six months after surgery, healing of the periapical area was assessed by periapical radiographs, cone-beam computed tomography (CBCT), micro computed tomography (CT), and histology. RESULTS: Minimal or no inflammatory response was observed in the majority of periapical areas regardless of the material. The degree of inflammatory infiltration and cortical plate healing were not significantly different between the 2 materials. However, a significantly greater root-end surface area was covered by cementum-like, periodontal ligament-like tissue, and bone in RRM group than in MTA group. When evaluating with periapical radiographs, complete healing rate in RRM and MTA groups was 92.6% and 75%, respectively, and the difference was not statistically significant (P = .073). However, on CBCT and micro CT images, RRM group demonstrated significantly superior healing on the resected root-end surface and in the periapical area (P = .000 to .027). CONCLUSIONS: Like MTA, RRM is a biocompatible material with good sealing ability. However, in this animal model RRM achieved a better tissue healing response adjacent to the resected root-end surface histologically. The superior healing tendency associated with RRM could be detected by CBCT and micro CT but not periapical radiography.

[A retrospective study of 180 cases of apical microsurgery].

OBJECTIVE: To evaluate the outcome and the potential prognostic factors of apical microsurgery. METHODS: The teeth with persistent periapical diseases were treated by microsurgery using micro instruments, ultrasonic retrotips and mineral trioxide aggregate (MTA) under dental operate microscope. The procedure includes incision and flap retraction, osteotomy, apicoectomy, retro- preparation and retro- filling of root canal. Patients were recalled at 1, 3, 6, and 12- month intervals. The outcome was evaluated by clinical and radiographic examinations, and the potential prognostic factors were analyzed. RESULTS: One hundred and eighty cases (240 teeth), including 132 upper anterior teeth, 22 lower anterior teeth, 31 upper premolars, 18 lower premolars, 19 upper molars and 18 lower molars, were treated by microsurgery between July 2010 and December 2012. A total of 152 cases (207 teeth) were recalled. The application of the apical microsurgery included failure of previous endodontic treatment, periapical lesion with post, periapical cyst, calcified canals, separated instruments, overfilling, open apex, root facture, failure of previous apical surgery, apical fenestration, and special root canal system. The success rate was 90.8% (188/207). Age, sex, tooth position, type of periapical radiolucency, fistula and clinical application type appeared to have a negative effect on the outcome. Endo-perio lesion was a significant factor. Eighteen cases (19 teeth) failed mainly because of periodontally involved lesion and vertical root fracture. CONCLUSIONS: Apical microsurgery, which combines the magnification and illumination provided by the microscope with the proper use of micro instruments, can treat the teeth with persistent periapical diseases precisely and less traumatically with high success rate. Case selection and standardized operations play a key role for success.

The effects of human platelet lysate on dental pulp stem cells derived from impacted human third molars.

Human platelet lysate (PL) has been suggested as a substitute for fetal bovine serum (FBS) in the large-scale expansion of dental pulp stem cells (DPSCs). However, the biological effects and the optimal concentrations of PL for the proliferation and differentiation of human DPSCs remain unexplored. We isolated and expanded stem cells from the dental pulp of extracted third molars and evaluated the effects of PL on the cells' proliferative capacity and differentiation potential in vitro and in vivo. Before testing, immunocytochemical staining and flow cytometry-based cell sorting showed that the cells derived from human dental pulp contained mesenchymal stem cell populations. Cells were grown on tissue culture plastic or on hydroxyapatite-tricalcium phosphate (HA/TCP) biomaterials and were incubated with either normal or odontogenic/osteogenic media in the presence or absence of various concentrations of human PL for further investigation. The proliferation of DPSCs was significantly increased when the cells were cultured in 5% PL under all testing conditions (P < 0.05). However, this enhancement was inconsistent when the cells were cultured in 1% PL or in 10% PL; 10% PL significantly inhibited cell proliferation and was therefore excluded from further differentiation testing. Culture medium containing 5% PL also significantly promoted the mineralized differentiation of DPSCs, as indicated by the measurement of alkaline phosphatase activity and calcium deposition under mineral-conditioned media (P < 0.05). Scanning electron microscopy and modified Ponceau trichrome staining showed that the cells treated with 5% PL and mineralizing media were highly capable of integrating with the HA/TCP biomaterials and had fully covered the surface of the scaffold with an extensive sheet-like structure 14 d after seeding. In addition, 5% PL showed significantly positive effects on tissue regeneration in two in vivo transplantation models. We conclude that the appropriate concentration of PL enhances the proliferation and mineralized differentiation of human DPSCs both in vitro and in vivo, which supports the use of PL as an alternative to FBS or a nonzoonotic adjuvant for cell culture in future clinical trials. However, the elucidation of the molecular complexity of PL products and the identification of both the essential growth factors that determine the fate of a specific stem cell and the criteria to establish dosing require further investigation.

Lipopolysaccharide enhances decorin expression through the Toll-like receptor 4, myeloid differentiating factor 88, nuclear factor-kappa B, and mitogen-activated protein kinase pathways in odontoblast cells.

INTRODUCTION: Lipopolysaccharide (LPS) has been shown to regulate the function of odontoblasts. However, the molecular mechanisms of the effect of LPS on odontoblasts are poorly understood. Decorin (DCN), one of the major matrix proteoglycans, is known to affect the mineralization of teeth. In this study, we investigated whether LPS can regulate the expression of DCN in odontoblasts and determined the intracellular signaling pathways triggered by LPS. METHODS: The DCN messenger RNA and protein expression changes in mouse odontoblast-lineage cells (OLCs) were detected by real-time polymerase chain reaction (PCR) analysis and enzyme-linked immunosorbent assay (ELISA). Whether TLR4, myeloid differentiating factor 88 (MyD88), nuclear factor-kappa B (NF-κB), or mitogen-activated protein kinase (MAPK) pathways were involved in the LPS-induced DCN expression was determined by examined real-time PCR, ELISA, and luciferase activity assay. The activation of extracellular signal-regulated kinase (ERK), p38, and JNK in OLCs was measured by Western blot analysis. RESULTS: We found that the mouse OLCs expressed DCN. DCN messenger RNA was rapidly induced by LPS in a time- and dose-dependent manner. Pretreatment with a MyD88 inhibitory peptide, a TLR4 antibody, or a specific inhibitor for NF-κB or I Kappa B alpha (IκBα) significantly inhibited LPS-induced DCN expression. Moreover, the LPS-mediated increase in κB-luciferase activity in OLCs was suppressed by the overexpression of dominant negative mutants of TLR4, MyD88, and IκBα but not by a dominant negative mutant of TLR2. In addition, LPS stimulation activated the ERK, p38, and JNK MAPK pathways. The pretreatment of OLCs with specific inhibitors of the ERK, p38, and JNK MAPK pathways markedly offset the LPS-induced up-regulation of DCN expression. CONCLUSIONS: Our results show that LPS stimulation can up-regulate the gene expression of DCN via the TLR4, MyD88, NF-κB, and MAPK pathways in odontoblast cells.

Differentiation of odontoblasts is negatively regulated by MEPE via its C-terminal fragment.

Matrix extracellular phosphoglycoprotein (MEPE) is an extracellular matrix protein that is mainly expressed in mineralizing tissues, including the dental pulp. The purposes of this study were to clarify the localization of MEPE in the tooth germ and to investigate the roles of MEPE in the differentiation of odontoblasts. The immunohistochemical staining in the tooth germ of the upper first molars of male Wistar rats (postnatal day 3) revealed that MEPE was mainly localized in odontoblasts during dentinogenesis. Stable MEPE-overexpressing and MEPE-knockdown cell lines, which were established in odontoblast-lineage cells (OLCs), showed lower and higher differentiation capabilities, respectively. Eukaryotic proteins of the N-terminal fragment of MEPE produced in HEK cells had no effect on the differentiation of OLCs, whereas the C-terminal fragment containing an RGD sequence inhibited their differentiation. These results indicated that the C-terminal fragment of MEPE containing an RGD sequence, cleaved in odontoblasts, appeared to be the active form of MEPE, which may play important roles in dentinogenesis and pulpal homeostasis by keeping the odontoblasts in immature condition.

Surgical endodontic treatment of refractory periapical periodontitis with extraradicular biofilm.

OBJECTIVE: This study explored the effect of surgical endodontic treatment of refractory periapical periodontitis with extraradicular biofilm. STUDY DESIGN: Endodontic surgery was conducted on a case of refractory periapical periodontitis with extraradicular biofilm. During the procedure, the samples of periapical tissues were collected for microbiologic analysis. The resected root ends were observed under scanning electron microscope. The patient was recalled every 3 months to evaluate the treatment effect for 1 year. RESULTS: The samples yielded 1 type of facultative anaerobic bacteria (Streptococcus sanguis) and 2 types of obligate anaerobic bacteria (Porphynomonas endodontalis and Prevotella oralis). Mature bacteria biofilms were formed on the surface of the root apexes. At the 1-year recall visit, the radiograph and the clinic examination showed the refractory periapical periodontitis was cured successfully. CONCLUSIONS: The periapical bacterial biofilm may contribute to the refractory periapical periodontitis. Endodontic surgery is a good option for definitive removal of an established extraradicular infection.

Root canal morphology of permanent three-rooted mandibular first molars--part I: pulp floor and root canal system.

INTRODUCTION: Racial variations in root form and canal anatomy present endodontic challenges for clinicians. This study examined root canal morphology of three-rooted mandibular first molars by micro-computed tomography scans. METHODS: A total of 122 extracted mandibular first molars were collected from a native Chinese population. After calculating the frequency of occurrence, 20 three-rooted (experimental group) and 25 two-rooted first molars (control group) were scanned and reconstructed three-dimensionally. RESULTS: The frequency of three-rooted mandibular first molars was 31.97% (39/122). The mean interorifice distances from the distolingual (DL) canal to the distobuccal (DB) and mesiolingual canal were 2.93 mm and 2.86 mm, respectively. The mesial root predominately contained a type 2-2 root canal, with an incidence of 65% in the experimental group and 64% in the control group. Type 1-1 canals were seen more frequently in the DL and DB roots of the three-rooted first molars as well as in the distal roots of the two-rooted first molars. The incidences were 100% (20/20), 95% (19/20), and 72% (18/25), respectively. Accessory and lateral canals rarely occurred in the extra DL roots. The incidence was only 10% (2/20). A furcation canal extending from the floor to the furcation region was not observed. CONCLUSION: Three-rooted mandibular first molars commonly have 4 separate canals with high incidences of accessory canals in the mesial and DB root. The geometric data of pulp floors are useful for locating the extra DL canal.

Root canal morphology of permanent maxillary teeth in the Han nationality in Chinese Guanzhong area: a new modified root canal staining technique.

INTRODUCTION: The purpose of this study was to investigate the canal morphology of 504 maxillary permanent teeth of subjects of Han nationality in Chinese Guanzhong area. METHODS: Maxillary permanent teeth were randomly collected in Guanzhong area. After regular preparation, the teeth were immersed into ink without preparing access cavities and then put into hyperbaric oxygen chamber (0.6 Mpa) for 2 hours to let the ink penetrate into root canal from apical foramen, apical deltas and foramen of lateral canals under stable positive pressure. After demineralization and clearing, the following observations were made: (1) number of root canals, (2) root canal configuration by using Vertucci's classification, (3) presence of lateral canals, and (4) frequency of apical deltas. RESULTS: All the teeth were well-stained, and the fine details were well-revealed. Apical deltas (12.2%-83.3%) and lateral canals (13.7%-68.8%) could be frequently found in all types of maxillary teeth. Most of central incisors (95.8%), lateral incisors (91.4%), and canines (75.4%) displayed type I canal configuration, whereas most of first premolars (87.3%) and second premolars (72.3%) possessed 2 canals with type II, IV, or VI canal configuration. The majority of distobuccal roots and palatal roots of first molars (88.9%, 97.8%), second molars (92.0%, 94.0%), and third molars (87.5%, 91.6%) possessed type I canal configuration. The prevalence of mesiobuccal roots with type I configuration was 66.7% in maxillary first molars, 82% in second molars, and 62.5% in third molars. CONCLUSIONS: The modified technique of canal staining can effectively reveal detailed root canal system. The canal configuration of maxillary teeth in subjects of Han nationality in Chinese Guanzhong area is consistent with previous reports in other races.

Root canal treatment in an unusual maxillary first molar diagnosed with the aid of spiral computerized tomography and in vitro sectioning: a case report.

This case report describes an unusual maxillary first molar variant of a single fused buccal root canal. This morphology of root canal was further confirmed by spiral computerized tomography and transverse sectioning of contralateral tooth in vitro.

[Establishment and application of an in vitro model for apatite crystal mineralization].

OBJECTIVE: To establish an in vitro model for the apatite crystal mineralization. To evaluate the influences of bovine serum albumin (BSA) and fluoride to the mineralization of apatite crystal. METHODS: The model was constructed using cation selective membrane (CMV) and dialysis membrane. Double distilled water (DDW), BSA, 5, 20, 100 mg x L(-1) fluoride were added into the reaction space of the model. Reaction was carried out at 37 degrees C for 3 days under gentle stirring. The crystals were identified by scanning electron microscope (SEM) and X-ray diffraction (XRD). RESULTS: The model was established successfully. When DDW and BSA were added respectively, the main component of the deposit was octacalcium phosphate (OCP), but the shape and size of the crystals differs from each other. When fluoride with different concentration were added, the main component of the crystal turned to rod-like and prism-like fluoroapatite (FAP) crystal. The size and crystallinity of the FAP increased with the increase of the fluoride concentration. CONCLUSION: It is an effective way to evaluate the influence factors of the apatite crystal mineralization by using the in vitro model.

[Tissue engineering of dentin-pulp complex-like structures by human dental mesenchymal cells].

OBJECTIVE: To establish three-dimensional culture model of human dental mesenchymal cells and bioengineer in vivo with ceramic bovine bone (CBB) and Collagraft as scaffolds. METHODS: Human dental mesenchymal cells induced upon stimulation of bFGF and IGF-1 or TGF-beta(1) were implanted onto CBB and Collagraft containing the same kinds of growth factors respectively. Then cell/scaffold constructs were transplanted into nude mice to establish in vivo culture model of dental mesenchymal cells. Control groups were set up at the same time. After 4 weeks or 10 weeks, the implants were taken out for histological and immunohistochemical analysis. RESULTS: Within 10-week implant tissues, typical dentin-pulp complex-like structures were generated in scaffolds containing growth factors. Human dentin sialoprotein (DSP) was expressed in the newly formed dentin. This phenomenon wasn't observed in control groups and 4-week implants. CONCLUSIONS: Dentin-pulp complex-like structures could be bioengineered successfully with human dental mesenchymal cells and CBB or Collagrafts containing growth factors in nude mice.

[Immortalized human odontoblast-like cell line expressed dentin extracellular matrix in vitro].

OBJECTIVE: To determine whether dentin matrix proteins were expressed by the human odontoblast-like cell line hTERT-hOd-1 in vitro. METHODS: Collagen type I, bone sialoprotein (BSP), dentin matrix protein 1 (DMP1) and the marker for odontoblast, dentin sialophosphoprotein (DSPP) and dentin sialoprotein (DSP) were detected in these cells by immunohistochemistry, RT-PCR and in situ hybridization. During being cultured in mineralizing medium for 5 weeks, the secretion of OC and activity of ALP were measured once a week. RESULTS: DSPP, DMP1, BSP and collagen type I were expressed in hTERT-hOd-1 either at mRNA or protein level. Under the induction of mineralizing medium, the cells showed higher activity of ALP and increased secretion of OC. CONCLUSION: hTERT-hOd-1 expressed dentin extracellular matrix in vitro, which means the cell line has the potential of mineralization.