Journal Of Endodontics[JOURNAL]
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200 papers
Signaling Pathways in Root Resorption: Linking Inflammation, Odontoclastogenesis, and Tissue Remodeling.
Rostami G, Hadagalu Revana Siddappa R, Kishen A
J Endod · 2026 Jan · PMID 40885489 · Publisher ↗
INTRODUCTION: Root resorption is a pathologic process characterized by the breakdown of dentin and cementum by odontoclasts, mirroring the mechanisms of osteoclast-driven bone resorption. Osteoclastogenesis is tightly re...
INTRODUCTION: Root resorption is a pathologic process characterized by the breakdown of dentin and cementum by odontoclasts, mirroring the mechanisms of osteoclast-driven bone resorption. Osteoclastogenesis is tightly regulated by the RANK/RANKL/OPG axis and other signaling pathways, including Wnt, ATP-P2RX7-IL-1, programmed cell death, and inflammasome activation. OBJECTIVE: This review provides a comprehensive analysis of the key signaling pathways and molecular mediators orchestrating root resorption in orthodontic, traumatic, and inflammatory conditions. METHODS: A literature-based analysis was conducted, focusing on molecular and cellular mechanisms involved in root resorption. Key pathways such as RANK/RANKL/OPG, Wnt signaling, ATP-P2RX7-IL-1, and inflammasome activation were examined. The role of proinflammatory and anti-inflammatory cytokines, matrix metalloproteinases, and periostin were also analyzed. RESULTS: Proinflammatory mediators such as IL-1, IL-6, IL-8, tumor necrosis factor-alpha, IL-17, IL-22, and IL-23 drive odontoclastic differentiation, whereas anti-inflammatory cytokines, including IL-4, IL-10, and transforming growth factor-beta, counteract resorptive activity. Additionally, matrix metalloproteinases and periostin modulate extracellular matrix remodeling, impacting resorption progression. The balance between resorptive and reparative processes is influenced by the inflammatory microenvironment, fibroblast-macrophage interactions, and mechanotransduction. While the molecular mechanisms underlying odontoclastogenesis parallel bone resorption, unique features of root structures, such as the cementoid layer, contribute to resistance against resorption. CONCLUSION: The intricate cross talk between pro-resorptive and antiresorptive factors, emphasizing their roles in odontoclast activation and extracellular matrix remodeling, dictate the extent of root degradation.
Relationship between Craniofacial Skeletal Patterns and the Prevalence of Tooth Fractures.
Jeong J, Kim L, Kim S … +2 more , Jeon HH, Setzer FC
J Endod · 2025 Dec · PMID 40865631 · Publisher ↗
INTRODUCTION: Tooth fractures are associated with various etiological factors, including occlusal stress. While science has shown associations between maximum bite force and craniofacial skeletal patterns, a direct link...
INTRODUCTION: Tooth fractures are associated with various etiological factors, including occlusal stress. While science has shown associations between maximum bite force and craniofacial skeletal patterns, a direct link between skeletal morphology and the prevalence of tooth fractures has not been established. This study aimed to investigate whether sagittal and vertical skeletal patterns, as determined by cephalometric analysis, are associated with the prevalence of tooth fractures in an adult orthodontic population. METHODS: A retrospective review was conducted of 1001 adult orthodontic patients with complete records, including lateral cephalometric radiographs and demographic data. Patients were classified into vertical (high, neutral, low mandibular angle) and sagittal (Angle Class I, II, III) skeletal patterns using population-specific cephalometric norms. Tooth fractures were identified through clinical records and Current Dental Terminology codes, including whether fractured teeth were extracted or retained, and whether endodontic treatment was involved. Statistical analysis included analysis of covariance, chi-square, and Fisher exact tests. RESULTS: No significant differences were observed in the prevalence of tooth fractures, either extracted or retained, across vertical or sagittal skeletal classes for the overall population. Within the Caucasian subpopulation, a significantly higher prevalence of tooth fractures was noted in ANGLE-I compared to ANGLE-II (P = .02). Similarly, previously endodontically treated teeth were more frequently extracted due to fracture in ANGLE-I and ANGLE-III compared to ANGLE-II (P = .02). No significant associations were found in the African-American, Asian, or Hispanic subpopulations. CONCLUSIONS: Craniofacial skeletal patterns may not aid in predicting tooth fracture risk in the general population. While limited associations were noted within the Caucasian subgroup, further prospective studies incorporating direct bite force measurements are warranted to clarify biomechanical contributions to tooth fractures.
Association between Apical Periodontitis and the Severity of Marginal Periodontitis in Root Canal-treated Teeth: A Retrospective Cohort Study.
Ruiz XF, Duran-Sindreu F, Snijders M … +3 more , Elenbass L, Shemesh H, Olivieri JG
J Endod · 2026 Jan · PMID 40850545 · Publisher ↗
INTRODUCTION: To evaluate whether the severity of marginal periodontitis is correlated with the development of apical periodontitis (AP) in root canal-treated teeth. The secondary aim was to investigate the variables ass...
INTRODUCTION: To evaluate whether the severity of marginal periodontitis is correlated with the development of apical periodontitis (AP) in root canal-treated teeth. The secondary aim was to investigate the variables associated with the development of AP in patients with different levels of bone loss. METHODS: This longitudinal, observational, retrospective cohort study entailed radiographic evaluation of root-canal-filled teeth in patients with and without periodontal involvement after a minimum period of 2 years. Independent, calibrated specialists evaluated the baseline periapical radiographs for the presence or absence of AP and periodontal bone loss (PBL). PBL was categorized as normal, mild, moderate, and severe. Logistic regression analysis was conducted to examine differences between groups and potential relationships among variables. RESULTS: A total of 1365 patients (2235 root canal-treated teeth) were initially screened, including 663 patients in the control group and 702 with periodontal involvement. 1011 root canal-filled teeth were included for analysis (normal PBL: 401 teeth; mild PBL: 304 teeth; moderate PBL: 228 teeth; and severe PBL: 78 teeth). 10.1% of teeth developed AP: 4.2% with normal PBL, 1.6% with mild PBL, 19.73% with moderate PBL, and 44.9% with severe PBL. Multivariable regression analysis showed no significant difference between teeth with normal and mild PBL (P > .05). Moderate PBL was associated with an 8.4-fold increase in the odds of developing AP (odds ratio [OR]: 8.38; 95% confidence interval [CI]: 3.06-22.98), whereas severe PBL was linked to a 41.3-fold increase (OR: 41.26; 95% CI: 8.15-208.95), both compared to normal PBL (P < .05). Furthermore, patients who smoke also showed a higher odd of developing AP (OR: 2.22; 95% CI: 1.11-4.46) (P < .05). CONCLUSIONS: A clear association was found between the severity of marginal periodontitis and the development of AP in root canal-treated teeth. Additionally, smoking habit showed a significant association with the development of AP acting as a confounding factor.
Performance of Advanced Artificial Intelligence Models in Pulp Therapy for Immature Permanent Teeth: A Comparison of ChatGPT-4 Omni, DeepSeek, and Gemini Advanced in Accuracy, Completeness, Response Time, and Readability.
Sezer B, Aydoğdu T
J Endod · 2025 Nov · PMID 40850544 · Publisher ↗
INTRODUCTION: This study aims to evaluate and compare the performance of three advanced chatbots-ChatGPT-4 Omni (ChatGPT-4o), DeepSeek, and Gemini Advanced-on answering questions related to pulp therapies for immature pe...
INTRODUCTION: This study aims to evaluate and compare the performance of three advanced chatbots-ChatGPT-4 Omni (ChatGPT-4o), DeepSeek, and Gemini Advanced-on answering questions related to pulp therapies for immature permanent teeth. The primary outcomes assessed were accuracy, completeness, and readability, while secondary outcomes focused on response time and potential correlations between these parameters. METHODS: A total of 21 questions were developed based on clinical resources provided by the American Association of Endodontists, including position statements, clinical considerations, and treatment options guides, and assessed by three experienced pediatric dentists and three endodontists. Accuracy and completeness scores, as well as response times, were recorded, and readability was evaluated using Flesch Kincaid Reading Ease Score, Flesch Kincaid Grade Level, Gunning Fog Score, SMOG Index, and Coleman Liau Index. RESULTS: Results revealed significant differences in accuracy (P < .05) and completeness (P < .05) scores among the chatbots, with ChatGPT-4o and DeepSeek outperforming Gemini Advanced in both categories. Significant differences in response times were also observed, with Gemini Advanced providing the quickest responses (P < .001). Additionally, correlations were found between accuracy and completeness scores (ρ: .719, P < .001), while response time showed a positive correlation with completeness (ρ: .144, P < .05). No significant correlation was found between accuracy and readability (P > .05). CONCLUSIONS: ChatGPT-4o and DeepSeek demonstrated superior performance in terms of accuracy and completeness when compared to Gemini Advanced. Regarding readability, DeepSeek scored the highest, while ChatGPT-4o showed the lowest. These findings highlight the importance of considering both the quality and readability of artificial intelligence-driven responses, in addition to response time, in clinical applications.
Treatment Outcomes and Prognostic Analysis of Root Canal-treated Posterior Cracked Teeth: The Modified Iowa Index.
Wongkornchaowalit N, Soontornkiat T, Krongbaramee T … +2 more , Lertpimonchai A, Krell KV
J Endod · 2026 Jan · PMID 40850543 · Publisher ↗
INTRODUCTION: Cracked teeth requiring root canal treatment present with variable prognoses. This study aimed to evaluate the treatment outcomes of root canal-treated posterior cracked teeth and to identify prognostic fac...
INTRODUCTION: Cracked teeth requiring root canal treatment present with variable prognoses. This study aimed to evaluate the treatment outcomes of root canal-treated posterior cracked teeth and to identify prognostic factors influencing endodontic outcomes. METHODS: A retrospective cohort of 263 cracked posterior teeth with 1- to 5-year follow-up was analyzed. The Iowa index was modified by subcategorizing each stage according to crack extension. Outcomes were assessed using strict clinical and radiographic criteria. Cox regression analysis was performed to identify significant predictors of failure. RESULTS: The overall success and survival rates were 82.9% and 89.7%, respectively, with a mean follow-up period of 40.3 months. The estimated 2-year and 5-year survival rates were 99.2% and 78.6%, respectively. Multivariable analysis identified 7 independent predictors of failure: increasing age, pocket depth ≥5 mm along the crack line, radicular extension ≥3 mm, preoperative periapical lesion, multiple crack lines, absence of occlusal splint in patients with parafunctional habits, and restoration with onlay or composite. Cracked teeth with probing depths <5 mm (Stages I-III) showed favorable outcomes (success rate: 78.9%-98.3%, survival rate: 86.5%-100%), whereas those exhibiting both radicular extension and periodontal pocket ≥5 mm (Stage IV-R) had poor prognosis (success rate: 33.3%, survival rate: 63.0%). CONCLUSIONS: The modified Iowa index, incorporating the classification of crack extension, demonstrated prognostic value. The combination of radicular crack and periodontal pocket ≥5 mm should be considered a high-risk profile when evaluating the treatment potential of cracked teeth.
Influence of Dentine Thickness and Intraradicular Reinforcement on Fracture Resistance of MTA-apexified Immature Anterior Teeth.
Utamavatin T, Banomyong D, Linsuwanont P
J Endod · 2026 Jan · PMID 40850542 · Publisher ↗
INTRODUCTION: The most common cause of failure of mineral trioxide aggregate (MTA)-apexified teeth is root fracture. This study aimed to identify the appropriate reinforcement materials following MTA apexification in imm...
INTRODUCTION: The most common cause of failure of mineral trioxide aggregate (MTA)-apexified teeth is root fracture. This study aimed to identify the appropriate reinforcement materials following MTA apexification in immature teeth under simulated oral conditions. METHODS: Part 1: To investigate the effect of dentine thickness: twenty-four teeth (n = 8) were assigned to 3 groups; intact, simulated immature teeth with 2.0 mm, and 1.5 mm dentin thicknesses. Roots were prepared using Peeso reamers until the predetermined thickness was achieved. Part 2: To evaluate the effect of reinforcement materials: forty teeth were prepared as simulated immature roots with 1.5 mm dentin thickness and received MTA apexification. They were randomly assigned into 5 groups (n = 8): gutta-percha, MTA, DUAL-cure composite resin, fiber post, and anatomic post. All teeth underwent thermocycling and cyclic loading before compression testing. Fracture patterns and maximum load to fracture were recorded. Data were analyzed using one-way analysis of variance with Tukey's test and Weibull regression for survival probability. RESULTS: Teeth with 1.5 mm dentin thickness showed significantly lower fracture resistance than intact and 2.0 mm groups. An oblique horizontal root fracture was observed in all samples. In fiber postgroup, the most observed fracture was at the interface between MTA and post. The DUAL-cure composite resin group showed fracture resistance and survival probability comparable to intact group. CONCLUSIONS: Within the limit of this study, MTA-apexified teeth could be reinforced with DUAL-cure composite resin.
A Grading System for Pulp Canal Calcification Based Upon 3-D Imaging to Aid in Assessment of Case Difficulty in Orthograde Endodontic Treatment.
Cruci P, Zavattini A, Gaon A … +2 more , Patel M, Al Salehi SK
J Endod · 2025 Dec · PMID 40840717 · Publisher ↗
INTRODUCTION: This article describes a novel grading system for quantifying potential difficulty in locating and instrumenting root canals where there is evidence of calcification. METHODS: The system is based upon limit...
INTRODUCTION: This article describes a novel grading system for quantifying potential difficulty in locating and instrumenting root canals where there is evidence of calcification. METHODS: The system is based upon limited field of view cone beam computed tomography which is an essential tool in the diagnosis and treatment of the calcified canal. RESULTS: The new grading system considers the vertical level at which the canal becomes radiographically evident (coronal, middle or apical), the length of patent canal, and whether the canal is patent at the terminus. CONCLUSIONS: At present there is no classification for canal calcification and no means of categorizing a canal in terms of the potential difficulty/feasibility involved in treating it. It is hoped that this novel grading system will be useful in treatment decision making.
Digital-guided Autotransplantation of Teeth with Autogenous Bone Augmentation: A Case Report.
Wu H, Ma Z, Li Y … +4 more , Chen G, Li W, Kuang J, Zhou L
J Endod · 2025 Dec · PMID 40840716 · Publisher ↗
Long-term dental defects are often accompanied by severe alveolar bone resorption, which compromises the maintenance of alveolar bone height and thickness, thereby increasing the complexity of restoration. This case repo...
Long-term dental defects are often accompanied by severe alveolar bone resorption, which compromises the maintenance of alveolar bone height and thickness, thereby increasing the complexity of restoration. This case report presents a 24-year-old female patient with a 6-month dental defect and alveolar bone resorption. The treatment consisted of autotransplanting the left mandibular third molar to the defect site, with the use of a three-dimensional printed donor tooth replica and the surgical guide for precise alveolar socket preparation. Simultaneously, autogenous bone harvested intraoperatively was transplanted to the buccal bone defect area. Root canal treatment was performed 2 weeks postoperatively. A 21-month follow-up demonstrated a stable transplanted tooth, satisfactory buccal bone regeneration, and notable esthetic improvement. This case highlights the potential benefits of integrating digital technology with autogenous bone grafting in autotransplantation of teeth for complex dentition defects.
Endotoxin Levels after Calcium Hydroxide Placement in Root Canals Irrigated with Continuous or Sequential Chelation in Previously Treated Teeth with Symptomatic Apical Periodontitis: A Randomized Controlled Clinical Trial.
Pandya DS, Kritika S, Sanjeev K … +2 more , Mahalaxmi S, Neelakantan P
J Endod · 2025 Nov · PMID 40835176 · Publisher ↗
INTRODUCTION: Endotoxins are proinflammatory components of Gram-negative bacteria. The aim of this randomized clinical trial was to test the null hypotheses that (i) there is no significant difference between continuous...
INTRODUCTION: Endotoxins are proinflammatory components of Gram-negative bacteria. The aim of this randomized clinical trial was to test the null hypotheses that (i) there is no significant difference between continuous chelation irrigation (5.25% sodium hypochlorite + 9% etidronic acid) and sequential chelation (5.25% sodium hypochlorite - 17% ethylene diaminetetra-acetic acid) in endotoxin reduction, and (ii) placement of calcium hydroxide (CH) does not further improve endotoxin reduction in previously treated teeth with symptomatic apical periodontitis. METHODS: Previously treated teeth with symptomatic apical periodontitis (n = 48) were randomly allocated to (n = 24) Group 1, sequential chelation (SC) or Group 2, continuous chelation (CC). Root canal sampling was performed with sterile paper points at three time intervals: immediately after gutta-percha removal (T), following chemomechanical preparation (T), and following 7 days of CH placement (T). A turbidimetric kinetic limulus amebocyte lysate assay was used for endotoxin quantification. Repeated measures ANOVA was used to compare SC and CC at different time points and between different time points for each protocol. P < .05 was considered to be statistically significant. RESULTS: Both SC and CC showed significant endotoxin reduction from T to T (P < .05), while only SC group exhibited further significant reduction from T to T (P < .05). CC group demonstrated significantly lower endotoxin levels than the SC group at T (P < .01) and T (P < .001). CONCLUSION: This study shows for the first time that CC irrigation resulted in significantly lower quantity of endotoxins than SC followed by calcium hydroxide.
Comparing Ultrasonically Activated Irrigation and Laser-Activated Irrigation for Postoperative Pain Reduction in Endodontics: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Sabeti M, Harouni A, Gabbay J
J Endod · 2026 Jan · PMID 40818665 · Publisher ↗
INTRODUCTION: This systematic review and meta-analysis evaluate the effects of ultrasonically activated irrigation (UAI) and laser-activated irrigation (LAI) on postoperative pain following root canal treatment (RCT). ME...
INTRODUCTION: This systematic review and meta-analysis evaluate the effects of ultrasonically activated irrigation (UAI) and laser-activated irrigation (LAI) on postoperative pain following root canal treatment (RCT). METHODS: An extensive search of the literature was performed using MEDLINE, Web of Science, Embase, and the Cochrane Library from January 2000 to March 2025. Eligible randomized controlled trials (RCTs) comparing UAI with LAI and reporting postoperative pain outcomes at multiple postoperative time on the visual analog scale were included. The included RCTs were thoroughly evaluated for potential risk of bias and overall quality of evidence, and their data were pooled and analyzed using a random-effects model. RESULTS: Seven RCTs (n = 490 teeth, 30 comparisons) were meta-analyzed, showing that LAI significantly reduced postoperative pain compared to UAI (standard mean difference [SMD] = -0.58; 95% CI: -0.94 to -0.22; P = .0016). Subgroup analysis highlighted the greatest pain reduction at 24-48 hours (SMD = -1.00), especially with pulsed Er: YAG lasers (PIPS: SMD = -1.10; SWEEPS: SMD = -1.57), while diode lasers showed no significant effect (SMD = 0.03). Sensitivity analyses supported the reliability of these findings. CONCLUSIONS: LAI provides a statistically and clinically meaningful reduction in postoperative endodontic pain compared to ultrasonic activation, with the most pronounced effects observed between 24- and 48-hours post-treatment. Among laser types, pulsed Er: YAG modalities-especially SWEEPS-demonstrated the strongest analgesic benefit.
Endodontic Microsurgery of Mandibular Molars with an Autonomous Robotic System.
Zhang H, Yang Z, Liu M … +4 more , Wang Y, Fu M, Hou B, Zhang C
J Endod · 2025 Dec · PMID 40818664 · Publisher ↗
Minimally invasive osteotomy and precise root-end resection are key factors in endodontic microsurgery (EMS), particularly in the mandibular molars. Autonomous robotic (ATR) systems facilitate accurate presurgical planni...
Minimally invasive osteotomy and precise root-end resection are key factors in endodontic microsurgery (EMS), particularly in the mandibular molars. Autonomous robotic (ATR) systems facilitate accurate presurgical planning and real-time robot-guided osteotomy and root resection. Integrating the ATR technique with EMS can enhance the accuracy and effectiveness of the treatment. This report presents 2 cases diagnosed with symptomatic apical periodontitis in the mandibular left and right first molar. Cone-beam computed tomography and intraoral scanning data were used to design the surgical plan via planning software. The ATR system guided the robotic arm to autonomously perform precise osteotomy and root resection based on the presurgical plan. At 3-12 months of follow-up, both patients were asymptomatic and radiographic examination revealed complete healing. The ATR technique enabled precise root-end resection despite thick and intact cortical plates, contributing to successful EMS outcomes during the 3- to 12-month follow-up period. This feasibility demonstration warrants further validation in clinical trials with extended follow-ups to assess its potential role in surgical endodontics.
An Innovative Injectable and Retrievable Drug Delivery System for Endodontic Therapy.
Mahmoud AH, Sloutski A, Fu S … +11 more , Luo H, Katevatis Z, Wong R, Fang Y, Zaliznyak T, Perez FA, Simon M, Walker SG, Manders T, Rafailovich M, Cymerman JJ
J Endod · 2025 Dec · PMID 40816576 · Publisher ↗
INTRODUCTION: Endodontic treatment failures remain a significant treatment challenge. Different bacterial combinations are implicated in posttreatment disease. Enterococcus faecalis is often detected in these biofilms. C...
INTRODUCTION: Endodontic treatment failures remain a significant treatment challenge. Different bacterial combinations are implicated in posttreatment disease. Enterococcus faecalis is often detected in these biofilms. Calcium hydroxide has many limitations, including low flowability, difficult retrieval, high pH, and limited efficacy against E. faecalis. Here, we show that these difficulties can be overcome using calcium salicylate (CASA) encapsulated in a photocrosslinked thermoreversible F127-dimethacrylamide (DMA) hydrogel. METHODS: CASA was prepared by mixing calcium hydroxide and salicylic acid in a 1:6 ratio, respectively and incorporated into F127-DMA at different concentrations. The mixture was photocrosslinked using lithium phenyl (2,4,6-trimethylbenzoyl) phosphinate. Chemical properties were analyzed using X-ray diffraction, Raman spectroscopy, Fourier transform infrared spectroscopy, and differential scanning calorimetry, while injectability and retrievability were assessed using plastic root canal training blocks, bovine teeth cone beam computed tomography scans, and oscillatory rheology. In Vitro antibacterial efficacy against E. faecalis biofilm was probed by injection of the compound, following inoculation on bovine extracted teeth. Cytotoxicity of the compound was measured using dental pulp stem cells. RESULTS: Encapsulation of CASA in F127-DMA reduced the viscosity by three orders of magnitude compared to the paste form, facilitating injection and enabling retrieval. Following retrieval, F127-DMA/CASA showed significantly lower residual medicament (∼6%) compared to Vista-Cal (26%). X-ray diffraction, Raman, and Fourier transform infrared spectroscopy analyses confirmed the formation of CASA and successful integration of CASA into photocrosslinked F127-DMA. Treatment with the F127-DMA/20% CASA following 21-day inoculation with E. faecalis resulted in a 6-log reduction in CFU and complete elimination of biofilm. No significant change in the doubling time of treated dental pulp stem cell was observed. CONCLUSIONS: F127-DMA/CASA exhibits superior flowability, retrievability, near-neutral pH (∼6), biocompatibility, and anti-E. faecalis efficacy, which highlights its potential as a significant improvement over calcium hydroxide as an endodontic intracanal medicament.
Cellular Crosstalk Between Periodontal Ligament Fibroblasts and Macrophages: Insights from 2D and 3D Culture Systems in External Inflammatory Root Resorption.
Revana Siddappa RH, Kishen A
J Endod · 2025 Dec · PMID 40783157 · Publisher ↗
INTRODUCTION: Root resorption following traumatic dental injuries is a complex process involving the breakdown of root dentin and cementum by odontoclasts, which differentiate from precursor macrophages. This differentia...
INTRODUCTION: Root resorption following traumatic dental injuries is a complex process involving the breakdown of root dentin and cementum by odontoclasts, which differentiate from precursor macrophages. This differentiation is regulated by periodontal ligament fibroblasts (PDLF). Macrophages can polarize into two types: proinflammatory (M1) and anti-inflammatory (M2), which can influence either disease progression or healing. METHODS: This review considers experimental models that have been utilized to study the interactions between PDLF and macrophages under normal and inflammatory conditions, including bacterial exposure and hypoxia. RESULTS: Under normal circumstances, PDLFmaintain the balance of periodontal tissues and the surrounding immune environment. However, during inflammatory conditions such as exposure to bacteria or hypoxia, injured PDLF interact with macrophages through signaling mechanisms that promote the differentiation of macrophages into odontoclasts. Various experimental models have been utilized to study the interactions between PDLF and macrophages. These interactions alter the balance of macrophage polarization, with M1 macrophages contributing to disease progression. CONCLUSION: This review highlights recent insights into the dynamic relationship between PDLF and macrophages in the context of external inflammatory root resorption, emphasizing the importance of their crosstalk in determining disease outcome.
Biomechanical Behavior of Maxillary Premolars with Non-carious Cervical Lesions: Influence of Minimally Invasive Endodontic Access and Restoration Protocols.
Lopes-Olhê FC, Cristina de Assis H, Creazzo G … +8 more , Macedo AP, Carvalho MA, Torres-Carrillo AJS, Altube LG, Jacob G, Alves Dos Santos GN, Mazzi-Chaves JF, Sousa-Neto MD
J Endod · 2025 Dec · PMID 40783156 · Publisher ↗
INTRODUCTION: Non-carious cervical lesions (NCCLs) compromise tooth structure and may cause inflammation requiring endodontic treatment. This study evaluated the influence of endodontic access design on fracture resistan...
INTRODUCTION: Non-carious cervical lesions (NCCLs) compromise tooth structure and may cause inflammation requiring endodontic treatment. This study evaluated the influence of endodontic access design on fracture resistance, failure patterns, and stress distribution in maxillary premolars with wedge-shaped NCCLs restored using different restorative strategies. METHODS: One hundred maxillary premolars were divided into ten groups based on access type (sound and NCCL with traditional, minimally invasive, and no access) and restorative material (provisional, conventional composite, high-viscosity bulk-fill resin, or low-viscosity bulk-fill resin combined with conventional resin composite). NCCLs were standardized, endodontic treatments performed, and restorations applied. After thermocycling, specimens underwent fracture resistance testing and failure mode analysis. One tooth was scanned for finite element analysis (FEA). RESULTS: The sound group and the minimally invasive access group restored with high-viscosity bulk-fill resin had numerically higher fracture resistance. No significant difference was found between traditional and minimally invasive access. Adhesive protocols performed significantly better than temporary restorations (P < .05). Type III (nonrestorable) fractures predominated (50%-90%). FEA revealed stress concentrations in the buccal cusp, central groove, marginal ridges, and cervical region, with similar patterns across groups and slightly lower stress in minimally invasive access. CONCLUSIONS: Endodontic access preparation reduced the fracture resistance of maxillary premolars with noncarious cervical lesions; however, the access design itself did not significantly influence this outcome. FEA revealed similar stress distribution patterns across all groups, regardless of access type. Adhesive restorative protocols, especially those employing bulk-fill composites, enhanced biomechanical performance compared to provisional restorations. These findings underscore the importance of minimally invasive access in preserving structural integrity and highlight the critical role of adhesive strategies in restoring biomechanical function.
Innervation Changes in Apical Periodontitis and its Correlation with Preoperative Symptoms.
Obadah A, Fu J, Wong D … +1 more , Diogenes A
J Endod · 2026 Jan · PMID 40774582 · Publisher ↗
INTRODUCTION: Previous anatomical studies have demonstrated the cellular composition of apical periodontitis (AP) lesions, primarily focusing on immune cells. Only recently has the innervation of an apical lesion been re...
INTRODUCTION: Previous anatomical studies have demonstrated the cellular composition of apical periodontitis (AP) lesions, primarily focusing on immune cells. Only recently has the innervation of an apical lesion been reported, but evidence regarding the quantity and quality of neural innervation in AP lesions remains largely unknown. Importantly, periapical innervation has been shown to modulate cellular response in AP, and the voltage-gated sodium channels Nav1.8, a marker of nociceptors, and Nav1.9 have been associated with various pain-related conditions. This study aimed to quantify sensory innervation and evaluate the expression of Nav1.8 and Nav1.9 in symptomatic vs asymptomatic AP. METHODS: Soft tissue biopsy samples (n = 20) were collected during endodontic microsurgery. Samples underwent protein extraction and immunohistochemistry. Enzyme-linked immunosorbent assay was used to quantify β-tubulin III Nav1.8 and Nav1.9. Immunoreactivity for calcitonin gene-related peptide, neurofilament heavy, PGP9.5, and Nav1.8 was analyzed using confocal microscopy. Data were analyzed using the Mann-Whitney U test with significance set at P < .05. RESULTS: Symptomatic lesions exhibited an approximately 6-fold increase in innervation density (410.6 ± 359.2 vs 63.4 ± 75.7 pg/μg) and significantly higher Nav1.8 (10.3 ± 10.3 vs 2.97 ± 2.5 pg/μg) and Nav1.9 (9.5 ± 8.5 vs 42.5 ± 39.6 pg/μg) expression compared to asymptomatic lesions (P < .05). Neuronal fibers were identified by the co-localization of neurofilament heavy and PGP9.5 immunoreactivity, revealing a higher density of innervation in apical lesions from symptomatic cases. Notably, the majority of these fibers exhibited strong Nav1.8 expression, indicating a predominance of nociceptive innervation within these lesions. CONCLUSIONS: This study provides novel evidence of increased sensory innervation and upregulation of Nav1.8 and Nav1.9 in symptomatic AP. These neural changes may contribute to pain mechanisms in AP and challenges in achieving local anesthesia.
Prevalence of Vertical Root Fractures in Root Filled Teeth and Their Clinical and Radiographic Risk Factors: A Modern Case-Control Analysis Based on Surgical Diagnosis.
Promchouy P, Chotvorrarak K, Osiri S
J Endod · 2026 Jan · PMID 40769327 · Publisher ↗
INTRODUCTION: Vertical root fractures (VRFs) are challenging in endodontic diagnosis. This study determined VRF prevalence and risk factors in root-filled teeth (RFT) requiring endodontic surgery. METHODS: From 411 RFT t...
INTRODUCTION: Vertical root fractures (VRFs) are challenging in endodontic diagnosis. This study determined VRF prevalence and risk factors in root-filled teeth (RFT) requiring endodontic surgery. METHODS: From 411 RFT that underwent endodontic surgery (2005-2022), 130 VRF cases and 260 randomly selected controls were analyzed. Demographic, clinical, and radiographic data were collected from dental records and images. Multiple imputations addressed missing data. Univariable and multivariable logistic regression analyses with robust standard errors to account for the clustering of multiple teeth within the same patient were performed, with subanalyses for teeth with intraradicular posts and molars. VRF characteristics were analyzed in individuals with available cone beam computed tomography images. RESULTS: VRF prevalence was 31.63% among RFT undergoing endodontic surgery. Significant risk factors included age (adjusted odds ratio [aOR] = 1.02), probing depth ≥5 mm (aOR = 2.37), isolated perilateral radiolucency (aOR = 4.05), halo radiolucency (aOR = 2.70), overfilled root canal (aOR = 2.11), and root canal space-to-root-width ratio >1/3 (aOR = 1.52). For teeth with posts, a post space-to-root-width ratio >1/3 increased VRF risk (unadjusted OR [uOR] = 2.46). Cone beam computed tomography findings revealed the absence of the buccal plate (uOR = 1.74) and space between the cortical plate and root surface (uOR = 2.73) as significant factors. CONCLUSIONS: VRFs affected nearly one-third of RFT requiring endodontic surgery; major risk factors included older age, overfilled root canals, and excessive root canal space-to-root-width ratio. VRF-associated clinical and radiographic signs included probing depth ≥5 mm, isolated perilateral radiolucency, and halo radiolucency.
Evaluation of Aluminum Chloride-based Hemostatic Agents in Endodontic Microsurgery: An In Vitro and In Vivo Preclinical Study.
Kim YL, Kim U, Lee S … +3 more , Jang S, Kim E, Kim S
J Endod · 2025 Nov · PMID 40759330 · Publisher ↗
INTRODUCTION: While the aluminum chloride-based hemostatic agent Expasyl is proposed for efficient hemostasis in endodontic microsurgery, its high viscosity may hinder removal and lead to adverse tissue reactions. Traxod...
INTRODUCTION: While the aluminum chloride-based hemostatic agent Expasyl is proposed for efficient hemostasis in endodontic microsurgery, its high viscosity may hinder removal and lead to adverse tissue reactions. Traxodent, with lower viscosity, is less studied. This study preclinically compared Expasyl and Traxodent to evaluate (1) cellular responses in human osteoblasts (HOBs) and (2) hemostatic efficacy and tissue response in a rabbit calvarial model. METHODS: HOBs were cultured in media containing high and low concentrations of each agent to assess short- and long-term effects. Cell viability was assessed using the Cell Counting Kit-8 assay, and osteogenic (ALPL, BGLAP, RUNX2) and inflammatory (interleukin 6, C-X-C motif chemokine ligand 8, transforming growth factor beta 1) gene expression were analyzed via reverse transcription-quantitative polymerase chain reaction. In vivo, six calvarial bone defects were surgically created in each of six rabbits. Defects were randomly assigned to six groups: control, epinephrine, Expasyl, or Traxodent with or without curettage. Hemostasis was evaluated using photographic bleeding scores. Histological analysis assessed tissue response and bone healing. RESULTS: Short-term exposure (2 min - 1 h) to Expasyl or Traxodent reduced HOB viability. Expasyl significantly decreased transforming growth factor beta 1 and increased C-X-C motif chemokine ligand 8 expression. Both agents reduced osteogenic markers. Expasyl showed the highest hemostatic efficacy but also induced more inflammation and delayed bone healing based on histological findings. Traxodent was easier to remove, left minimal residue, and did not impair healing but demonstrated no significant improvement in bleeding control. CONCLUSIONS: Expasyl provided effective hemostasis but was associated with delayed healing and inflammation. Both agents showed cytotoxicity and reduced osteogenic gene expression. Residual Expasyl may hinder healing in endodontic microsurgery.
Cetrimide-enhanced Calcium Hydroxide Paste: A Biocompatible and Bioactive Option for Regenerative Endodontics.
Iglesias JE, Pinheiro LS, Ferreira GC … +3 more , Cuppini M, Collares FM, Grecca FS
J Endod · 2025 Nov · PMID 40716739 · Publisher ↗
INTRODUCTION: This study compared the cytotoxicity, bioactivity, and biocompatibility of calcium hydroxide paste (CHP) with or without 0.2% cetrimide in microspheres (CETm) or in pure form (CET). METHODS: CETm or CET wer...
INTRODUCTION: This study compared the cytotoxicity, bioactivity, and biocompatibility of calcium hydroxide paste (CHP) with or without 0.2% cetrimide in microspheres (CETm) or in pure form (CET). METHODS: CETm or CET were added to CHP and evaluated for cytocompatibility (3-(4,5-dimethyl-thiazoyl)-2,5-diphenyl-tetrazolium bromide assay) and bioactivity (Alizarin Red and alkaline phosphatase), using stem cells from the apical papilla. Biocompatibility was assessed by implanting polyethylene tubes containing the materials into rat subcutaneous tissue. One-way ANOVA followed by Tukey post hoc was used to analyze the results of 3-(4,5-dimethyl-thiazoyl)-2,5-diphenyl-tetrazolium bromide, alkaline phosphatase, and Alizarin Red assays. Kruskal-Wallis with Dunn's post hoc test was used for the biocompatibility test (P < .05). RESULTS: All pastes exhibited cell viability above 100% and bioactivity in alkaline phosphatase and Alizarin Red assays. No abscesses, eosinophils, neutrophils, or giant cells were observed. After 90 days, all materials induced fibrous condensation, and inflammation decreased from mild to insignificant. CONCLUSION: Adding CETm or CET to CHP may offer a potential intracanal medication for regenerative endodontic procedures, demonstrating favorable biological properties.
Bacterial Viability in Persistent Apical Periodontitis: A Systematic Review.
Nascimento D, Guedes IC, Brand LM … +7 more , Bernardi L, Vasconcelos JM, Figueiredo JAP, Visioli F, Lamers ML, Hashizume LN, Rados PV
J Endod · 2025 Nov · PMID 40714054 · Publisher ↗
INTRODUCTION: Apical inflammatory lesions are a response to microbial infections. However, their persistence despite adequate clinical and radiographic conditions remains incompletely understood. This systematic review a...
INTRODUCTION: Apical inflammatory lesions are a response to microbial infections. However, their persistence despite adequate clinical and radiographic conditions remains incompletely understood. This systematic review aimed to analyze the evidence regarding the presence of viable microorganisms in cases of persistent apical periodontitis. METHODS: A search was conducted in MEDLINE/PubMed, EMBASE, Scopus, Web of Science, The Cochrane Library, the CAPES Bank of Theses and Dissertations, and gray Literature. Restrictive inclusion criteria were applied, limiting the selection to studies in which periapical tissue samples were obtained during apical surgery. The quality of the included studies was assessed using a Joanna Briggs Institute Checklist. RESULTS: The search yielded 522 studies, and 4 were selected for full analysis. The main finding of this review indicated the presence of viable microorganisms in persistent apical periodontitis. One study demonstrated bacterial viability through cell culture, while 3 others used RNA-based methods. The studies employing RNA analysis showed methodological heterogeneity. It was also noted that infections associated with persistent apical periodontitis are characterized by a diversity of microorganisms. CONCLUSIONS: The evidence presented in this review suggests the presence of viable bacteria in persistent apical periodontitis. However, it remains unclear whether the persistence of the lesion is due to viable bacteria within the lesion itself, microorganisms located intra- and extraradicular surfaces, or a combination of both.
Factors Influencing Discrepancies between Presurgery Cone-beam Computed Tomography and Intraoperative Measurements in Apical Surgery.
Levy DH, Yavnai N, Rozenfeld S … +6 more , Levin A, Assouline M, Batashvili G, Ben Itzhak J, Talmon A, Solomonov M
J Endod · 2025 Nov · PMID 40712899 · Publisher ↗
INTRODUCTION: This study evaluated the accuracy of cone-beam computed tomography (CBCT) in apical surgery planning by comparing preoperative CBCT measurements with intraoperative findings and identifying factors associat...
INTRODUCTION: This study evaluated the accuracy of cone-beam computed tomography (CBCT) in apical surgery planning by comparing preoperative CBCT measurements with intraoperative findings and identifying factors associated with discrepancies. METHODS: Ninety patients (107 teeth) scheduled for apical surgery underwent preoperative CBCT imaging using a Planmeca ProMax 3D Classic unit (90 kV, 10 mA, 100 μm voxel size, 5 × 5 cm field of view). Three calibrated examiners measured the apico-coronal and mesiodistal dimensions of buccal cortical bone perforations, as well as the apico-coronal length of the remaining buccal cortical plate (BCP) collar. CBCT measurements were compared to intraoperative measurements. Statistical analyses assessed associations between CBCT inaccuracies and variables including age, sex, lesion size, tooth type (anterior vs posterior), location (maxilla vs mandible), root canal status, and time interval between CBCT and surgery. RESULTS: A total of 101 surgical sites were analyzed. CBCT demonstrated a sensitivity of 90.6% and a specificity of 93.9% for detecting cortical plate perforations. Paired statistical tests revealed that CBCT significantly underestimated the mesiodistal dimension of lesions (P = .011) and overestimated the BCP collar dimension (P = .005). Multivariate generalized linear model analysis indicated that larger lesion size, mandibular location, and the presence of a root filling were significantly associated with greater discrepancies. CONCLUSIONS: CBCT demonstrates inherent limitations in measurement accuracy for apical surgery planning. Discrepancies are influenced by lesion size, tooth location, and root canal status. Clinicians should account for these factors when interpreting CBCT data to minimize preoperative planning errors.
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