Treatment outcome of partial pulpotomy using two different calcium silicate materials in mature permanent teeth with symptoms of irreversible pulpitis: A randomized clinical trial

AIM To assess the clinical and radiographic outcome of partial pulpotomy by comparing MTA Angelus and Total Fill BC, as pulpotomy agents, in mature teeth with deep caries and symptoms indicative of irreversible pulpitis. METHODOLOGY The study was designed as a parallel-two arm, double-blind, randomized superiority clinical trial registered at www. CLINICALTRIALS gov (NCT04870398). Symptomatic mature permanent teeth with deep caries fulfilling the inclusion criteria were randomly treated using either MTA Angelus or Total Fill BC. A partial pulpotomy was performed and following complete haemostasis, the capping material was placed over the remaining pulp tissue and a postoperative periapical radiograph was taken. Clinical and radiographic follow-up evaluation was performed for a median time of 2 years, whereas levels of pain intensity were evaluated preoperatively and for 7 days after intervention using Visual Analogue Scale. For the primary outcome (failure/success of treatment), the Kaplan-Meier survival curves for the capping materials were plotted and a log-rank test for equality of survivor functions was applied. A multivariable random effects Cox Regression model was also applied. For the secondary outcome (postoperatively reported pain), a multivariable mixed effects ordinal logistic regression was structured. RESULTS One hundred and thirty-seven teeth in 123 patients underwent partial pulpotomy using randomly either MTA Angelus (N = 74) or Total Fill BC (n = 63). The percentage failure for MTA Angelus and Total Fill BC was 10.8% (8/74) and 17.5% (11/63), respectively, but the difference was not statistically significant [adjusted HR: 1.83; 95% confidence interval (CI): 0.68, 4.91; p = .23]. Weak evidence was found that secondary caries involvement may impose a 3.54 times greater hazard for treatment failure (adjusted HR: 3.54; 95% CI: 1.00, 12.51; p = .05). For each passing minute of procedural bleeding control, there was also a 57% higher hazard for treatment failure (adjusted HR: 1.57; 95% CI: 0.99, 2.48; p = .05). The odds for higher postoperative pain were 4.73 times greater for the Total Fill BC compared to MTA Angelus (adjusted OR: 4.73; 95% CI: 2.31, 9.66; p < .001). CONCLUSIONS Both materials exhibited similar and favourable outcome rates after partial pulpotomy in teeth with deep caries and symptoms of irreversible pulpitis. Total Fill BC was associated with a higher level of postoperative pain intensities

Outcome of Partial Pulpotomy in Immature Permanent Teeth with Symptomatic Irreversible Pulpitis: A Prospective Case Series Assessment

INTRODUCTION The aim of this prospective case series was to assess the clinical and radiographic outcome of partial pulpotomy in caries-exposed symptomatic, vital, immature, permanent molars. METHODS Thirty-four immature molars with deep caries and symptoms of irreversible pulpitis were treated by partial pulpotomy and ProRoot MTA as a capping material. After complete caries removal, the inflamed part of the pulp was removed. Complete hemostasis was achieved using a sterile cotton pellet moist initially with sodium hypochlorite 1.5% and then with sterile saline. ProRoot MTA (Dentsply Sirona, Charlotte, NC) was placed as a capping material onto the remaining pulp tissue. The cavity was sealed using a light-curing resin-modified Ca(OH)$_{2}$ cavity liner, and patients were referred to a pediatric dentist for permanent restoration. Descriptive statistics and cross tabulations were performed including variables examined before, during, and after the procedure. RESULTS All examined teeth presented a favorable clinical and radiographic outcome with normal periapical tissues, complete apical closure, and formation of a dentinal bridge beneath the capping material. Signs of partial pulp chamber calcification were only detected in 2 cases. Postoperatively, most patients did not report any pain (23/34, 67.7%), whereas the rest reported minor intensity pain (11/34, 32.3) and the use of analgesic or anti-inflammatory drugs only for 1 day (10/34, 29.4%). CONCLUSIONS Partial pulpotomy seems to provide a universally successful outcome when managing symptomatic vital immature teeth with no signs of complications and completion of apical closure. It could be a viable treatment of choice in cases of caries-exposed vital immature teeth with symptoms of irreversible pulpitis

Changes in the Pulp Tissue Complex Induced by Orthodontic Forces: Is There a Need for Concern? A Systematic Review and Meta-Analysis of RCTs and Prospective Clinical Trials

PURPOSE To identify and assess any changes in the pulp tissue complex following orthodontic force application. MATERIALS AND METHODS Published and unpublished literature was searched in seven databases until 9 August 2022 for randomised controlled trials (RCTs) and prospective trials (nR-PCT). Representative key words included 'pulp response', 'pulp tissue', 'orthodontic force', and 'tooth movement'. Study selection, data extraction, risk of bias and certainty of evidence assessment were conducted independently by two reviewers. Random effects meta-analyses with respective confidence intervals (95%CIs) were conducted where applicable. RESULTS A total of 363 records were screened, a final number of 24 articles were eligible for qualitative synthesis, while 8 of those contributed to meta-analyses. There was evidence that pulpal blood flow (PBF) decreased after 3 weeks of tooth movement compared to no force application (4 studies, mean difference: -1.68; 95% CI: -3.21, -0.15; p = 0.03). However, this was not the case after 6 months of treatment (p = 0.68). A rise in the activity of aspartate aminotransferase (AST) was detected after 7 days of treatment, but combining 2 studies, this was not statistically significant (p = 0.25). Other outcomes were assessed through single studies. Risk of bias was within the range of 'some concerns/moderate to high/critical overall', while certainty of evidence was low to very low according to GRADE. CONCLUSIONS As a short-term effect, PBF decreased upon initiation of orthodontic force application, while enzymatic and peptide activity within the pulp was transiently affected. Further long-term evidence of improved quality and certainty is needed

Publication bias in randomized controlled trials in dentistry. What factors affect statistical significance of outcomes?

OBJECTIVES To record the proportion of Randomized Controlled Trials (RCTs) reporting significant (versus non- significant) primary outcomes, published across 12 high impact journals in Dentistry, covering 6 specialty domains. Associations with certain journal, publication and outcome characteristics were examined. METHODS We identified and included all RCTs published from January 1st, 2017 to December 31st, 2021 in the two journals with the highest impact factors (Clarivate Analytics, 2020) from each of the following domains: Periodontology, Endodontics, Restorative Dentistry/ Prosthodontics, Orthodontics, Paediatric Dentistry, Oral and Maxillofacial Surgery. The primary outcome was the proportion of significant/ non- significant findings reported for the primary outcomes under study, while a range of characteristics such as: journal, year of publication, impact factor, funding, registration and others, were tested for associations. RESULTS A total of 474 RCTs were identified and included, with the majority reporting statistically significant outcomes (321/474; 67.7%). The multivariable model revealed significant effects of predictors related to specialty domain (p = 0.01), continent (p = 0.003) and registration (p = 0.004). Compared to Periodontology, RCTs published in Endodontics (OR= 0.40; 95%CIs: 0.22, 0.76) and Orthodontics (OR= 0.41; 95%CIs: 0.23, 0.74) were less likely to present statistically significant effects. There was strong evidence that registered trials presented lower odds of reporting statistically significant findings (OR= 0.52; 95%CIs: 0.34, 0.81). CONCLUSIONS The entirety of dentistry domains demonstrated preferential publication practices of outcomes considered as "successful" and statistically significant, with domains such as Orthodontics and Endodontics being more balanced. Trial non- registration is still prevalent and associated with reporting of statistically significant effects. CLINICAL SIGNIFICANCE The findings of this empirical report bring attention to the interpretation of Systematic Reviews (SRs) conclusions. These largely depend on the availability and nature of outcomes of randomized controlled trials (RCTs) on a topic, which may impact on the synthesized estimate of a pooled effect and its direction

The Effect of Cone-Beam Computed Tomography (CBCT) Evaluation on Treatment Planning after Endodontic Instrument Fracture

Intracanal instrument fracture is a procedural iatrogenic event during endodontic treatment that may affect treatment planning and eventually treatment outcome. Cone Beam Computed Tomography (CBCT) has offered several advantages, especially in endodontic cases in which information from conventional periapical radiograph may not be adequate to allow a precise treatment planning decision and a subsequent appropriate management of the cases. The present study was firstly conducted to assess the effect of CBCT evaluation on the decision-making process after instrument fracture; secondly, to introduce a new clinical approach in cases with fractured instruments located in the mesial roots of mandibular and maxillary molars. The study design was observational. The sample comprised all cases of mandibular and maxillary molars where an instrument fracture had occurred in the mesial roots. Two qualified (National and Kapodistrian University of Athens, Greece) and experienced (more than fifteen years of daily practicing) endodontists evaluated all the cases. The initial treatment plan made by evaluating periapical radiographs of each case was compared to the final plan set after CBCT evaluation. A marginal homogeneity test for paired data was conducted to test the concordance of treatment planning with periapical radiographs versus CBCT. Multivariable logistic regression was structured to identify predictors of modification in treatment planning following CBCT assessment, and to record estimators for decision to remove, bypass or retain the fragment. The level of statistical significance was pre-specified at p &lt; 0.05. Of a total 52 cases evaluated, change in treatment planning with conventional periapical radiograph as a reference, following evaluation of CBCT, was observed in more than half of the teeth. The difference was statistically significant (p &lt; 0.001). Apical location of the fragment was more likely to induce a perceived change in treatment planning after CBCT evaluation (p &lt; 0.01). Canal merging induced 95% lower odds (p = 0.01) for taking a decision to remove or bypass, revealing that retaining the fragment was by far a more likely decision. A significant impact of CBCT preoperative evaluation on treatment planning for the management of such cases was demonstrated. Apical location of the fragment and canal merging seem to influence the decision-making process. Keywords: cone-beam computed tomography; decision making; instrument fracture; treatment plannin

Cardiovascular Disease and Chronic Endodontic Infection. Is There an Association? A Systematic Review and Meta-Analysis

The aim of the present study was to systematically assess existing evidence on the possible association between chronic endodontic infections and cardiovascular disease (CVD). An electronic database search was implemented until 2 October 2020. The main outcome was risk of CVD diagnosis. Risk of bias was assessed through the ROBINS-I tool, while random effects meta-analyses were conducted. The quality of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation. Twenty-one studies were eligible for inclusion, while 10 were included in the quantitative synthesis. Risk for CVD diagnosis in patients with chronic endodontic infection was 1.38 times those without infection (RR = 1.38; 95% CIs: 1.06, 1.80; p = 0.008). Risk of bias ranged from moderate to serious, while the quality of the evidence was graded as very low. Indications for an identified association between chronic endodontic infection and CVDs do exist; however, they are not grounded on high-quality evidence at present. Further research for an establishment of an association based on temporal sequence of the two entities and on unbiased well-conducted cohort studies would be highly valued

Comparison of Bacterial Community Composition of Primary and Persistent Endodontic Infections Using Pyrosequencing

Elucidating the microbial ecology of endodontic infections (EI) is a necessary step in developing effective intra-canal antimicrobials. The aim of the present study was to investigate the bacterial composition of symptomatic and asymptomatic primary and persistent infections in a Greek population, using high throughput sequencing methods

Trial registration and selective outcome reporting in Endodontic Research: Evidence over a 5-year period

AIM To assess the prevalence of registration of clinical trials in endodontic research and to identify outcome reporting discrepancies between trial registration entries and respective final publications. Associations with publication characteristics, such as journal, year of publication, origin, number of centres and authors, funding and statistical significance of the findings, were also sought. METHODOLOGY All reports of endodontic randomized controlled trials (RCTs) published in 4 endodontic specialty and 4 general dental journals from 1 January 2016 to 31 December 2020 were identified. Trial registration frequency patterns were assessed for the included RCTs, whilst for the ones registered, outcome reporting discrepancies were recorded. Article characteristics such as year of publication, geographic region, number of centres, authors participating in the publication, funding, type of registration and others were identified. Descriptive statistics and univariable/multivariable logistic regression were performed to examine the effect of study characteristics on identified registration practices. RESULTS One hundred and fifty-five RCTs were included, with the majority published in specialty journals (121/155; 78.1%). A total of 42.6% of the identified RCTs was registered (66/155), mostly retrospectively (38/66; 57.6%). There was strong evidence that each additional year for more recent publication accounted for 1.42 times higher odds of being registered (adjusted Odds Ratio = 1.42; 95%CI: 1.11, 1.80; p = .004). More than 1/3 of registered RCTs presented outcome reporting discrepancies (24/66; 36.4%), whilst such inconsistencies were almost evenly distributed between primary and secondary outcomes. CONCLUSIONS Trial registration policies in endodontic research should be reviewed and active endorsement of prospective registration practices should be prioritized for better clarity and transparency of the disseminated research. Outcome reporting discrepancies shall thus be eliminated, offering increased credibility in research findings and eliminating bias in this respect

Uncertainty Bounds in Clinical Trials Published in Endodontic Journals within the Last 5 Years: Are We Confident on What We Read

INTRODUCTION The aim of this study was to assess the prevalence of reporting of confidence intervals (CIs) in clinical trials in endodontics and discover any further associations with a range of publication characteristics. METHODS The electronic contents of the 3 leading endodontic journals with the highest impact factors (International Endodontic Journal, Journal of Endodontics, and Australian Endodontic Journal) were assessed from January 2016 to December 2020. The number and proportion of clinical trials reporting CIs for the difference in effectiveness/safety of competing interventions for the outcome of interest were recorded. Associations with journal, year of publication, study design, use of analyses for more complex sets of data, and others were assessed. Univariable and multivariable logistic regressions were used to identify significant predictor variables. Yearly linear trend effects were also sought. RESULTS A total of 141 reports of clinical trials were identified. The majority were published in the Journal of Endodontics (90/141, 63.8%) followed by the International Endodontic Journal (41/141, 29.1%). CI reporting was confirmed only for 29.1% of the sample of reports (41/141). There was strong evidence that reports of clinical trials including analyses of more complex sets of data presented 11.47 times higher odds for CI reporting (adjusted odds ratio = 11.47; 95% CI, 4.19-31.41; P < .001). CONCLUSIONS The inclusion of uncertainty measures as represented by the reporting of CIs is suboptimal within endodontic clinical trial reports

Is data missing? An assessment of publication bias in orthodontic systematic reviews from 2010 to 2021

AIM To assess the extent of publication bias assessment in systematic reviews (SRs) across the orthodontic literature over the last 12 years and to identify the appropriateness of assessment and association with publication characteristics, including year of publication, journal, searching practices within unpublished literature or attempts to contact primary study authors and others. MATERIALS AND METHODS We searched six journals and the Cochrane Database of Systematic Reviews for relevant articles, since January 2010, until November 2021. We recorded practices interrelated with publication bias assessment, at the SR and meta-analysis level. These pertained to reporting strategies for searching within unpublished literature, attempts to communicate with authors of primary studies and formal assessment of publication bias either graphically or statistically. Potential associations between publication bias assessment practices with variables such as journal, year, methodologist involvement, and others were sought at the meta-analysis level. RESULTS A sum of 289 SRs were ultimately included, with 139 of those incorporating at least one available mathematical synthesis. Efforts to search within unpublished literature were reported in 191 out of 289 Reviews (66.1%), while efforts to communicate with primary study authors were recorded for 150 of 289 of those (51.9%). An appropriate strategy plan to address issues of publication bias, conditional on the number of studies available and the methodology plan reported, was followed in 78 of the 139 meta-analyses (56.1%). Formal publication bias assessment was actually reported in 35 of 139 meta-analyses (25.2%), while only half of those (19/35; 54.3%) followed an appropriately established methodology. Ten of the latter 19 studies detected the presence of publication bias (52.6%). Predictor variables of appropriate publication bias assessment did not reveal any significant effects. CONCLUSIONS Appropriate methodology and rigorous practices for appraisal of publication bias are underreported in SRs within the orthodontic literature since 2010 and up-to-date, while other established methodologies including search strategies for unpublished data or communication with authors appear currently suboptimal