ENDODONTIE

Prognostication of External Cervical Resorption Based on Heithersay's and Patel et al. Classifications: A Narrative Review

Tiago Pimentel, Shanon Patel — Wed, 10 Jun 2026 21:14:17 -0700

International Endodontic Journal, EarlyView.

What If the External Crown Surface of Teeth Could Predict the Pulp Chamber? A DeepSDF‐Based Approach

Mon, 08 Jun 2026 03:30:13 -0700

ABSTRACT

Aim

Spatial localisation of the pulp chamber is critical for safe and effective dental treatments. This study aimed to assess the performances of DeepSDF models to predict the 3D pulp chamber space and cervical line of molars using only external crown surfaces.

Methodology

A fully connected auto-decoder DeepSDF network was trained on μCT-derived 3D tooth-models collected across three centres (n = 265) to learn a joint latent representation of the external and internal anatomy. Model evaluation was performed on a validation dataset from an independent external centre (n = 10). Only the external crown surface was provided to reconstruct the pulp chamber. The models were subsequently applied to clinical intraoral scans (IOS) and evaluated against corresponding cone-beam CT (CBCT) references (n = 39). Reconstruction accuracy was quantified using average surface distance, Hausdorff distance, and volumetric overlap metrics.

Results

On μCT-derived models, the best performing DeepSDF-model reconstructed the pulp chamber with a mean surface distance of 0.18 ± 0.04 mm and a Hausdorff distance of 1.75 ± 0.21 mm, with a median of 95.9% [87.2–97.8] of surface vertices per tooth within 1 mm distance to the ground truth. The largest deviations corresponded to areas of the pulp horns (1.2 ± 0.58 mm). On clinical IOS data, predicted external surfaces showed a median distance error of 0.21 mm [0.18–0.23] and maximum distance error of 1.21 mm [1.03–1.93]. The pulp chamber was reconstructed with a median distance error of 0.49 mm [0.36–0.69], and maximum distance error of 1.49 mm [1.12–1.95]. Predicted pulp volumes were smaller, with a volumetric precision of 47% [26.5–80.7] relative to the CBCT-derived reference.

Conclusion

DeepSDF models learned consistent relationships between the external tooth morphology and pulp anatomy when trained and evaluated on μCT-derived data. When applied to intraoral scans, local variability was observed, particularly at the level of pulp horns. However, the overall position of the pulp chamber remained consistent. These reconstructions could be considered as an approximate representation of the internal anatomy and may provide useful support for non-invasive visualisation from intraoral scan derived surfaces and planning in digital endodontics and augmented reality-assisted procedures.

Comments on the Evidentiary Framework of the EFCD‐ESE‐ORCA Guideline on Deep Caries Management

Domenico Ricucci — Sun, 07 Jun 2026 21:40:36 -0700

International Endodontic Journal, EarlyView.

Impedance‐Guided Localisation of Pulp Chambers and Canal Orifices in Calcified Root Canal Systems: Biological Foundations and Conceptual Application

Mohammad Hossein Nekoofar, Paul M. H. Dummer — Sun, 07 Jun 2026 21:39:27 -0700

ABSTRACT

Aim

To outline the biological and electrochemical principles supporting impedance-guided localisation of pulp chambers and canal orifices in calcified root canal systems, and to present an accessory concept relating to impedance patterns at the coronal dentine–gutta-percha interface, potentially serving as a surrogate marker of fluid leakage associated with deficient non-conductive root fillings.

Summary

Calcific metamorphosis produces structural alterations that complicate localisation of pulp chambers and canal orifices. Adjunctive modalities such as CBCT, guided endodontics, microscopic magnification and ultrasonic troughing provide geometric information but lack real-time biological feedback. Electrical impedance behaviour differs significantly between sclerotic dentine and residual conductive pathways and offers a biological cue during access. The impedance-guided localisation concept applies these principles through a structured, conservative workflow. In addition, impedance patterns observed at coronal dentine–gutta-percha interfaces will, in theory, reflect electrochemical variations associated with potential fluid leakage and the reduced effectiveness of existing non-conductive root fillings to provide a fluid-tight seal.

Conclusion

Impedance-guided localisation may provide a biologically grounded adjunct to visual and geometric strategies for locating pulp chambers and canal orifices when managing calcified root canal systems during root canal treatment. The interface-related impedance concept serves as an optional scientific extension, derived from established electrochemical principles, that may offer insight into potential fluid leakage or reduced sealing effectiveness associated with non-conductive root canal fillings.

Clinical Significance

Impedance-guided pulp chamber and canal orifice localisation provides real-time biological feedback that reduces the risk of iatrogenic perforations and enhances conservative dentine management, particularly for inexperienced clinicians with potential relevance for preclinical training and early clinical education. The accessory interface-related impedance concept may offer surrogate insight into potential leakage or reduced sealing effectiveness of root fillings.

Endodontic Management Before, During and After Head and Neck Radiotherapy: Biological, Diagnostic and Clinical Considerations in Head and Neck Cancer Patients

Jing‐zhi Ma, Franklin Tay — Fri, 05 Jun 2026 02:15:51 -0700

ABSTRACT

Background

Head and neck radiotherapy creates a high-consequence dental environment in which tooth loss may precipitate osteoradionecrosis, particularly after extraction in high-dose mandibular regions. Tooth preservation through nonsurgical root canal treatment is therefore a risk reduction strategy. However, evidence relevant to endodontic decision-making remains dispersed among clinical series, laboratory research, pulp testing studies and oncology dental guidance.

Objective

To synthesise contemporary evidence relevant to endodontic management before, during and after head and neck radiotherapy, and to present a clinically applicable, dose-informed framework for diagnosis, treatment planning, technical modification and follow-up.

Methods

A narrative review with integrative synthesis was undertaken using evidence from clinical outcome studies, dosimetric and planning studies, pulp sensibility and vascular assessment studies, laboratory investigations of irradiated dental tissues and materials and guideline-based oncology dental literature. Evidence was organised by radiotherapy phase as before treatment, during treatment, early after radiotherapy and late after radiotherapy, and interpreted using three tooth-level dose tiers: below 30 Gray, 30–60 Gray and at least 60 Gray.

Results

Radiotherapy depresses neural sensibility responses, yielding false-negative cold and electric pulp testing results that do not reliably indicate pulp necrosis. Vascular-oriented assessments suggest that pulpal blood flow may be partly preserved or recover later in some teeth. Hyposalivation and radiation-related caries accelerate structural breakdown and often trigger pulpal disease through restorative destabilisation. Laboratory evidence indicates dose-dependent alterations in dentine structure and mechanics that may complicate adhesion, fracture resistance and retreatment. Direct clinical outcome data remain limited, yet available series in irradiated patients report symptom control and tooth retention after primary root canal treatment, with no osteoradionecrosis events attributed to nonsurgical endodontics. Technical priorities include conservative working length control, minimisation of apical extrusion of debris, irrigants, intracanal medicaments, filling materials and rapid establishment of a durable coronal seal. Evidence gaps include prospective dose-annotated cohorts, retreatment-specific data and outcome reporting in proton-based radiotherapy populations.

Conclusion

Endodontic care before, during and after radiotherapy should be dose-informed, phase-matched and centred on tooth preservation in high-dose regions, with cautious interpretation of sensibility testing and explicit linkage of prognosis to restorability and coronal integrity.

The Role of Neuropeptide Y in Dental Pulp: Balancing Neurogenic Inflammation and Pain Modulation

Fri, 05 Jun 2026 02:08:52 -0700

ABSTRACT

Background

The citation impact of endodontic evidence synthesis reviews is primarily influenced by temporal factors, author academic standing and journal prestige rather than methodological rigour alone. These findings reveal a disconnect between indicators of research quality and citation performance and highlight the necessity of promoting transparency as a scientific value rather than as a surrogate for visibility.

Trial Registration

This study was registered in the Open Science Framework (https://osf.io/jf9et/)

The Efficacy of Intracanal Medicaments Within the Regenerative Endodontic Procedures on Permanent Necrotic Immature Teeth: Systematic Review and Naïve Indirect‐Comparison Meta‐Analysis

Mario Alovisi, Paolo G. Arduino, Stefano Petti — Tue, 02 Jun 2026 00:16:26 -0700

ABSTRACT

Objectives

The objectives of this study were to estimate and compare the 1-year clinical success rates of triple antibiotic paste (TAP), double antibiotic paste (DAP), calcium hydroxide (CH) within regenerative endodontic procedures (REPs) on permanent necrotic immature teeth.

Materials and Methods

Trials investigating REP success were searched through MEDLINE, Scopus, Embase, Web of Science, GOOGLE Scholar (last update December 2025). Primary study quality was evaluated through the revised Cochrane Risk of Bias tool for Randomised Trials (RoB2). Pooled success rates with 95% confidence intervals (95% CIs) were assessed. Heterogeneity was investigated with the Cochran's Q and quantified with I ²: The random-effects model was preferred to the fixed-effect model for I ² > 50%. Sensitivity (study quality, publication bias, study inclusion) and subgroup (scaffold type, world Region) analyses were made. The differences in pooled success rates between protocols were assessed and were evaluated using an equivalence range of −2.5%/+2.5%. The GRADE system was employed to evaluate the Quality of Evidence of the pooled success rates.

Results

Twenty-four studies of average quality were included involving 544, 64, 183 patients, for TAP, DAP, CH, respectively. The pooled success rates (tooth survival after 1 year with periapical healing, absence of signs and symptoms of pathology) were TAP 96.7% (95% CI, 94.8%–98.0%), DAP 84.2% (95% CI, 73.2%–92.0%), CH 97.4% (95% CI, 93.9%–99.1%). The pooled differences in success rates were TAP-DAP 12.5% (95% CI, 2.8%–22.1%, TAP superiority demonstrated), TAP-CH −0.7% (95% CI, −0.9%–2.5%, TAP/CH equivalence demonstrated), CH-DAP 13.2% (95% CI, 3.3%–23.0%, CH superiority demonstrated). Secondary analyses corroborated these results, although the overall statistical test power was low due to small sample sizes. The GRADE quality of evidence was high for TAP and CH, and low for DAP, due to substantial imprecision attributed to the small number of studies with small sample sizes.

Conclusions

True regeneration of the pulp-dentine complex is the ultimate goal of regenerative endodontic procedures (REPs). Despite favourable clinical outcomes, such as resolution of apical periodontitis, continued root elongation and apical closure, histological evidence suggests that most clinical cases result in tissue repair rather than true regeneration. This discrepancy arises from the intricate requirements for optimising the microenvironment, which encompasses two essential stages: disinfection and regeneration. These two stages are not necessarily sequential; they can overlap and be highly interconnected, influencing each other. Current REPs protocols have limitations in both disinfection and regeneration. Endodontic biofilms exhibit a notable tolerance to disinfectants and have the capability of recovery, which negatively affects the odontogenic potential of stem cells. Additionally, immune cells, particularly M1 and M2 macrophages, interact with stem cells and affect their regenerative capacity. Standard irrigants and intracanal medicaments often fail to eliminate biofilms, compromising stem cell viability and differentiation potential. On the regeneration side, age-related decline in stem cell function reduces cell survival and differentiation capacity, while insufficient delivery and lack of control over signalling molecules limit odontogenesis, angiogenesis, and neurogenesis. Commonly used scaffolds for REPs lack the structural, biochemical and biological precision required to guide regeneration of well-organised tissue. Furthermore, a microenvironment characterised by hypoxia, restricted nutrients and limited neurovascular ingrowth further constrains regenerative outcomes. This review will focus on the limitations of the current regenerative microenvironment in REPs and discuss emerging strategies aimed at integrating infection control with tissue engineering design. It also highlights the need for novel antimicrobial approaches and advanced tissue engineering strategies in REPs. Multifunctional biomaterials, such as chitosan nanoparticles, antimicrobial peptides and hierarchically structured scaffolds, may ultimately facilitate true biological regeneration of the pulp-dentine complex.

Association Between the Root Canal Microbiome and Apical Lesion Size: An Observational Shotgun Metagenomic Study

Tue, 02 Jun 2026 00:00:00 -0700

ABSTRACT

Aim

The aim was to characterize the taxonomic and functional composition of the microbiome involved in primary endodontic infections and to evaluate their association with the periapical lesion size using shotgun metagenomic sequencing.

Methodology

Samples from primary root canal infections diagnosed with apical periodontitis were analysed with shotgun sequencing. Samples were classified according to the lesion size as small (< 3 mm) or large (> 7 mm). The bacterial DNA copies in each group were quantified by qPCR. Taxonomic and functional annotations were made using Bracken/Kraken2 and HUMAnN3 software. Species richness, Shannon, Simpson and Pielou indices were used to measure alpha diversity. The similarity of the bacterial communities between study groups was evaluated by Principal Coordinate Analysis based on Bray–Curtis distances. The ALDEx2 package was used to infer the differences between species, and the edgeR package for KEGG pathways. For all statistical analyses, p < 0.05 was considered as significant.

Results

A total of 49 samples were analysed, 27 with small lesions and 22 with large lesions. Species richness and Shannon indices showed differences between both groups, whereas no differences were seen according to Simpson and Pielou indices. A different community composition (PERMANOVA, p = 0.0019) was observed between the two groups. Three species were significantly enriched in the large lesion samples, Filifactor alocis, Lachnospiraceae bacterium oral taxon 500 and Olsenella uli, while three others were enriched in small lesion samples, Acinetobacter baumannii, Acinetobacter pittii and Cutibacterium acnes. Functionally, benzoate, flavonoid and steroid degradation, the sphingolipid signalling pathway and proteasome function were enriched in samples with large lesions. Monoterpenoid biosynthesis, phospholipase D signalling, the sulphur relay system and staurosporine biosynthesis were enriched in small lesions.

Conclusions

Teeth with large periapical lesions harbour greater bacterial loads and exhibit a more diverse microbial community than those with small lesions. Differences in species-level taxonomic composition were observed between both groups. Functionally, large lesions are enriched in pathways associated with immune evasion and pro-inflammatory activity, whereas small lesions are characterized by pathways related to apoptosis, metabolic adaptation and anti-inflammatory processes. These findings suggest that lesion severity is also shaped by the functional potential of the microbiome to modulate host inflammation.

Multiple External Invasive Root Resorption and Calcification in Systemic Sclerosis—Case Report

Jee‐Yun Leung, Geoffrey Heithersay, Richard Logan, Sharon Liberali — Sun, 31 May 2026 00:00:00 -0700

ABSTRACT

Aim

There are few reports in the literature of multiple external invasive root resorption (EIRR) lesions in patients with systemic sclerosis (SSc), and an association between root resorption and SSc is not well established. We report the only case that comprehensively illustrates—with the combination of histopathology, cone beam computed tomography (CBCT), orthopantomograms and photography—pulpal and periodontal ligament calcifications, multiple EIRR lesions progressing over time and the sequelae of treatment. Sixteen affected teeth, documented over 14 years, are presented.

Summary

A 51-year-old female presented for overall oral management of progressive SSc. Extraction of symptomatic teeth 16 and 26 revealed palatal EIRR. Retrospective dental record review revealed four previously extracted affected teeth. Subsequent CBCT revealed a further 10 affected teeth. Rapid EIRR progression of teeth 25 and 47 ensued and were extracted with tooth 46. Histopathology revealed ankylosis with mature bony infill of EIRR lesions, bone abutting dentine with absent cementum and pulpal and PDL calcifications. The teeth 46–47 extraction site developed stage I medication-related osteonecrosis of the jaw secondary to denosumab use, was managed with conservative measures and resolved.

Key Learning Points

Patients with SSc may display a higher prevalence of EIRR. Awareness should be raised about this potential association. Dentists treating patients with SSc should conscientiously search for these easily unnoticed, often subgingival lesions, since early management may reduce the risk of teeth succumbing to pathological fracture. However, if multiple progressive lesions present, no intervention may be appropriate due to the aggressive nature of EIRR and potential futile outcome of treatment.

RE: Outcomes of Root Canal Treatment in Patients With Autoimmune Disease: A Retrospective Case–Control Study

Mehran Farajollahi, Christopher T. Sexton — Thu, 28 May 2026 04:45:14 -0700

International Endodontic Journal, EarlyView.

Redefining the Evolution of Pulpal Pathology: Inflammasomes as Central Integrative Hubs and Biological Switches Governing the Transition From Reversible to Irreversible Pulpal Inflammation Beyond Symptom‐Based Classification

Tue, 26 May 2026 00:50:19 -0700

ABSTRACT

Background

No significant differences were observed between retreatment protocols, regardless of the use of orange oil solvent, for any evaluated parameter (p > 0.05). Additional apical enlargement with the HyFlex EDM 50/0.03 instrument significantly reduced the overall volume of remaining filling material in both groups (p < 0.05). However, complete removal of the filling material was not achieved in any specimen. Apical enlargement did not result in significant changes in canal transportation or centering ability (p < 0.05).

Conclusion

The use of an orange oil solvent did not improve filling material removal or influence canal shaping in S-shaped mesial root canals of mandibular molars. Additional apical enlargement with the HyFlex EDM 50/0.03 instrument enhanced root canal cleanliness without compromising canal anatomy, although residual filling material persisted.

Letter to the Editor

Conclusion

Based on the available evidence, reference values for pulp oxygen saturation in permanent teeth with complete root development and healthy pulps ranged from 86.26% to 91.73%. These findings support the clinical relevance of establishing preliminary reference values for pulp oximetry and highlight the need for further standardisation before routine clinical implementation.

Trail Registration

This study was registered in the PROSPERO database: CRD42023437995.

Micro–Computed Tomographic Evaluation of Shaping Ability by Novice Dental Students and Their Preference of Nikel‐Titanium File; Rotation Versus Reciprocation System

Akshay Keerthy, Hae Young Hong, Jong Ryul Kim — Sun, 05 Apr 2026 21:00:39 -0700

ABSTRACT

Aim

Nickel–titanium (NiTi) rotary instruments have helped clinicians in enhancing canal preparation, with two different kinematic systems employing either reciprocating or rotary motion. This study aimed to evaluate the influence of this kinematics on canal transportation and centering ratios when used by novice dental students and their preference after use.

Methodology

Forty-two mesial canals of 3D-printed mandibular first molars were instrumented by 21 sophomore dental students. Students were randomly assigned to instrument both mesiobuccal (MB) and mesiolingual (ML) canals using either ProTaper Gold (PTG) or WaveOne Gold (WOG) while measuring instrumentation time. Micro-computed tomography (micro-CT) scans were taken before and after instrumentation. Canal transportation and centering ratios were calculated at apical, middle and coronal levels. A questionnaire was completed after instrumentation regarding students' perception with 5-point Likert scale: ease of use, flexibility, cutting efficiency, screwing effect, overall impression and their preferred file. Canal transportation and centering ratios were compared using paired t-tests. Data from the questionnaire were analysed using the Pearson chi-square test and independent t-tests. The statistical significance level was set at p < 0.05.

Results

PTG showed significantly more canal transportation than WOG in both apical and middle thirds of the ML canals (p < 0.05). The centering ratios of WOG were also significantly higher at the apical and middle thirds of ML canal but lower at the apical thirds of MB canal. The time for WOG instrumentation was shorter than for PTG (218 ± 83.6 vs. 446.6 ± 231.4 s, p < 0.05). WOG had significantly higher scores in the categories of ‘ease of use’, ‘screwing effect’ and ‘overall impression’ (p < 0.05) than those of PTG. 19/21 students (90.48%) preferred WOG to PTG.

Conclusions

The reciprocation system was preferred in aggregate over the rotation system by novice dental students and showed less canal transportation and better centering ability with shorter instrumentation time.

Generative Artificial Intelligence for Computer Vision in Endodontics: A Review of Current State and Future Potential

Wed, 01 Apr 2026 03:55:34 -0700

ABSTRACT

Background

Computer vision methods based on artificial intelligence (AI) have found numerous applications in endodontic diagnosis and treatment planning. While most current applications employ discriminative deep learning models for detection and classification tasks, the field is now witnessing the rise of generative AI (GenAI), a class of AI models that learn to generate new data samples resembling the original training data. Despite the potential of GenAI, its current state, applications in endodontics and challenges have not been thoroughly explored.

Objectives

This narrative review aims to explore the current state and potential applications of GenAI models in computer vision and imaging within endodontics.

Methods

A literature search was conducted in PubMed/MEDLINE, Web of Science, Embase, Scopus and arXiv through July 2025, using predefined keywords related to generative models, dental imaging and endodontics. This comprehensive narrative review examines the fundamental principles and current applications of vision GenAI models in endodontics, aiming to clarify their capabilities and evaluate their prospective implications for future applications in endodontic diagnosis, image enhancement and treatment planning.

Results

Diverse applications of GenAI in endodontics were identified. Synthetic data generation models can produce unconditional and conditional dental images to augment training datasets and create educational content for rare pathologies. Image enhancement techniques, including super-resolution, denoising and artefact reduction, show promise in improving diagnostic quality by revealing fine anatomical details. Studies report improvements in quantitative metrics and clinical detection rates, particularly for challenging structures such as second mesiobuccal canals in maxillary molars. Modality conversion applications include 2D-to-3D reconstruction from radiographs, cone-beam computed tomography (CBCT) to magnetic resonance imaging conversion for enhanced soft tissue visualisation, and CBCT to micro-computed tomography transformation for improved spatial resolution. Treatment enhancement applications encompass customised surgical guide design, treatment outcome prediction and AI-based computer-aided design for restoration of endodontically treated teeth. However, current research is predominantly found in other fields of dentistry and emphasises technical feasibility rather than clinical validation in real-world scenarios.

Conclusion

GenAI models are promising tools for enhancing endodontic treatments through data synthesis, image quality improvement and treatment optimisation. However, there are significant gaps between technical demonstrations and clinical implementation.

New Associate Editor and Artificial Intelligence Advisor

Henry F. Duncan — Wed, 01 Apr 2026 03:54:18 -0700

International Endodontic Journal, EarlyView.

Prevalence and Predisposing Factors of Periapical Mucositis: A Cross‐Sectional Study

Mon, 30 Mar 2026 05:31:48 -0700

ABSTRACT

Aim

Periapical mucositis (PAM) is defined as inflammation of the periapical tissues and localized oedema of the maxillary sinus mucosa, typically resulting from periradicular disease. Radiographically on cone-beam computed tomography (CBCT), PAM presents as mucosal thickening or a dome-shaped soft tissue expansion along the floor of the maxillary sinus, adjacent to the affected root apex. Although several studies have evaluated PAM, their findings vary considerably. This study aims (1) to evaluate the prevalence of PAM in maxillary posterior teeth amongst patients at NYU College of Dentistry, Department of Endodontics, and (2) to identify predisposing factors associated with PAM.

Methodology

CBCT evaluation and chart review were conducted at NYU College of Dentistry from 2016 to 2021. A total of 586 scans were screened, and 335 scans were included. The presence of PAM, periapical osteoperiostitis, maxillary sinus floor bony erosion, age, sex, pulpal and periapical diagnosis, size of the lesion, the vertical and horizontal distance between the sinus floor and roots, number of roots with apical lesions, type of tooth and iatrogenic errors during treatment were recorded. Chi-square, Fisher's exact tests and logistic regression were used to analyse the data.

Results

Of the 335 scans included, 13 presented with mucositis without periradicular disease and were excluded from the analysis. A total of 322 scans were analysed. The prevalence of PAM was 55.5%. The presence of maxillary sinus floor bone erosion was associated with 7.56 times higher odds of PAM than those without sinus floor erosion (p < 0.001). Each incremental increase in CBCTPAI was associated with a 1.43-fold increase in the odds of PAM occurrence (p = 0.004).

Conclusion

PAM was present in over half of patients presenting with apical periodontitis affecting the posterior maxillary dentition. Maxillary sinus bony floor erosion and periapical lesion size were predisposing factors to PAM development.

Establishment of an MRI‐Based Diagnostic Approach to Identify Critical Pulpal Inflammation Zones in a Rat Caries‐Derived Pulpitis Model

Sun, 29 Mar 2026 21:55:48 -0700

ABSTRACT

Aim

To establish a magnetic resonance imaging (MRI)-based diagnostic approach for identifying ‘critical pulpal inflammation’ zones in a rat model of caries-derived pulpitis.

Methodology

Caries-derived pulpitis was induced in the molars of Sprague–Dawley rats using the caries-derived pulpitis model. T2-weighted images by 7 Tesla MRI and micro-computed tomography (CT) images were taken weekly to sequentially monitor the caries progression and pulp conditions in the same individuals. Caries lesions were classified into moderate, severe and exposed groups with reference to the micro-CT images. Sound teeth without caries were used as controls. Histopathological observations were performed to confirm the pulp inflammation. Pulpotomy was performed to remove the low magnetic resonance (MR) signal area suspected to be a ‘critical pulpal inflammation’ zone, which is considered unlikely to be preserved. Six weeks after pulpotomy, T2-weighted and micro-CT images of the molars were obtained, and histopathological evaluation was performed to observe the outcome of the pulpotomy.

Results

High MR signal areas expanded with caries progression from the moderate to the severe group, indicating a spreading inflammatory response, which was confirmed histologically. The exposed group showed a significantly lower MR signal area compared with the others (one-way analysis of variance, Tukey's post hoc test, p < 0.05). Matrix Metalloproteinase 9 (MMP9), a candidate molecular biomarker of serious pulpal inflammation, and inflammatory cell infiltration were observed in the same area. After pulpotomy, the remaining pulp tissue showed tertiary dentine formation without pulp necrosis and absence of inflammatory markers and MMP9, suggesting successful removal of critical pulpal inflammation.

Conclusions

This study suggests the potential of MRI as a novel non-invasive and quantitative diagnostic method for critical pulpal inflammation zones. Moreover, MMP9 was identified as a reliable biomarker of critical pulpal inflammation. Future studies will focus on validating the potential biomarker role of MMP9 and analysing low MR signal areas for other novel biomarkers of critical pulpal inflammation.

Beyond the Evidence: Why Do Clinical Guidelines and Recommendations Differ?

Results

Ten observational studies (14 881 participants) were included. At the patient level, the pooled prevalence of hypercementosis was 3.9% (95% CI: 2.0%–7.3%), with very high heterogeneity (I² = 98%). Tooth-level meta-analysis, based on three studies evaluating 52 666 teeth, showed a pooled prevalence of 0.25% (95% CI: 0.06%–1%), also with substantial heterogeneity (I² = 98%). Variability across studies was influenced by imaging modality, sampling strategies and diagnostic thresholds.

Conclusions

Hypercementosis is uncommon at the tooth level but present in a clinically relevant proportion of patients. However, extreme heterogeneity and very low certainty of evidence limit the precision of prevalence estimates. Standardized diagnostic criteria and harmonized imaging protocols are needed to improve reproducibility. Within contemporary CBCT-based prognostic frameworks, hypercementosis may be considered a potential modifier of anatomical complexity, warranting further outcome-oriented investigation.

When Novelty Outpaces Evidence: Social Media as an Unregulated Force Propelling Innovation in Endodontics: A Narrative Review

Mohammed Turky, Paul M. H. Dummer — Fri, 20 Mar 2026 02:15:18 -0700

ABSTRACT

Aim

This narrative review explores how social media is influencing the pathways of innovation within endodontics, examines the rise of influencer-led clinical authority, and investigates the ethical, educational, and regulatory challenges associated with this trend, advocating for a comprehensive framework for responsible innovation.

Summary

Social media platforms have undergone a remarkable transformation, evolving from mere channels for informal communication to formidable agents of clinical influence in the healthcare field. Dentistry, and endodontics in particular, has seen platforms such as Facebook, LinkedIn, Instagram, YouTube, and TikTok increasingly serving as conduits for innovation. These platforms facilitate the rapid dissemination of new techniques, groundbreaking devices, and streamlined workflows, often circumventing traditional academic and regulatory structures that traditionally oversee and govern the spread of dental information. This shift has broadened accessibility to a wide range of ideas, promoting global engagement among dental professionals and patients alike. However, the unregulated media has also introduced considerable risks as the growing emphasis on visual appeal, rapid content production, and trendy innovations often overshadows the essential principles of biological plausibility, evidence-based validation, and consideration of long-term patient outcomes. Such dynamics raise critical questions about the reliability and safety of the information being shared on social media and the training and competence of the authors.

Conclusions

Social media is increasingly shaping the perception and adoption of endodontic innovations beyond traditional academic governance. Influencer-driven content often lacks transparent citations, robust critical appraisal, and an adequate discussion of clinical limitations. Advanced techniques may be advocated without proper consideration of operator competence, requisite training, or necessary armamentarium. Commercial interests and patient expectations can expedite the premature adoption of innovations that are inadequately validated. Applying frameworks of responsible research and innovation can provide a balanced perspective on integrating innovation, education, and patient safety in the field of endodontics.

Clinical Relevance

Social media may influence how endodontic innovations are perceived and adopted in routine practice. Clinicians must engage in critical appraisal of online content, especially when techniques surpass their training or available resources, to mitigate the risk of inappropriate implementations and safeguard patient well-being.

Clarifying Methodological and Educational Implications of Engine‐Driven NiTi Instrumentation in Undergraduate Endodontic Training: A Response to Correspondence

Results

AI support reduced average costs per case and increased treatment effectiveness, outperforming unaided examiner performance. These gains were primarily driven by improved specificity, reducing false-positive detection. However, effects varied by examiner experience; junior clinicians achieved the greatest cost savings and effectiveness gains, whereas senior examiners showed reduced sensitivity and slightly lower effectiveness at similar costs.

Conclusion

AI-assisted diagnostics offer significant potential to improve cost-effectiveness by reducing overtreatment, with benefits being most pronounced among less experienced practitioners. Adapting AI systems to individual examiners or experience levels might further enhance clinical and economic impact.

A Comparison of Endodontic Microbiomes Associated With Symptomatic and Asymptomatic Apical Periodontitis by Next‐Generation Sequencing

Fri, 13 Mar 2026 02:02:26 -0700

ABSTRACT

Aim

This cross-sectional study aimed to compare the endodontic microbiome assessed from root canals of teeth associated with either symptomatic or asymptomatic apical periodontitis and analysed by 16S rDNA gene sequencing.

Methodology

60 teeth presenting clinical and radiographic signs of symptomatic or asymptomatic apical periodontitis (n = 30) were included in this cross-sectional study after participants had given their written informed consent. After isolation with rubber dam, disinfection and access cavity preparation, glide paths were prepared using C-Pilot Files and K-Files under electronic root canal length control. Microbial samples were collected from a total of 120 root canals (symptomatic apical periodontitis, SAP: n = 62, asymptomatic apical periodontitis, AAP: n = 58) each with a sterile file (size 20/0.06) in a single length technique. Only one specimen per tooth was included in the analysis; in multi-rooted teeth, the specimen with highest sequencing depth. After DNA extraction, the hypervariable region V4 of the bacterial 16 S rRNA gene was amplified and sequenced (Illumina MiSeq). Taxonomy was assigned based on the expanded Human Oral Microbiome Database (eHOMD). Statistical analysis of diversity parameters comprised Mann–Whitney U tests and PERMANOVA. Compositional differences were evaluated by differential abundance analyses using DESeq2, LinDA, and ANCOM-BC2 methods.

Results

No differences were observed in richness and diversity (Shannon diversity index) on the genus or ASV level (p > 0.05). According to PERMANOVA, SAP and AAP microbiomes did not differ significantly both on genus and ASV levels (p > 0.05). Among highly abundant genera, Fusobacterium was indicated to be more abundant in SAP samples whereas Actinomyces was more abundant in AAP samples.

Conclusions

The expression of clinical symptoms in apical periodontitis does not appear to be determined by specific microorganisms but may instead reflect shifts of the relative abundance of the microbial community.

Correction to ‘Does the Use of a Bioceramic Sealer Reduce Postoperative Pain Compared With an Epoxy Resin‐Based Sealer After Primary Root Canal Treatment and Retreatment?—An Umbrella Review’

Mon, 23 Feb 2026 23:25:11 -0800

International Endodontic Journal, EarlyView.

Transfer Learning From Micro‐CT to Periapical Radiographs for Three‐Dimensional Root Canal Morphological Identification

Mon, 23 Feb 2026 20:26:15 -0800

ABSTRACT

Aim

This study investigated the transfer of implicit anatomical features from micro-CT to periapical radiographs using fused-rooted mandibular second molars (MSMs) as a model. The objective was to evaluate the feasibility and effectiveness of multimodal transfer learning for the three-dimensional (3D) morphological identification of root canals, and to examine how task complexity influences transfer performance.

Methodology

Fused-rooted MSMs were scanned using high-resolution micro-CT to generate virtual radiographs. Clinically simulated periapical radiographs (CSPRs) were obtained from ex vivo mandibles to reproduce realistic clinical conditions. Based on micro-CT classification, root canals were divided into merging, symmetrical and asymmetrical types. Four convolutional neural network (CNN) architectures (VGG19, ResNet18, ResNet50 and EfficientNet-b5) were trained under three conditions: (1) CSPRs with ImageNet-pretrained CNNs, (2) virtual radiographs with ImageNet-pretrained CNNs, and (3) CSPRs with CNNs pretrained on virtual radiographs. Grad-CAM visualisation was used to interpret model attention, and results were compared with those of four endodontic residents. To reduce task complexity, symmetrical and asymmetrical types were later merged into a “separating” group to generate a two-class classification task.

Results

In the three-class task, CNNs pretrained on virtual radiographs achieved an average accuracy of 69.68% (95% CI: 64.61%–74.76%), significantly higher than ImageNet-pretrained models (64.36%, 95% CI: 61.12%–67.61%) and endodontic residents (61.17%, 95% CI: 56.09%–66.25%) (p < 0.05). Grad-CAM visualisation revealed that virtual radiograph-pretrained models concentrated attention on root structures, whereas ImageNet-pretrained networks showed diffuse or misplaced focus. In the two-class task, accuracies were 79.79% (95% CI: 73.30%–86.27%) for CNNs pretrained on virtual radiographs, 73.41% (95% CI: 67.54%–79.27%) for ImageNet-pretrained models and 76.60% (95% CI: 69.28%–83.91%) for residents, with no significant differences (p > 0.05). The overall diagnostic balance improved following transfer learning, indicating better feature representation across classes.

Conclusions

Implicit 3D features extracted from micro-CT-based virtual radiographs can be effectively transferred to CSPRs through transfer learning. This approach enhances CNN interpretability and diagnostic precision in identifying root canal morphology. The benefits of transfer learning are greater for complex, multi-class tasks that require the extraction of intricate morphological features, whereas its effect diminishes in simplified binary classifications. These findings provide a theoretical and experimental foundation for applying multimodal transfer learning to clinical dental imaging.

A Scoping Review on Synthetic Datasets: Opportunities, Challenges and Future Directions for Endodontics

Nighat Naved, Fahad Umer — Wed, 18 Feb 2026 23:59:46 -0800

ABSTRACT

Background

Recent advances in Artificial Intelligence (AI) and machine learning algorithms have transformed diagnostic tasks in dentistry and endodontics. However, the development of robust AI systems remains constrained by the scarcity of annotated, high-quality datasets along with issues like class imbalance and privacy concerns. Synthetic data, replicating the statistical and visual characteristics of real data, may offer a promising solution to these limitations.

Objective

The scoping review aimed to map (i) existing synthetic datasets in dentistry/endodontics, (ii) commonly used synthetic data generation techniques, (iii) their fidelity and diagnostic utility, and (iv) current limitations and future research directions in endodontics.

Methods

A comprehensive search was conducted across PubMed, Scopus, EBSCO, and Google Scholar using keywords related to synthetic datasets in dentistry and endodontics. Data regarding synthetic image modality most used, model architecture, training dataset size, evaluation metrics, and the real-world clinical utility (use-cases) of synthetic datasets generated were extracted and analysed descriptively.

Results

Eleven studies met the inclusion criteria, primarily using Generative Adversarial Networks (GANs), with only one utilising a hybrid GAN–diffusion model. The most common synthetic imaging modalities were panoramic radiographs (n = 4), intraoral clinical images and lateral cephalograms (n = 2 each), followed by periapical, bitewing, and TMJ Magnetic Resonance Imaging (MRI) (n = 1 each). Training datasets ranged from 509 to 35 254 images, with stable generation achieved using as few as 1720 images in the hybrid model. Evaluation metrics varied, with Fréchet Inception Distance (FID), Signal-to-Noise Ratio (SNR), and visual Turing tests being most common. Only four studies evaluated clinical utility, using synthetic images to train AI models. While synthetic data alone showed moderate fidelity, combining it with real images consistently improved accuracy across tasks like canal classification, implant segmentation, tooth numbering, and skeletal pattern recognition.

Conclusion

Synthetic data use in endodontics is still emerging but holds strong potential. While GANs dominate current research, diffusion and hybrid models may yield more realistic images. Future efforts should focus on generating diverse, clinically representative datasets to improve diagnostics, education, and AI-driven endodontic care.

Comment on ‘Influence of Engine‐Driven NiTi Files on the Effectiveness and Technical Quality of Endodontic Treatment Performed by Undergraduate Students: A Systematic Review and Meta‐Analysis’

Conclusions

AI research in endodontics has evolved into a rapidly expanding, imaging-centred research domain characterised by increasing output but limited methodological diversity, restricted use of explainable AI and inconsistent adoption of reporting guidelines. These findings provide a structured overview of the field's development and current research profile.