Publications by authors named "Shanon Patel"

37 Publications

The impact of an enhanced infection control protocol on molar root canal treatment outcome - a randomized clinical trial.

Int Endod J 2021 Aug 5. Epub 2021 Aug 5.

Department of Endodontics, Centre for Oral, Clinical and Translational Sciences, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK.

Aim: To evaluate the effect of an enhanced infection control protocol on root canal treatment outcomes and on microbial load within root canals after chemomechanical preparation.

Methodology: A total of 144 molar teeth from 139 healthy patients receiving primary root canal treatment were block randomized to a standard protocol (StP) or an enhanced infection control protocol (EnP). Both treatment arms adhered to current best practice recommendations, while the EnP comprised additional steps that included replacing rubber dams, gloves, files, all instruments and surface barriers at the time of canal filling to reduce the chances of iatrogenic contamination. Patients and radiographic examiners were blinded to the protocol used. Intracanal microbial samples were taken at baseline (S1) and after completion of chemomechanical preparation (S2). Microbial 16S rDNA copy numbers were enumerated by quantitative polymerase chain reaction (qPCR). Cone beam computed tomography (CBCT) scans were taken before treatment and at one-year follow-up. The outcome was assessed clinically and radiographically using CBCT by logistic regression modelling.

Results: At one-year follow-up, 115 teeth were analysed (54 in StP and 61 in EnP). The percentage of favourable outcomes assessed by CBCT was 85.2% in the EnP and 66.7% in the StP. The odds of 12-month success was three times higher in the EnP group compared with the StP group (OR=2.89; p=0.022, CI: 1.17 - 7.15). The median bacterial reads were reduced from 8.1×10 in S1 samples to 3.5×10 in the StP group and from 8.6×10 to 1.3×10 in the EnP group. The enhanced protocol significantly reduced bacterial counts in pre-canal filling samples when compared to the standard protocol (p=0.009).

Conclusions: The implementation of a facile, enhanced infection control protocol in primary root canal treatment resulted in less detectable bacterial DNA before canal filling and significantly more successful outcomes at one year.
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http://dx.doi.org/10.1111/iej.13605DOI Listing
August 2021

Calcium Silicate-Based Root Canal Sealers: A Narrative Review and Clinical Perspectives.

Materials (Basel) 2021 Jul 15;14(14). Epub 2021 Jul 15.

Assistance Publique des Hôpitaux de Marseille, 13005 France; Aix Marseille Univ, CNRS, ISM, Inst Movement Sci, 13288 Marseille, France.

Over the last two decades, calcium silicate-based materials have grown in popularity. As root canal sealers, these formulations have been extensively investigated and compared with conventional sealers, such as zinc oxide-eugenol and epoxy resin-based sealers, in in vitro studies that showed their promising properties, especially their biocompatibility, antimicrobial properties, and certain bioactivity. However, the consequence of their higher solubility is a matter of debate and still needs to be clarified, because it may affect their long-term sealing ability. Unlike conventional sealers, those sealers are hydraulic, and their setting is conditioned by the presence of humidity. Current evidence reveals that the properties of calcium silicate-based sealers vary depending on their formulation. To date, only a few short-term investigations addressed the clinical outcome of calcium silicate-based root canal sealers. Their use has been showed to be mainly based on practitioners' clinical habits rather than manufacturers' recommendations or available evidence. However, their particular behavior implies modifications of the clinical protocol used for conventional sealers. This narrative review aimed to discuss the properties of calcium silicate-based sealers and their clinical implications, and to propose rational indications for these sealers based on the current knowledge.
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http://dx.doi.org/10.3390/ma14143965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8306764PMC
July 2021

A simple guide to using dental dam.

Br Dent J 2021 05 28;230(10):644-650. Epub 2021 May 28.

Centre for Oral, Clinical and Translational Sciences, Floor 25, Tower Wing, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, Guy's Hospital, London Bridge, SE19RT, UK.

The coronavirus (COVID-19) pandemic has caused a major impact on the provision of dental care. The 'new normal' in primary and secondary care is to apply specific measures to reduce the potential impact of aerosol generating exposure (AGE), for example, use of appropriate personal protective equipment and fallow time after aerosol generating procedures. The use of dental dam is essential to reduce the degree of AGE and also potentially reduce fallow time.
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http://dx.doi.org/10.1038/s41415-021-3016-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8161708PMC
May 2021

The impact of the Dental Practicality Index on treatment planning.

Br Dent J 2021 May 13. Epub 2021 May 13.

Centre for Oral, Clinical and Translational Sciences, King's College London Dental Institute, London, UK.

Aim To compare the treatment planning decisions made by undergraduate and postgraduate dental students before and after training on the use of the Dental Practicality Index (DPI).Methodology One hundred and eight undergraduate and postgraduate dental students were randomly assigned to test (DPI) or control groups. The baseline knowledge was assessed in the first session; both groups were shown 15 clinical scenarios and asked to assign one of four treatment plan options (no treatment, simple treatment, complex treatment or extract). The most appropriate treatment plan had been agreed by a consensus panel of experienced dentists. The test group was then trained on the use of the DPI. In the second session, both groups were shown the same clinical scenarios again in a different order and asked to assign one of the four treatment plan options. Both groups completed the confidence questionnaire.Results Training with the DPI improved the test (DPI) group mean scores from 9.1 in the first session to 10.3 out of 15 in the second session, which was a statistically significant difference (p = 0.005) when compared to the control group mean scores of 8.9 in the first session to 9.2 out of 15 in the second session. The mean confidence score of the students was 6.5 out of 10. There was no correlation between self-reported confidence scores of the students and the treatment planning result scores.Conclusions The DPI aids in the systematic assessment and appropriate treatment planning of dental restorative problems by dental students.
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http://dx.doi.org/10.1038/s41415-021-2948-5DOI Listing
May 2021

Diagnosis and Management of Traumatic Dental Injuries Using Intraoral Radiography and Cone-beam Computed Tomography: An In Vivo Investigation.

J Endod 2021 Jun 8;47(6):914-923. Epub 2021 Mar 8.

Centre for Oral, Clinical and Translational Science, King's College London Dental Institute, London, United Kingdom.

Introduction: The aim of this study was to compare periapical radiographs (PRs) and upper standard occlusal (USO) radiographs with cone-beam computed tomographic (CBCT) imaging on clinicians' confidence in the diagnosis and management of traumatic dental injuries (TDIs).

Methods: This study included 35 maxillary anterior teeth from 25 patients with at least 1 PR (parallax view) and a CBCT scan. Fourteen patients also had a USO radiograph. Ten examiners selected a diagnosis and treatment plan, which were compared with a reference standard. Sensitivity, specificity, positive and negative predictor values, and receiver operating characteristic analysis were used to determine the diagnostic accuracy.

Results: CBCT imaging exhibited significantly higher sensitivity than both conventional radiographic techniques combined (PRs and PRs + USO radiographs) for all diagnoses (TDI: 99% vs 84%, lateral luxation: 80% vs 34%, extrusions: 92% vs 42%, and cortical plate fracture: 58% vs 1%) other than horizontal root fractures in which the results were close to statistical significance (88% vs 69%). CBCT imaging was significantly more accurate for all diagnoses (TDI: 91% vs 70%, lateral luxations: 83% vs 61%, extrusive luxations: 92% vs 68%, alveolar cortical plate fractures: 78% vs 48%, and horizontal root fractures: 93% vs 82%). Examiners had the most confidence with CBCT imaging and the least confidence in diagnosing using PRs + USO radiographs than with PRs alone. Agreement with management plans was significantly better using CBCT imaging compared with PRs and PRs + USO radiographs.

Conclusions: CBCT imaging improved the clinical diagnosis of TDIs. The addition of USO radiographs to PRs did not improve the diagnosis of TDIs in this investigation. CBCT imaging improved confidence in the diagnosis of TDI cases and treatment planning compared with conventional radiography.
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http://dx.doi.org/10.1016/j.joen.2021.02.015DOI Listing
June 2021

Use of preoperative cone-beam computed tomography to aid in establishment of endodontic working length: A systematic review and meta-analysis.

Imaging Sci Dent 2020 Sep 16;50(3):183-192. Epub 2020 Sep 16.

Department of Endodontics, The Faculty of Dentistry, Oral and Craniofacial Sciences at Kings' College London, London, United Kingdom.

Purpose: This study was performed to assess the accuracy of preoperative cone-beam computed tomography (CBCT), when justified for other reasons, in locating the apical foramen and establishing the working length.

Materials And Methods: Six electronic databases were searched for studies on this subject. All studies, of any type, were included if they compared measurements of working length with preoperative CBCT to measurements using an electronic apex locator (EAL) or histological reference standard. Due to the high levels of heterogeneity, an inverse-variance random-effects model was chosen, and weighted mean differences were obtained with 95% confidence intervals and values.

Results: Nine studies were included. Compared to a histological reference standard, CBCT indicated that the apical foramen was on average 0.40 mm coronal of its histological position, with a mean absolute difference of 0.48 mm. Comparisons were also performed to an EAL reference standard, but the conclusions could not be considered robust due to high levels of heterogeneity in the results.

Conclusion: A low level of evidence is produced suggesting that preoperative CBCT shows the apical foramen to be on average 0.40 mm coronal to its histological position, with a mean absolute difference of 0.48 mm.
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http://dx.doi.org/10.5624/isd.2020.50.3.183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7506090PMC
September 2020

Guided Endodontic Treatment of Calcified Lower Incisors: A Case Report.

Dent J (Basel) 2020 Jul 8;8(3). Epub 2020 Jul 8.

Department of Endodontics, Saint Joseph University of Beirut, Beirut 1107-2180, Lebanon.

A 52-year-old female patient was diagnosed with chronic periapical periodontitis associated with severely calcified lower central incisors. Radiographic examination revealed no visible root canal in the coronal-third of the root. After choosing the guided endodontic treatment, an intraoral scan (Trios, 3shape, Copenhagen, Denmark), in conjunction with a cone beam computed tomography (CBCT) scan, was taken in order to design and fabricate a printed guide. Virtual implant software was used to visualize the surgical access into the sclerosed root canals. After locating the canals, the guide was removed, and the teeth were treated under a rubber dam. The guided approach allows predictable, efficient endodontic treatment of teeth presenting calcified canals, with minimal removal of sound dentine and less risk of root perforations.
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http://dx.doi.org/10.3390/dj8030074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558261PMC
July 2020

Rapid Chairside Microbial Detection Predicts Endodontic Treatment Outcome.

J Clin Med 2020 Jul 3;9(7). Epub 2020 Jul 3.

Department of Endodontics, Faculty of Dentistry, Oral and Craniofacial Sciences, Floor 22 Tower Wing, Guy's Dental Hospital, London SE1 9RT, UK.

Background: The aim of this longitudinal, one-year cohort study was to explore the hypothesis that fluorescence sampling of the root canal space prior to obturation could predict the outcome of root canal treatment (RCT).

Methods: Sixty-five teeth underwent primary RCT and were followed up clinically and radiographically. The outcome was determined radiographically with periapical radiographs (PR) and cone beam computed tomography (CBCT) scans.

Results: Success at 12 months was predictable based on the fluorescence score. When the fluorescence score (defined as the percentage of signal over total signal including background) was lower than 67, there was a 4.5 times (Odds ratio (OR) = 0.028; 95% confidence interval (CI): 0.003, 0.291, = 0.001) greater chance of success (90% overall). When the readings were above this threshold, the success rate was 20%.

Conclusion: A chairside sampling method is able to predict the outcome of RCT, through the use of paper point sampling and fluorescence staining. This has reduced the prevalence of persistent infections by guiding the optimum time for obturation. ClinicalTrials.gov trial NCT03660163.
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http://dx.doi.org/10.3390/jcm9072086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7408726PMC
July 2020

Cone-beam Computed Tomographic Analysis to Detect the Association between Primary and Secondary Endodontic Infections and Mucosal Thickness of Maxillary Sinus.

J Endod 2020 Sep 5;46(9):1235-1240. Epub 2020 Jun 5.

Department of Endodontics, Universitat Internacional de Catalunya, Barcelona, Spain.

Introduction: This retrospective study used cone-beam computed tomographic (CBCT) imaging to evaluate the differences in the mucosal thickness of the Schneiderian membrane in primary and secondary endodontic lesions.

Methods: A total of 121 CBCT scans were analyzed. Clinical features such as sex, age, size and volume of the periapical lesion, dimension of the bone, morphology, and relationship between the roots and the mucosal thickness were recorded and analyzed in primary and secondary endodontic lesions in CBCT sagittal and coronal planes. Data were analyzed using the chi-square test, the Mann-Whitney U test, and multiple logistic regression (P < .05).

Results: Statistical analysis revealed no significant differences in membrane thickness between the primary and secondary lesions in the sagittal and coronal planes (P = .08 and .06). Differences between age groups were statistically significant in both groups (P < .05). The volume of the periapical lesions of the secondary endodontic lesions were statistically greater than that of the primary lesions (P < .05). Mucosal thickness prevalence increased when the volume of the lesion was greater, and the bone dimension was narrower in maxillary second premolars and first and second molars. Teeth with 2 or more affected roots were directly related to increased sinus mucosa thickening.

Conclusions: CBCT images showed no differences in mucosal thickening between primary and secondary endodontic lesions.
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http://dx.doi.org/10.1016/j.joen.2020.05.015DOI Listing
September 2020

Schneiderian membrane thickness variation following endodontic procedures: a retrospective cone beam computed tomography study.

BMC Oral Health 2020 05 6;20(1):133. Epub 2020 May 6.

Department of Endodontics, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, Guy's Hospital, Tower Wing, Floor 22, London, SE1 9RT, UK.

Background: To assess the change of the Schneider membrane thickness measured by CBCT before and after root canal treatment, retreatment and pulp capping procedures.

Methods: This retrospective study was conducted on CBCT scans of a patient population of Guy's Hospital NHS Foundation Trust, London. Three groups of patients were studied: Group 1 consisted of patients referred for primary endodontic treatment; Group 2 for endodontic retreatment; Group 3 for indirect pulp capping procedures (serving as a control group). Follow up scans were carried out 1 year after treatment. Measurements were carried out on CBCT scans and data were analysed statistically by Wilcoxon Signed Rank Test. Linear regression was used to assess predictive parameters for membrane thickness.

Results: A statistically significant reduction of the Schneider membrane thickness was observed one year after endodontic treatment and retreatment (P < 0.05) but no significant reduction was observed after pulp capping procedures. Linear regression showed that age and gender were significant predictors influencing the Schneider membrane thickness.

Conclusions: Within the limitations of this retrospective study, following root canal treatment and re-treatment a Schneiderian membrane thickness reduction occurred at 1-year follow-up. The removal of odontogenic infection following endodontic treatment may help reducing the thickness of the Schneider membrane.
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http://dx.doi.org/10.1186/s12903-020-01122-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204013PMC
May 2020

Guidelines and template for reporting on CBCT scans.

Br Dent J 2020 01;228(1):15-18

Department of Restorative Dentistry, King's College London Dental Institute, London, UK.

The aim of this paper is to provide guidelines on how to report a small volume cone beam computed tomography (CBCT) scan.
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http://dx.doi.org/10.1038/s41415-019-1115-8DOI Listing
January 2020

The Impact of Different Diagnostic Imaging Modalities on the Evaluation of Root Canal Anatomy and Endodontic Residents' Stress Levels: A Clinical Study.

J Endod 2019 Apr 13;45(4):406-413. Epub 2019 Feb 13.

Department of Endodontology, King's College London Dental Institute, London, UK.

Introduction: The purpose of this study was firstly to compare the impact of radiographs, cone-beam computed tomographic (CBCT) imaging, and 3D Endo software (Dentsply Sirona, Ballaigues, Switzerland) on the assessment of root canal anatomy and radiographic quality of endodontic treatment and secondly to assess stress levels in the same cohort of residents performing endodontic treatment.

Methods: Sixty patients requiring primary molar endodontic treatment were allocated randomly into 3 groups: group 1 (n = 20), conventional radiographs (periapical radiography [PR]) only; group 2 (n = 20), PR and CBCT imaging; and group 3 (n = 20), PR, CBCT imaging, and 3D Endo software. All treatment was performed using a standardized protocol. Residents completed a questionnaire to assess their stress levels and usefulness of the imaging modality used. The radiographic quality of completed cases was assessed by 2 experienced endodontists who were not involved in the supervision of the cases being assessed.

Results: Groups 2 (CBCT imaging) and 3 (PR, CBCT imaging, and 3D Endo) proved significantly better than group 1 (PR) (P < .001) for assessing the number of root canals and anatomy and estimating the working lengths. Group 3 provided a significantly more accurate determination of the working level (P = .002). There were significantly more cases with obturation short of the apex (<2 mm) and voids in group 1 compared with group 3 (P < .05) and a significantly higher number of cases with voids in group 1 compared with group 3 (P < .01). Clinicians found treatment to be moderately or very stressful in 75%, 5%, and 0% in groups 1, 2, and 3, respectively.

Conclusions: 3D Endo software followed by CBCT imaging were found to be more desirable for the evaluation of root canal anatomy and working lengths and reducing the residents' stress levels.
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http://dx.doi.org/10.1016/j.joen.2018.12.001DOI Listing
April 2019

Evaluation of the efficacy of calcium silicate vs. glass ionomer cement indirect pulp capping and restoration assessment criteria: a randomised controlled clinical trial-2-year results.

Clin Oral Investig 2019 Apr 19;23(4):1931-1939. Epub 2018 Sep 19.

Conservative & MI Dentistry (including Endodontics), King's College London Dental, Institute at Guy's Hospital, King's Health Partners, London, UK.

Objectives: Assess calcium silicate cement (Biodentine™) vs. glass ionomer cement (Fuji IX™, control) as indirect pulp capping (IPC) materials in patients with reversible pulpitis after a 2-year follow-up. Evaluate the integrity of the overlying resin composite restorations using modified USPHS criteria and FDI criteria. Investigate the sensitivity of the modified USPHS criteria compared to the FDI criteria in the assessment of the restorations.

Materials And Methods: Seventy-two restorations (36 Biodentine™, 36 Fuji IX™) were placed randomly in 53 patients. Periapical radiographs were taken at pre-treatment (T0), 12-month (T12), and 24-month (T24) review. Restorations were assessed using the modified USPHS and FDI criteria at T12 and T24.

Results: At 24 months, 15 teeth had failed to maintain vitality (6 Biodentine™, 9 Fuji IX™). Clinical success rate of IPC for both materials was 72% and is related to the intensity of reversible pulpitis symptoms. No difference was found between T12 and T24 in the periapical (PA) radiographs and in the integrity of the resin composite restorations overlying Biodentine™ compared to Fuji IX™. There was no difference in the efficacy of the USPHS criteria compared to the FDI criteria in the assessment of the resin composite restorations.

Conclusions: Biodentine™ and Fuji IX™ were clinically effective when used as IPC materials in teeth with reversible pulpitis at T24. Resin composite restorations overlying both materials performed well at T24. Using the USPHS or FDI criteria is equally efficient at T24; however, longer term follow-up is needed to establish whether there are sensitivity differences between these assessment criteria.

Clinical Significance: Teeth with deep carious lesions approaching the pulp and with signs of reversible pulpitis can be treated successfully by indirect pulp capping using either Biodentine™ or Fuji IX™. Using the USPHS or FDI criteria to assess restorations is equally effective at 2 years.

Trial Registration: NCT02201641.
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http://dx.doi.org/10.1007/s00784-018-2638-0DOI Listing
April 2019

The ins and outs of root resorption.

Br Dent J 2018 05;224(9):691-699

Department of Conservative Dentistry, King's College London Dental Institute, Guy's Dental Hospital, Tower Wing, London.

Root resorption is a poorly understood phenomenon and is often misdiagnosed and, as a result, inappropriately treated. The aim of this paper is to provide a practical guide for diagnosis of root resorption lesions using a simple classification, and to describe the principles of management of these resorptive defects in everyday practice.
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http://dx.doi.org/10.1038/sj.bdj.2018.352DOI Listing
May 2018

Assessment of residual coronal tooth structure postendodontic cavity preparation using digital dental impressions and micro-computed tomography.

Int J Comput Dent 2017;20(4):377-392

Objectives: To evaluate the in vitro accuracy of digital impressions for three-dimensional (3D) volumetric measurement of residual coronal tooth structure postendodontic cavity preparation, with reference to micro-computed tomography (μCT).

Methods: Quantification of the accuracy and precision of the intraoral digital scanner (3M True Definition Scanner - IOS) was performed using a metrology gauge block and a profilometric calibration model. Thirty-four human extracted molars with endodontic access cavities were scanned using both intraoral scanning (test scanner) in high-resolution mode, and µCT (reference scanner: GE Locus SP μCT scanner) in high- (HiResCT) and low- (LoResCT) resolution modes. Comparisons of volumetric accuracy and 3D profilometric deviations were performed using surface metrology software. One-way repeated measures analysis of variance (ANOVA), in combination with the Bonferroni post hoc test, was implemented to compare the differences in volume measurements between scanning methods.

Results: Digital scanning revealed smaller volume measurements by 1.36% and 0.68% compared to HiResCT and LoResCT, respectively. There was a statistically significant difference in the volumetric measurements obtained from the IOS scanner and both HiResCT and LoResCT scans (P < 0.001). Analysis of the mean 3D profilometric deviations revealed that the IOS displayed greater surface deviation (± 27/33 μm) vs HiResCT and LoResCT (± 16/32 μm).

Conclusions: Although volumetric measurements of endodontically accessed teeth were up to 1.36% smaller in comparison to µCT, the digital scanner was able to reliably measure the extra- and intracoronal aspect of the endodontically accessed tooth.
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February 2018

Bacterial Contamination of Endodontic Materials before and after Clinical Storage.

J Endod 2017 Nov 23;43(11):1852-1856. Epub 2017 Sep 23.

Endodontic Postgraduate Unit, King's College London Dental Institute at Guy's, King's and St Thomas' Hospital, Guy's Hospital, London, UK. Electronic address:

Introduction: The aim of this study was to evaluate the bacterial contamination in endodontic consumables (gutta-percha points, rubber dams, paper mixing pads, caulking agents, and endodontic instrument sponges [EISs]) before and after clinical use and storage.

Methods: Materials were randomly sampled in triplicates at 3 time points (t, at package opening; t, at 7 days; and t, at 14 days) during their clinical usage. The gutta-percha points and caulking agent (25 mg) were added to 1 mL phosphate-buffered saline (PBS). The rubber dam, paper mixing pad, and EIS were added to 25 mL PBS. After vortexing, centrifuging, and removing the supernatant, the pellet was resuspended in 1 mL PBS, plated on fastidious anaerobic agar, and incubated aerobically and anaerobically. The grown colonies were identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). The total bacterial load was calculated in the remaining volume (800 μL) from each sample by quantitative polymerase chain reaction after DNA extraction.

Results: All tested materials showed a varied number of contaminated samples at the 3 time points (except EIS at t) using MALDI-TOF MS. The most isolated genera were Propionibacterium (42%) and Staphylococcus (32%). By using non-culture-based approaches, all tested materials at the 3 time points (except gutta-percha at t and the caulking agent at t t and t) carried bacterial DNA.

Conclusions: The majority of the tested materials harbored bacteria in their samples before and after clinical storage. Nosocomial infection derived from commonly used consumables could have an impact on the outcome of endodontic treatment.
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http://dx.doi.org/10.1016/j.joen.2017.06.036DOI Listing
November 2017

Influence of Cone-beam Computed Tomography on Endodontic Retreatment Strategies among General Dental Practitioners and Endodontists.

J Endod 2017 Sep 8;43(9):1433-1437. Epub 2017 Jul 8.

Department of Restorative Dentistry and Endodontics, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain. Electronic address:

Introduction: Treatment options for endodontic failure include nonsurgical or surgical endodontic retreatment, intentional replantation, and extraction with or without replacement of the tooth. The aim of the present study was to determine the impact of cone-beam computed tomographic (CBCT) imaging on clinical decision making among general dental practitioners and endodontists after failed root canal treatment. A second objective was to assess the self-reported level of difficulty in making a treatment choice before and after viewing a preoperative CBCT scan.

Methods: Eight patients with endodontically treated teeth diagnosed as symptomatic apical periodontitis, acute apical abscess, or chronic apical abscess were selected. In the first session, the examiners were given the details of each case, including any relevant radiographs, and were asked to choose 1 of the proposed treatment alternatives and assess the difficulty of making a decision. One month later, the examiners reviewed randomly the same 8 cases with the additional information from the CBCT data.

Results: The examiners altered their treatment plan after viewing the CBCT scan in 49.8% of the cases. A significant difference in the treatment plan between the 2 imaging modalities was recorded for endodontists and general practitioners (P < .05). After CBCT evaluation, neither group altered their self-reported level of difficulty when choosing a treatment plan (P = .0524). The extraction option rose significantly to 20% after viewing the CBCT scan (P < .05).

Conclusions: CBCT imaging directly influences endodontic retreatment strategies among general dental practitioners and endodontists.
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http://dx.doi.org/10.1016/j.joen.2017.04.004DOI Listing
September 2017

Influence of Cone-beam Computed Tomography in Clinical Decision Making among Specialists.

J Endod 2017 Feb;43(2):194-199

Department of Restorative Dentistry and Endodontics, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain.

Introduction: Clinical information and diagnostic imaging are essential components of preoperative diagnosis. The aim of this study was to determine the influence of cone-beam computed tomographic (CBCT) imaging on clinical decision-making choices among different specialists (prosthodontists, endodontists, oral surgeons, and periodontists) in endodontic treatment planning. A secondary objective was to assess the self-reported level of difficulty in making a treatment choice before and after viewing a preoperative CBCT scan.

Methods: In accordance with the endodontic case difficulty guidelines of the American Association of Endodontists, 30 endodontic cases with varying degrees of complexity were selected. Each case included clinical photographs, digital periapical radiographs, and a small-volume CBCT scan. In the first evaluation, examiners were given all the information of each case, except the CBCT scan. Examiners were asked to select one of the proposed treatment alternatives and assess the difficulty of making a decision. One month later, the examiners reviewed randomly the same 30 cases with the additional information from the CBCT data.

Results: The CBCT scans only had a significant influence on the treatment plan when the endodontic case was classified as high difficulty (P < .05). The level of difficulty in choosing a treatment choice was significantly more difficult after viewing a preoperative CBCT scan (P < .05), with the exception of the endodontists (P = .033). After viewing the CBCT scan, the extraction option increased significantly (P < .05).

Conclusions: CBCT imaging has a substantial impact on endodontic decision making among specialists, particularly in high difficulty cases.
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http://dx.doi.org/10.1016/j.joen.2016.10.012DOI Listing
February 2017

External Cervical Resorption: A Comparison of the Diagnostic Efficacy Using 2 Different Cone-beam Computed Tomographic Units and Periapical Radiographs.

J Endod 2017 Jan 6;43(1):121-125. Epub 2016 Dec 6.

Postgraduate Endodontic Unit, Kings College Dental Institute at Guy's King's and St Thomas' Hospital, London, UK. Electronic address:

Introduction: The aim of this study was to compare the diagnostic efficacy of 2 cone-beam computed tomographic (CBCT) units with parallax periapical (PA) radiographs for the detection and classification of simulated external cervical resorption (ECR) lesions.

Methods: Simulated ECR lesions were created on 13 mandibular teeth from 3 human dry mandibles. PA and CBCT scans were taken using 2 different units, Kodak CS9300 (Carestream Health Inc, Rochester, NY) and Morita 3D Accuitomo 80 (J Morita, Kyoto, Japan), before and after the creation of the ECR lesions. The lesions were then classified according to Heithersay's classification and their position on the root surface. Sensitivity, specificity, positive predictive values, negative predictive values, and receiver operator characteristic curves as well as the reproducibility of each technique were determined for diagnostic accuracy.

Results: The area under the receiver operating characteristic value for diagnostic accuracy for PA radiography and Kodak and Morita CBCT scanners was 0.872, 0.99, and 0.994, respectively. The sensitivity and specificity for both CBCT scanners were significantly better than PA radiography (P < .001). There was no statistical difference between the sensitivity and specificity of the 2 scanners. The percentage of correct diagnoses according to the tooth type was 87.4% for the Kodak scanner, 88.3% for the Morita scanner, and 48.5% for PA radiography.The ECR lesions were correctly identified according to the tooth surface in 87.8% Kodak, 89.1% Morita and 49.4% PA cases. The ECR lesions were correctly classified according to Heithersay classification in 70.5% of Kodak, 69.2% of Morita, and 39.7% of PA cases.

Conclusions: This study revealed that both CBCT scanners tested were equally accurate in diagnosing ECR and significantly better than PA radiography. CBCT scans were more likely to correctly categorize ECR according to the Heithersay classification compared with parallax PA radiographs.
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http://dx.doi.org/10.1016/j.joen.2016.09.008DOI Listing
January 2017

Isolation of Propionibacterium acnes among the microbiota of primary endodontic infections with and without intraoral communication.

Clin Oral Investig 2016 Nov 9;20(8):2149-2160. Epub 2016 Feb 9.

Department of Restorative Dentistry, King's College London Dental Institute at Guy's, King's and St Thomas' Hospital, Floor 22, Tower Wing, Guy's Hospital, St Thomas' St, London, SE1 9RT, UK.

Objectives: The presence of opportunistic pathogens such as Propionibacterium acnes (P. acnes) may contribute to the endodontic pathology. The presence of P. acnes may be influenced by different endodontic conditions. The aims of the study were firstly, to identify P. acnes within the whole cultivable microbiota of primary endodontic infections, to investigate which P. acnes phylotypes predominate in such infections and secondly to determine if the presence of an "open" communication (e.g. a sinus) can be associated with the isolation of P. acnes from the root canal.

Material And Methods: The predominant cultivable microbiota of 15 primary endodontic lesions (7 without communication with the oral environment and 8 with an open communication) were identified using partial 16S ribosomal RNA (rRNA) gene sequence analysis. The identification of the organism was determined by interrogating the Human Oral Microbiome Database. The P. acnes isolates were typed on the basis of the recA gene sequence comparison. A neighbor-joining tree was constructed using MEGA 4.1 with the inclusion of known recA sequences.

Results: There was no difference in the number of species identified from lesions without communication (5.86 ± 3.7) and those with communication (5.37 ± 3.6) (P > 0.05). PCR-based 16S rRNA gene sequencing revealed P. acnes as the most prevalent isolate recovered from lesions with communication. recA gene sequencing revealed two phylogenetic lineages present in lesion with communication, with mainly type I (further split into type IA and type IB) and type II.

Conclusions: The presence of P. acnes as opportunistic pathogens has been confirmed and may sustain the traits observed in specific clinical presentations.

Clinical Relevance: Clinical management of open lesions may require further disinfection to eliminate opportunistic bacteria.
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http://dx.doi.org/10.1007/s00784-016-1739-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5069318PMC
November 2016

The Assessment and Management of External Cervical Resorption with Periapical Radiographs and Cone-beam Computed Tomography: A Clinical Study.

J Endod 2016 Oct 6;42(10):1435-40. Epub 2016 Aug 6.

Department of Endodontology, Kings College Dental Institute, London, United Kingdom. Electronic address:

Introduction: This in vivo study assessed whether there was a difference between periapical radiographs (PRs) and cone-beam computed tomographic (CBCT) imaging in the detection, assessment, and management of external cervical resorption (ECR). The secondary aim was to determine if parallax radiographs were of any further benefit compared with a single PR.

Methods: PR and CBCT data were gathered for 115 teeth (98 patients) consecutively diagnosed with ECR. The diagnosis and treatment plan of each tooth were determined with PRs and CBCT imaging. Sensitivity, specificity, positive predictive values, negative predictive values, and receiver operator characteristic values were determined.

Results: The overall sensitivity (0.86) and specificity (0.89) of PRs was significantly lower than CBCT imaging (P < .001). PRs had a limited ability to accurately detect the size (0.75), circumferential spread (0.60), and location of ECR compared with CBCT imaging (P < .001). PRs also underestimated the size of the ECR lesion. Significant differences (P < .001) were apparent in the treatment plans formed when PRs were assessed versus CBCT imaging. Parallax radiographs were shown to be of no additional benefit compared with a single radiograph.

Conclusions: PRs have significant limitations in the detection, assessment, and treatment planning of ECR when compared with CBCT imaging. A CBCT scan should be considered before the management of a potentially restorable ECR lesion.
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http://dx.doi.org/10.1016/j.joen.2016.06.014DOI Listing
October 2016

The Use of Intentional Replantation to Repair an External Cervical Resorptive Lesion Not Amenable to Conventional Surgical Repair.

Prim Dent J 2016 May;5(2):78-83

Department of Endodontology, Kings College Dental Institute at Guy's King's and St Thomas' Hospital, London, UK.

Intentional replantation consists of purposefully extracting a tooth, correcting the defect and replanting it into its original socket. This case report describes how this technique was used to successfully restore an external cervical resorptive (ECR) lesion. A 22-year-old man was diagnosed with ECR of the mandibular right canine following clinical and radiographic examination. CBCT showed the lesion had been initiated distally and extended circumferentially around the root canal. The nature of the resorptive lesion meant that it was inaccessible to repair conventionally in a predictable manner. This report describes how intentional replantation was used to access and restore the lesion with minimal patient cooperation and postoperative discomfort. At an 18-month recall the tooth was clinically sound with no radiographic evidence of inflammatory or replacement root resorption. Intentional replantation should be considered a viable treatment option when ECR is inaccessible and cannot be restored using conventional techniques.
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http://dx.doi.org/10.1308/205016816819304213DOI Listing
May 2016

Association between the Presence of Apical Periodontitis and Clinical Symptoms in Endodontic Patients Using Cone-beam Computed Tomography and Periapical Radiographs.

J Endod 2015 Nov 5;41(11):1824-9. Epub 2015 Sep 5.

Department of Endodontics, School of Dentistry, University of Washington, Seattle, Washington.

Introduction: Cone-beam computed tomographic (CBCT) imaging is a valuable adjunct to endodontic practice. Among the endodontic applications of CBCT imaging, it aids in the diagnosis of apical periodontitis, often in cases in which there is no evidence of pathosis identified by conventional imaging. The purpose of this study was to correlate the presence of apical periodontitis of teeth evaluated with 2-dimensional periapical (PA) radiographs and 3-dimensional CBCT volumes with clinical signs and symptoms.

Methods: Clinical records were reviewed from patients examined at the graduate endodontics clinic. The examination included clinical examination, sensibility tests, PA radiographs, and limited field-of-view CBCT scans. Of 498 cases, 67 fulfilled the inclusion criteria and were evaluated for apical periodontitis and symptomology. CBCT slices and PA radiographs were evaluated by 2 board-certified endodontists and a board-certified oral and maxillofacial radiologist for the presence of apical periodontitis.

Results: Thirty eight of 67 teeth showed the presence of apical radiolucencies on PA radiographs and on CBCT imaging, whereas 14 teeth had no evidence of apical radiolucencies on either imaging modality. Fifteen cases showed the presence of apical radiolucencies visible on CBCT imaging that were not visible on PA radiographic images. The presence of apical radiolucencies on CBCT slices and PA radiographic images was correlated with clinical signs and symptoms, including the chief complaint.

Conclusions: This research has important implications to prevent overexposure to radiation and to provide treatment for those patients with persistent symptoms lacking proper diagnosis based on conventional (2D) radiographs.
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http://dx.doi.org/10.1016/j.joen.2015.06.004DOI Listing
November 2015

Cone-beam Computed Tomography Analysis of the Root Canal Morphology of Maxillary First and Second Premolars in a Spanish Population.

J Endod 2015 Aug 5;41(8):1241-7. Epub 2015 May 5.

Department of Restorative Dentistry and Endodontics, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain. Electronic address:

Introduction: We investigated the root canal configuration of maxillary premolars in a Spanish population by using cone-beam computed tomography.

Methods: Images of 804 maxillary first and second premolars were obtained from 620 patients who underwent cone-beam computed tomography scanning during preoperative assessment (before implant surgery, orthodontic treatment, dentoalveolar trauma diagnosis, or difficult root canal treatment). We determined tooth position, number of roots, root canal configuration (Vertucci's classification), number of root canals, and number of apical foramina per root and used the χ(2) test to analyze the correlation between root number and tooth position.

Results: In the maxillary first premolar group (n = 430), 46% (n = 198) had 1 root, 51.4% (n = 221) had 2 roots, and 2.6% (n = 11) had 3 roots. Most exhibited a type IV canal configuration (n = 227, 52.8%). Single-rooted teeth had a more variable canal configuration, whereas most 2-rooted teeth showed a type IV configuration (n = 215, 97.3%). In the maxillary second premolar group (n = 374), 82.9% (n = 310) had 1 root, 15.5% (n = 58) had 2 roots, and 1.6% (n = 6) had 3 roots. The majority of single-rooted second premolars exhibited a type I configuration (n = 147, 47.2%). Overall, type VIII canals were only observed in 3-rooted teeth. No statistical correlation was evident between root number and gender and tooth position.

Conclusions: There was a high frequency of 2-rooted and single-rooted teeth among maxillary first and second premolars, respectively. The canal morphology of single-rooted teeth was highly variable.
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http://dx.doi.org/10.1016/j.joen.2015.03.026DOI Listing
August 2015

External cervical resorption associated with the use of bisphosphonates: a case series.

J Endod 2015 May 18;41(5):742-8. Epub 2015 Mar 18.

Endodontic Postgraduate Unit, King's College London Dental Institute.

Although the pathogenesis and etiology of external cervical resorption (ECR) are not well understood, several predisposing factors have been reported to potentially contribute toward the initiation of ECR. However, a potential link between systemic medication and ECR has not been reported. Bisphosphonates (BSPs) are 1 group of these medications (the amino-containing BSP), which are associated with an acute-phase response and the release of proinflammatory cytokines, which could be associated with the initiation of ECR. Therefore, a possible causal link between BSPs and ECR could be drawn.
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http://dx.doi.org/10.1016/j.joen.2015.01.035DOI Listing
May 2015

The effect of alteration of the exposure parameters of a cone-beam computed tomographic scan on the diagnosis of simulated horizontal root fractures.

J Endod 2015 Apr 13;41(4):520-5. Epub 2015 Jan 13.

Department of Endodontology, Kings College Dental Institute, Guys Hospital, London, UK. Electronic address:

Introduction: The purpose of this study was to determine the effect of alteration of the exposure parameters of a cone-beam computed tomographic (CBCT) scan on the detection of the presence or absence of simulated horizontal root fractures (HRFs).

Methods: CBCT scans of the lower incisor region of 5 human, dentate, dry mandibles were performed with 11 different exposure parameters. Ten teeth were extracted, and simulated HRFs were created near the apical thirds of the root. The fragments were reattached and the teeth replanted. The mandibles were rescanned over the same range of exposure parameters. Receiver operator characteristic analysis and kappa analyses were performed to assess diagnostic accuracy and intra- and interexaminer agreement for each scan setting.

Results: The overall Az value (area under receiver operator curve) for the manufacturer's default setting was 0.95. The sensitivity was 0.94 and the specificity 0.96. A reduction in the tube current to 2 mA at 360° or 180° of rotation had no significant impact on the Az value, sensitivity, or specificity of CBCT imaging in the detection simulated HRFs. A reduction in the current to 1 mA at 360° or 180° of rotation significantly reduced the Az value (0.9 and 0.75, respectively) in comparison with the manufacturer's default setting (P < .05).

Conclusions: CBCT scans are an accurate and reliable technique to detect HRFs. Within the limitations of this study, it is possible to reduce the radiation dose by altering the exposure parameters without a significant reduction in the diagnostic quality of the CBCT scan generated for the detection of HRFs.
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http://dx.doi.org/10.1016/j.joen.2014.11.022DOI Listing
April 2015

Comparing the in vivo diagnostic accuracy of digital periapical radiography with cone-beam computed tomography for the detection of vertical root fracture.

J Endod 2014 Oct 22;40(10):1524-9. Epub 2014 Aug 22.

Department of Endodontology, Kings College Dental Institute, London, United Kingdom. Electronic address:

Introduction: The purpose of this study was to determine whether there is a difference in the in vivo diagnostic accuracy of digital radiography (DR) and cone-beam computed tomography (CBCT) imaging in the detection of vertical root fracture (VRF). The presence/absence of VRF was confirmed by visual inspection of the extracted root surface and was the reference standard against which both imaging modalities were compared.

Methods: Twenty-one unsalvageable teeth from 20 patients that had been radiographed and scanned with CBCT imaging were included in the study. The teeth were atraumatically extracted and visually inspected under a microscope to confirm the presence/absence of fracture. The widest point of each fracture was recorded using an optical coherence tomography scanner in order to quantify the size of fractures. Images were viewed under standardized conditions by 13 examiners and repeated 2 weeks later to assess their consistency.

Results: DR and CBCT imaging showed similarly poor sensitivity of 0.16 and 0.27, respectively. Both imaging modalities had similarly high specificity of 0.92 and 0.83, respectively. There was no statistical difference between the diagnostic accuracy of either imaging modality. Fracture width did not affect the detection rate of either imaging modality. Receiver operating characteristic analysis revealed mean Az values of 0.535 and 0.552 for DR and CBCT imaging, respectively.

Conclusions: Both DR and CBCT imaging have significant limitations when detecting vertical root fractures.
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http://dx.doi.org/10.1016/j.joen.2014.05.011DOI Listing
October 2014

Synchrotron light-based μCT to analyse the presence of dentinal microcracks post-rotary and reciprocating NiTi instrumentation.

Clin Oral Investig 2015 Jan 15;19(1):11-6. Epub 2014 Feb 15.

Department of Restorative Dentistry, King's College London Dental Institute at Guy's, King's and St Thomas' Hospital, Floor 17, Tower Wing, Guy's Hospital, St Thomas' St, London, SE1 9RT, UK.

Objectives: The purpose of this study was to determine in vitro using a synchrotron radiation-based μCT (SRCT) whether rotary and reciprocating nickel titanium (NiTi) instrumentations lead to the formation of dentine microcracks.

Material And Methods: Fourteen extracted human molars were obtained with ethical approval. Seven distobuccal roots of the maxillary molars and seven mesial roots of the mandibular molars were assigned to two experimental groups: (A) prepared with rotary Pro Taper instrumentation (n = 6) and (B) reciprocating WaveOne (n = 6). Irrigation with 1 % NaOCl and 17 % EDTA solutions was carried out. The remaining roots served as positive control with induced fractures (group C). SRCT was used to scan all samples pre and post-operatively. An imaging software was used to determine the number and length of microcracks. Statistical analyses weighed differences between pre and post-instrumentation and between shaping methods.

Results: A significant increase in the number and length of microcracks was detected post-shaping. No significant difference between rotary and reciprocating instrumentation was observed.

Conclusions: Within the limitations of this in vitro study, an increased number and length of microcracks was induced by mechanical instrumentation. Reciprocating and rotary instrumentation are similar in terms of effect.

Clinical Significance: Dentinal damage may occur following rotary and reciprocating instrumentation.
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http://dx.doi.org/10.1007/s00784-014-1206-5DOI Listing
January 2015

An in vitro comparison of the accuracy of measurements obtained from high- and low-resolution cone-beam computed tomography scans.

J Endod 2013 Mar 20;39(3):394-7. Epub 2012 Dec 20.

Unit of Conservative Dentistry, King's College London, Dental Institute at Guy's Hospital, King's Health Partners, London, United Kingdom.

Introduction: This study aimed to investigate in an ex vivo model the reduction in patient radiation dose while maintaining accurate linear measurements by comparing cone-beam computed tomography (CBCT) scans taken at 360° versus 180° rotation, with porcine jaw specimens as a reference standard.

Methods: CBCT scans of 12 sectioned porcine hemimandibles at 360° and 180° rotations were taken with standardized clinical exposure parameters. To assess interobserver variability, 6 assessors who were blinded to the degree of rotation took linear measurements of anatomic structures on each scan. The measurements were repeated after 2 weeks to assess intraobserver variability. Accuracy of measurement was judged against the corresponding measurements taken from the porcine jaw specimens.

Results: Intraclass correlations signaled good-to-excellent intraobserver and interobserver agreement (0.65-0.98 and 0.79-0.98), respectively. Mixed regression analysis found no significant difference between the measurements from 180° or 360° rotations and no difference between the 2 rotations and porcine jaw specimens.

Conclusions: A CBCT image sufficient to make accurate clinical measurements with a reduced radiation exposure may be obtained by using 180° rotation of the CBCT tube head.
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http://dx.doi.org/10.1016/j.joen.2012.11.017DOI Listing
March 2013
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