Expert consensus on difficulty assessment of endodontic therapy

Endodontic diseases are a kind of chronic infectious oral disease. Common endodontic treatment concepts are based on the removal of inflamed or necrotic pulp tissue and the replacement by gutta-percha. However, it is very essential for endodontic treatment to debride the root canal system and prevent the root canal system from bacterial reinfection after root canal therapy(RCT). Recent research, encompassing bacterial etiology and advanced imaging techniques, contributes to our understanding of the root canal system’s anatomy intricacies and the technique sensitivity of RCT. Success in RCT hinges on factors like patients, infection severity, root canal anatomy, and treatment techniques. Therefore, improving disease management is a key issue to combat endodontic diseases and cure periapical lesions. The clinical difficulty assessment system of RCT is established based on patient conditions, tooth conditions, root canal configuration, and root canal needing retreatment, and emphasizes pre-treatment risk assessment for optimal outcomes. The findings suggest that the presence of risk factors may correlate with the challenge of achieving the high standard required for RCT. These insights contribute not only to improve education but also aid practitioners in treatment planning and referral decision-making within the field of endodontics.

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

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

Expert consensus on irrigation and intracanal medication in root canal therapy

Chemical cleaning and disinfection are crucial steps for eliminating infection in root canal treatment. However, irrigant selection or irrigation procedures are far from clear. The vapor lock effect in the apical region has yet to be solved, impeding irrigation efficacy and resulting in residual infections and compromised treatment outcomes.

Activation of hypoxia-inducible factor 1 attenuates periapical inflammation and bone loss

Hypoxia（low oxygen level） is an important feature during infections and affects the host defence mechanisms. The host has evolved specific responses to address hypoxia, which are strongly dependent on the activation of hypoxia-inducible factor 1（HIF-1）.Hypoxia interferes degradation of HIF-1 alpha subunit（HIF-1α）, leading to stabilisation of HIF-1α, heterodimerization with HIF-1 beta subunit（HIF-1β） and subsequent activation of HIF-1 pathway. Apical periodontitis（periapical lesion） is a consequence of endodontic infection and ultimately results in destruction of tooth-supporting tissue, including alveolar bone. Thus far, the role of HIF-1 in periapical lesions has not been systematically examined. In the present study, we determined the role of HIF-1 in a wellcharacterised mouse periapical lesion model using two HIF-1α-activating strategies, dimethyloxalylglycine（DMOG） and adenovirusinduced constitutively active HIF-1α（CA-HIF1 A）. Both DMOG and CA-HIF1 A attenuated periapical inflammation and tissue destruction. The attenuation in vivo was associated with downregulation of nuclear factor-κappa B（NF-κB） and osteoclastic gene expressions. These two agents also suppressed NF-κB activation and subsequent production of proinflammatory cytokines by macrophages. Furthermore, activation of HIF-1α by DMOG specifically suppressed lipopolysaccharide-stimulated macrophage differentiation into M1 cells, increasing the ratio of M2 macrophages against M1 cells. Taken together, our data indicated that activation of HIF-1 plays a protective role in the development of apical periodontitis via downregulation of NF-κB, proinflammatory cytokines, M1 macrophages and osteoclastogenesis.

Chemical composition of Galla chinensis extract and the effect of its main component(s) on the prevention of enamel demineralization in vitro

To determine the chemical composition of Galla chinensisextract （GCE） by several analysis techniques and to compare the efficacy of GCE and its main component（s） in inhibition of enamel demineralization, for the development of future anticaries agents, main organic composition of GCE was qualitatively determined by liquid chromatography-time of flight-mass spectrometry （LC-TOF-MS） and quantified by high-performance liquid chromatography-diode array detector （HPLC-DAD）. Inorganic ions were tested by inductively coupled plasma-atomic emission spectroscopy and F was especially measured by ion chromatography. Then, bovine enamel blocks were randomly divided into four treatment groups and were subjected to a pH-cycling regime for 12 times. Each cycle included 5-min applications with one of four treatments： 4g.L-1 GCE solution, 4g.L-1 gallic acid （GA） solution, I g.L-1 NaF solution （positive control）, deionized water （DDW, negative control）, and then 60-min application in pH 5.0 acidic buffer and 5-min application in neutral buffer. Acidic buffers were retained for calcium analysis. The main organic composition of GCE were GA and its isomer, and, to a lesser extent, small molecule gallotannins. The content of GA in GCE was 71.3%±0.2% （w/w）. Inorganic ions were present in various amounts, of which Ca was （136±2.82） μg.g-1, and Zn was （6.8±0.1） μg.g-1. No F was detected in GCE. in pH cycling, GA showed an effect similar to GCE in inhibiting enamel demineralization （P〉0.05）. GA was found to be the main effective, demineralization inhibiting component of GCE and could be a promising agent for the development of anticaries agents.

The functional significance of dentin sialoprotein-phosphophoryn and dentin sialoprotein

Phosphophoryn (PP) and dentin sialoprotein (DSP) are the most dominant non-collagenous proteins in dentin. PP is an extremely acidic protein that can function as a mineral nucleator for dentin mineralization. DSP was first identified in 1981, yet its functional significance is still controversial. Historically, these two proteins were considered to be independently synthesized and secreted by dental pulp cells into the developing dentin matrix. However, with the identification of the DSP coding sequence in 1994, followed2 years later by the finding that the PP coding sequence was located immediately downstream from the DSP sequence, it became immediately clear that DSP and PP proteins were derived from a single DSP-PP (i.e., dentin sialophosphoprotein, DSPP) transcript.Since DSPP cDNA became available, tremendous progress has been made in studying DSP-PP mRNA distribution and DSP generation from the DSP-PP precursor protein at specific cleavage sites by protease tolloid-related-1 (TLR1) or bone morphogenetic protein 1 (BMP1). The functions of DSP-PP and DSP were investigated via DSP-PP knockout (KO) and DSP knockin in DSP-PP KO mice. In addition, a number of in vitro studies aimed to elucidate DSPP and DSP function in dental pulp cells.

Evaluation of four final irrigation protocols for cleaning root canal walls

The aim of this study was to compare the efficiency of four final irrigation protocols in smear layer removal and bacterial inhibition in root canal systems.Thirty roots inoculated with Enterococcus faecalis were prepared with ProTaper Universal files.The teeth were disinfected by conventional needle irrigation,sonic agitation using the EndoActivator device,passive ultrasonic irrigation,or an M3 Max file.Teeth with no root canal preparation served as blank controls for the establishment of the infection baseline.Teeth with preparation but no final irrigation served as a post-instrumentation baseline.After the final irrigation,the teeth were sectioned in half.One half of each tooth was examined by scanning electron microscopy(SEM)to assess smear layer removal using a five-point scale.The other half was examined by confocal laser scanning microscopy(CLSM)using the LIVE/DEAD BackLight bacterial viability kit to evaluate the depth of bacterial survival in dentinal tubules.SEM analysis revealed no significant difference in smear layer removal throughout the whole canal among the EA,PUI,and M3 Max groups(P>0.05).CLSM revealed that PUI achieved the greatest bacterial inhibition depth in the coronal((174.27±31.63)μm),middle((160.94±37.77)μm),and apical((119.53±28.49)μm)thirds of the canal(all P<0.05 vs.other groups).According to this comprehensive SEM and CLSM evaluation,PUI appears to have the best infection control ability in root canal systems.

Effect of Galla chinensis on the In Vitro Remineralization of Advanced Enamel Lesions

Aim The effect of Galla chinensis on de-/re-mineralization of advanced enamel lesions was investigated by using micro-CT in a prolonged in vitro experiment. Methodology Baseline mineral contents of sound enamels were first analyzed. Then lesions were produced in an acidic buffer solution （2.2 mmol.L-1 Ca（NO3）2, 2.2 mmol-L1 KH2PO4, and pH=4.5） for 21 days, with thrice daily three-minute treatments, divided into four groups： Group A, 4 000 ppm crude aqueous extract of Galla chinensis （GCE）; Group B, 4 000 ppm gallic acid; Group C, 1 000 ppm F aq. （as NaF, positive control）; Group D, deionized water （negative control）. Next, the blocks were immersed in a remineralization solution （1.5 mmol.Lz CaC12, 0.9 mmol.L1 KH2PO4, 0.1 ppm F, and pH=7,0） for 200 days. Mineral loss （ML） in each region of interest （ROI） and integrated mineral loss （IML） of the lesions were calculated （comparing with baseline mineral content of sound enamel） at different time points. Results After 21 days demineralization, fluoride treatment showed a statistically significant demineralization-inhibiting effect among the four groups, and after 200 days of remineralization, mineral content recovery was ordered （lowest to highest） as A=C〈B〈D. Conclusion GCE could slow down the remineralization of enamel in the surface layer and thereby facilitate ion transport into the lesion body. The mechanism of Galla chinensis in enhancing the remineralization of dental caries is different from fluoride.

Epigenetic regulation of dental pulp stem cells and its potential in regenerative endodontics

Regenerative endodontics(RE)therapy means physiologically replacing damaged pulp tissue and regaining functional dentin–pulp complex.Current clinical RE procedures recruit endogenous stem cells from the apical papilla,periodontal tissue,bone marrow and peripheral blood,with or without application of scaffolds and growth factors in the root canal space,resulting in cementum-like and bone-like tissue formation.Without the involvement of dental pulp stem cells(DPSCs),it is unlikely that functional pulp regeneration can be achieved,even though acceptable repair can be acquired.DPSCs,due to their specific odontogenic potential,high proliferation,neurovascular property,and easy accessibility,are considered as the most eligible cell source for dentin–pulp regeneration.The regenerative potential of DPSCs has been demonstrated by recent clinical progress.DPSC transplantation following pulpectomy has successfully reconstructed neurovascularized pulp that simulates the physiological structure of natural pulp.The self-renewal,proliferation,and odontogenic differentiation of DPSCs are under the control of a cascade of transcription factors.Over recent decades,epigenetic modulations implicating histone modifications,DNA methylation,and noncoding(nc)RNAs have manifested as a new layer of gene regulation.These modulations exhibit a profound effect on the cellular activities of DPSCs.In this review,we offer an overview about epigenetic regulation of the fate of DPSCs;in particular,on the proliferation,odontogenic differentiation,angiogenesis,and neurogenesis.We emphasize recent discoveries of epigenetic molecules that can alter DPSC status and promote pulp regeneration through manipulation over epigenetic profiles.

Biofilm three-dimensional architecture influences in situ pH distribution pattern on the human enamel surface

To investigate how the biofilm three-dimensional(3D) architecture influences in situ pH distribution patterns on the enamel surface. Biofilms were formed on human tooth enamel in the presence of 1% sucrose or 0.5% glucose plus 0.5% fructose. At specific time points, biofilms were exposed to a neutral pH buffer to mimic the buffering of saliva and subsequently pulsed with 1% glucose to induce re-acidification. Simultaneous 3D pH mapping and architecture of intact biofilms was performed using two-photon confocal microscopy. The enamel surface and mineral content characteristics were examined successively via optical profilometry and microradiography analyses. Sucrose-mediated biofilm formation created spatial heterogeneities manifested by complex networks of bacterial clusters(microcolonies). Acidic regions(pH<5.5) were found only in the interior of microcolonies,which impedes rapid neutralization(taking more than 120 min for neutralization). Glucose exposure rapidly re-created the acidic niches, indicating formation of diffusion barriers associated with microcolonies structure. Enamel demineralization(white spots),rougher surface, deeper lesion and more mineral loss appeared to be associated with the localization of these bacterial clusters at the biofilm-enamel interface. Similar 3D architecture was observed in plaque-biofilms formed in vivo in the presence of sucrose. The formation of complex 3D architectures creates spatially heterogeneous acidic microenvironments in close proximity of enamel surface, which might correlate with the localized pattern of the onset of carious lesions(white spot like) on teeth.

The Oral Microbiome Bank of China

The human microbiome project（HMP） promoted further understanding of human oral microbes. However, research on the human oral microbiota has not made as much progress as research on the gut microbiota. Currently, the causal relationship between the oral microbiota and oral diseases remains unclear, and little is known about the link between the oral microbiota and human systemic diseases. To further understand the contribution of the oral microbiota in oral diseases and systemic diseases, a Human Oral Microbiome Database（HOMD） was established in the US. The HOMD includes 619 taxa in 13 phyla, and most of the microorganisms are from American populations. Due to individual differences in the microbiome, the HOMD does not reflect the Chinese oral microbial status. Herein, we established a new oral microbiome database—the Oral Microbiome Bank of China（OMBC,http：//www.sklod.org/ombc）. Currently, the OMBC includes information on 289 bacterial strains and 720 clinical samples from the Chinese population, along with lab and clinical information. The OMBC is the first curated description of a Chinese-associated microbiome; it provides tools for use in investigating the role of the oral microbiome in health and diseases, and will give the community abundant data and strain information for future oral microbial studies.

Disturbed bone remodelling activity varies in different stages of experimental, gradually progressive apical periodontitis in rats

Bone remodelling keeps going through the lifespan of human by bone formation and bone resorption.In the craniofacial region,mandibles act as the main force for biting and chewing,and also become susceptible to a common bone-loss disease,namely,apical periodontitis,once infected dental pulp is not treated timely,during which bone resorption occurs from the apical foramen to the apical bone area.Although conventional root canal treatment(RCT)can remove the most of the infection,chronical apical periodontitis due to incomplete removal of dental pulp and subsequent microleakage will become refractory and more challenging,and this process has scarcely been specifically studied as a bone remodelling issue in rat models.Therefore,to study chronical and refractory apical periodontitis owing to incomplete cleaning of infected dental pulp and microleackage in vivo,we establish a modified rat model of gradually progressive apical periodontitis by sealing residual necrotic dental pulp and introducing limited saliva,which simulates gradually progressive apical periodontitis,as observed in the clinical treatment of chronical and refractory apical periodontitis.We show that bone-loss is inevitable and progressive in this case of apical periodontitis,which confirms again that complete and sound root canal treatment is crucial to halt the progression of chronical and refractory apical periodontitis and promote bone formation.Interestingly,bone remodelling was enhanced at the initial stage of apical periodontitis in this model while reduced with a high osteoblast number afterwards,as shown by the time course study of the modified model.Suggesting that the pathological apical microenvironment reserve its hard tissue formation ability to some degree but in a disturbed manner.Hopefully,our findings can provide insights for future bone regenerative treatment for apical periodontitisassociated bone loss.

Intestinal microbiota: a potential target for the treatment of postmenopausal osteoporosis

Postmenopausal osteoporosis （PMO） is a prevalent metabolic bone disease characterized by bone loss and structural destruction, which increases the risk of fracture in postmenopausal women. Owing to the high morbidity and serious complications of PMO, many efforts have been devoted to its prophylaxis and treatment. The intestinal microbiota is the complex community of microorganisms colonizing the gastrointestinal tract. Probiotics, which are dietary or medical supplements consisting of beneficial intestinal bacteria, work in concert with endogenous intestinal microorganisms to maintain host health. Recent studies have revealed that bone loss in PMO is closely related to host immunity, which is influenced by the intestinal microbiota. The curative effects of probiotics on metabolic bone diseases have also been demonstrated. The effects of the intestinal microbiota on bone metabolism suggest a promising target for PMO management. This review seeks to summarize the critical effects of the intestinal microbiota and probiotics on PMO, with a focus on the molecular mechanisms underlying the pathogenic relationship between bacteria and host, and to define the possible treatment options.

Characterizing Diversity of Lactobacilli Associated with Severe Early Childhood Caries: A Study Protocol

Lactobacilli have been consistently associated with dental caries for decades;however, knowledge of this group of bacteria in the etiology of the disease is limited to quantitative elucidation. Nowadays, explicit identification of oral Lactobacillus species is possible, despite their taxonomic complexity. Here we describe a combined approach involving both cultivation and genetic methods to ascertain and characterize the diversity and abundance of the Lactobacillus population in the oral cavities of children with severe early childhood caries (S-ECC). Eighty 3- to 6-year-old children (40 S-ECC and 40 caries free) who were seeking dental care at the Pediatric Dental Clinic of Bellevue Hospital in New York City were invited to participate in this study. Clinical data on sociodemographic information and oral health behavior were obtained from the primary caregiver. The data included a detailed dental examination, children’s medical history, and a questionnaire survey. Combined non-stimulated saliva and supragingival plaque samples were collected from each child and cultivated on selective media for quantitative measures of lactobacilli levels. The procedure for Lactobacillus species screening will include the random selection of 50 colonies per plate, ex- traction of DNA from each colony, and genotyping by arbitrarily primed polymerase chain reaction (AP-PCR). Each unique Lactobacillus AP-PCR genotype will be selected for taxonomic assessment by 16S rRNA gene sequencing analysis. Lactobacillus species will be identified by comparing the 16S rRNA sequences with the Ribosomal Database and the Human Oral Microbiome Database. Meanwhile, the same set of clinical samples will be independently subjected to genomic DNA isolation, 16S rRNA amplification with Lactobacillus genus-specific primers, sequencing, and taxonomic identification, both at genus and species levels with a customized pipeline. The distribution and phylogenetic differences of these Lactobacillus species will be compared between children with or without S-ECC. One of the main objectives of this study is to establish a study protocol for the identification and characterization of lactobacilli in the oral cavity. Future caries risk assessments can include lactobacilli counts (quantitative) and the presence/absence of specific cario- genic genetic signatures of a Lactobacillus species (qualitative) associated with S-ECC.

Impact of Dentinal Tubule Orientation on Dentin Bond Strength

This study aimed to determine the impact of dentinal tubule orientation on dentin bond strength to provide a reference for clinical cavity preparation in resin-bonded restoration. Patients aged 13-16 years were selected, including 18 males and 21 females. Forty-eight human maxillary first premolars from orthodontic extractions were chosen to prepare the test models with the dentinal tubule orientations perpendicular and parallel to the bonding substrate. The test models in the vertical and parallel groups were divided into three groups： total-etching with 20% phosphoric acid, total-etching with 35% phosphoric acid and self-etching, with the dentinal tubule surfaces bonded with composite resin blocks in each group. After the standard test models of dentinal tubule-composite resin blocks were placed in distilled water and stored at 37℃ for 24 h, shearing tests were performed using a universal material testing machine at a crosshead speed of 0.5 mm/min. The bond strength values in the vertical group were 19.33＋1.59 MPa for the 20% phosphoric acid group, 21.39±2.34 MPa for the 35% phosphoric acid group, and 16.88±1.54 MPa for the self-etching group. The bond strength values in the parallel group were 24.53±1.99 MPa for the 20% phosphoric acid group, 25.16＋2.88 MPa for the 35% phosphoric acid group, and 20.83±1.99 for the self-etching group. After using same total-etching adhesive, the shear bond strength of the parallel group was higher than that of the vertical group, and the difference was statistically significant （P〈0.05）. Regardless of vertical group or parallel group, the difference in the bond strength value between the total-etching groups and the self-etching group was statistically significant （P〈0.05）. It was concluded that the dentin bonding substrate which was parallel to the direction of the dentin tubule achieved an improved bond strength; the total-etching adhesives achieved higher bond strengths in dentin bond than the self-etching adhesives.

Metabolic-epigenetic nexus in regulation of stem cell fate

Stem cell fate determination is one of the central questions in stem cell biology,and although its regulation has been studied at genomic and proteomic levels,a variety of biological activities in cells occur at the metabolic level.Metabolomics studies have established the metabolome during stem cell differentiation and have revealed the role of metabolites in stem cell fate determination.While metabolism is considered to play a biological regulatory role as an energy source,recent studies have suggested the nexus between metabolism and epigenetics because several metabolites function as cofactors and substrates in epigenetic mechanisms,including histone modification,DNA methylation,and microRNAs.Additionally,the epigenetic modification is sensitive to the dynamic metabolites and consequently leads to changes in transcription.The nexus between metabolism and epigenetics proposes a novel stem cell-based therapeutic strategy through manipulating metabolites.In the present review,we summarize the possible nexus between metabolic and epigenetic regulation in stem cell fate determination,and discuss the potential preventive and therapeutic strategies via targeting metabolites.

Network Modelling and Visualisation Analysis of the Undergraduate Dental Curriculum System in China

Objectives: This study aims to present the characteristics of the undergraduate dental curriculum system using network modelling and visualisation analysis based on complex network theory, thus providing a theoretical foundation for the course development and curriculum reform. Methods: The correlation coefficient was used to quantify the intensity of the correlation between courses, and a visualisation complex network of the dental curriculum was built to explore the curriculum pattern from a dynamic perspective. Further, the statistical measurements of curriculum network were adopted to express the most relevant topological features. Subsequently, the minimum spanning tree and parallel coordinates plot were drawn to explore the curriculum community structure, quantify the key courses, and present different courses in time and space relationships. Results: The correlation analysis results show that the courses are closely related to each other. The main courses focus on pathology, pathophysiology, oral anatomy and physiology, closely connecting almost all medicine-related courses. The whole course network has an average degree value of 41.53, and a clustering coefficient of 0.78, indicating an obvious small-world characteristic. From the perspective of curriculum attributes, the number of public and theoretical courses was more than that of skills and practical courses. Moreover, the academic performance of skills and practical courses was lower than that of public and theoretical courses. Conclusion: The undergraduate dental courses have a progressive structure from basic professional knowledge to professional skills, which is reasonable for the dental education in China. However, some efforts towards curriculum reform based on this study are needed.

Meeting report: a close look at oral biofilms and microbiomes

The "Biofilms, Microbiomes and Oral Diseases: Challenges and Future Perspectives" symposium jointly organized by Penn Dental Medicine and West China School of Stomatology was held on 30 September 2017 at Penn Wharton China Center(PWCC) in Beijing,China. The topics included the pathogenicity of oral biofilms, novel strategies for the control of biofilm-related diseases, oral microbiome and single-cell approaches, and the link between oral diseases and overall health. Researchers from a number of disciplines, representing institutions from China and Penn Dental Medicine, gathered to discuss advances in our understanding of biofilms, as well as future directions for the control of biofilm-related oral and systemic diseases.

Quantitative detection of Streptococcus mutans from saliva using FTA^(TM) elute cards and real-time polymerase chain reaction

Dental caries is a localized, transmissible, pathological infection process that ends up in the destruction of hard dental tissue. Numerous reports have shown the close relationship between salivary levels of Streptococcus mutans and dental caries. As S. mutans, is considered to be the principle etiological agent of dental caries, the development of a quick and convenient method for detection and quantification of these bacteria from patient saliva samples would simplify diagnosis and treatment. The purpose of this study was to compare a new means of quantifying bacteria using FTATM Elute cards and Real-Time Polymerase Chain Reaction to a conventional culture-based assay using oral S. mutans as a model sample. A total of 60 different saliva samples were investigated. The results show a significant negative correlation between the two methods, with a correlation coefficient of -0.577 (Spearman’s Correlation) and p < 0.01. The method demonstrates a high sensitivity, specificity and reliable quantitative results, covering a large range of bacterial concentrations.

Expert consensus on digital guided therapy for endodontic diseases

Digital guided therapy(DGT)has been advocated as a contemporary computer-aided technique for treating endodontic diseases in recent decades.The concept of DGT for endodontic diseases is categorized into static guided endodontics(SGE),necessitating a meticulously designed template,and dynamic guided endodontics(DGE),which utilizes an optical triangulation tracking system.Based on cone-beam computed tomography(CBCT)images superimposed with or without oral scan(OS)data,a virtual template is crafted through software and subsequently translated into a 3-dimensional(3D)printing for SGE,while the system guides the drilling path with a real-time navigation in DGE.DGT was reported to resolve a series of challenging endodontic cases,including teeth with pulp obliteration,teeth with anatomical abnormalities,teeth requiring retreatment,posterior teeth needing endodontic microsurgery,and tooth autotransplantation.Case reports and basic researches all demonstrate that DGT stand as a precise,time-saving,and minimally invasive approach in contrast to conventional freehand method.This expert consensus mainly introduces the case selection,general workflow,evaluation,and impact factor of DGT,which could provide an alternative working strategy in endodontic treatment.