Abstract

Background: Contemporary deep and extremely deep caries management increasingly favors selective or stepwise excavation because these strategies reduce pulpal exposure and preserve tooth structure. However, clinical survival is often interpreted beyond its biological meaning.

Objective: This perspective examines why asymptomatic tooth survival, retained sensibility, absence of radiographic disease, and lack of retreatment are incomplete markers of pulpal health.

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Abstract

Background: Endodontic diagnosis usually assumes that pain, tenderness, swelling, sensibility test responses, and radiographic change reflect the interaction between microbial irritation and host response. Under altered host immunity, this relationship becomes less predictable because disease activity and disease expression may no longer progress in parallel. Biologically important pulpal or periapical disease may therefore appear deceptively mild, whereas competing oral or systemic conditions may complicate localization and interpretation. 

Objectives: To examine how altered host immunity changes the diagnostic expression of pulpal and periapical disease, distinguish immune suppression from immune dysregulation as biologically distinct states, and propose a practical clinical approach to diagnostic uncertainty in these patients.

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Abstract
Pulpal and periapical diagnosis in endodontics depends largely on radiographic evidence of mineralized tissue changes. Cone beam computed tomography (CBCT) improves three-dimensional assessment of periapical bone loss, root anatomy, and surgical planning. However, it does not directly depict pulpal status or soft tissue inflammatory changes. This narrative review examined dental-dedicated magnetic resonance imaging (ddMRI) for periapical diagnosis compared with CBCT, with emphasis on the transition from historical dental MRI to a dedicated dental platform.
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Abstract
Persistent periapical radiolucency after apparently adequate root canal treatment is often interpreted as post-treatment failure that requires non-surgical retreatment or surgery. However, radiographic persistence does not invariably represent ongoing apical periodontitis. This report describes two anterior teeth with large preoperative periapical radiolucencies that showed progressive reduction after nonsurgical root canal treatment, yet retained residual radiolucency for years. Cone-beam computed tomography disclosed internal, non-homogeneous high-density areas within the residual radiolucent regions.
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Abstract
Instrument separation during root canal treatment is a frequent procedural complication particularly with nickel–titanium rotary systems. Although commonly perceived by clinicians as a technical failure requiring immediate correction, the prognostic significance of a separated instrument is primarily determined by biological and anatomical factors rather than by the mere presence of the fragment.
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Abstract
The endodontic management of necrotic teeth with open apices presents substantial disinfection, shaping, and obturation challenges due to the thin dentin walls and wide canals. Fourteen necrotic teeth with open apices underwent primary treatment or retreatment through apexification using silicate-based apical plugs. Cone-beam computed tomography was utilized as needed for diagnostics and treatment planning. Disinfection involved irrigation with 2.5% sodium hypochlorite, followed by 17% EDTA, and a final rinse with saline.
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Abstract
Background: Dens invaginatus (DI) is a developmental anomaly characterized by a deepening or invagination of the enamel organ into the dental papilla before calcification of dental tissues.
Case description: A 9-year-old female Hispanic patient was referred for evaluation of the upper left central incisor, due to swelling of the attached gingiva. Clinical examination revealed a talon cusp on the palatal surface, a draining sinus tract tracing to the apical area of tooth #9, and radiographically, a possible radiolucency. The cone beam computed tomography (CBCT) scan revealed a hypodense area involving the buccal and mesial cortical bone. The tooth was classified as Oehlers’ Type IIIB dens invaginatus.
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Abstract
Gemination is a rare morphoanatomical alteration that may lead to aesthetic, functional, and orthodontic issues. This study presents a clinical case of multidisciplinary treatment of a geminated maxillary central incisor. A 12-year-old patient presented with aesthetic concerns due to gemination in the left maxillary central incisor, dental agenesis, and malocclusion. Root canal treatment was performed using an operating dental microscope, an apex locator, and motor-driven instruments, which were essential for facilitating the planned aesthetic and orthodontic procedures. Clinical and radiographic follow-ups conducted six years and three months after treatment revealed no clinical or radiographic signs or symptoms, indicating success in all endodontic, orthodontic, and aesthetic outcomes.
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Abstract
Introduction: Transient apical breakdown (TAB) is a rare, reversible condition following lateral luxation. It presents as resorption in the apical root and periapical area, often seen radiographically as a periapical radiolucency. Crown discoloration may be noted clinically but typically resolves. Although self-limiting, TAB can mimic apical periodontitis or pulp necrosis, risking misdiagnosis and unnecessary intervention. CBCT imaging plays a critical role in achieving diagnostic clarity.

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Abstract
Objective: This study evaluated the impact of traditional, conservative/contracted, and ultraconservative/”ninja” access cavities on root canal shaping using micro-computed tomography (micro-CT).

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Abstract
Background: Pre-eruptive intracoronal resorption (PEIR) is a rare pathology in permanent teeth and occurs even less frequently in primary teeth.
Case description: This case report describes vital pulp therapy in a permanent and a primary tooth, respectively, presenting with pre-eruptive intracoronal resorptions. The literature on this rare dental pathology is reviewed.

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Abstract
Background: This article reports on a case of extraosseous inflammatory lesion of endodontic origin (EILEO) that was recalcitrant to nonsurgical root canal treatment and was caused by a complex intraradicular and extraradicular bacterial infection.
Case description: The histopathological and histobacteriological aspects of the biopsy specimen were evaluated. The affected tooth was a mandibular premolar that exhibited an abraded crown with exposed dentin and enamel cracks, but no caries. The patient reported previous abscess episodes and presented with symptoms and a sinus tract. Nonsurgical root canal treatment was not effective in controlling infection, even after using ultrasonic agitation of irrigants and intracanal medication.

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Abstract
Background: Given the anatomical proximity, pathologic conditions and endodontic treatment procedures in maxillary posterior teeth may affect the maxillary sinus.
Case description: This report describes a case of large extrusion of filling material to the maxillary sinus, resulting in persistent acute pain and requiring hospitalization and surgical removal of the material via videolaparoscopy. A 34-year-old female experienced persistent pain in the left upper posterior region of the face, three months after endodontic treatment of tooth 14.

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Abstract
Background: The success rate of contemporary apical surgery is high after the introduction of magnification, ultrasonics, and bioceramic materials. Persistent apical periodontitis following surgical treatment is usually related to the failure in eliminating or at least sealing residual bacteria occurring in the root canal system.
Case Description: This article reports on a clinical case of postsurgical apical periodontitis associated with a mandibular molar exhibiting failing root-end filling with a bioceramic (calcium silicate-based) material. The tooth had been subjected to retreatment and later to apical surgery because of persistent apical periodontitis. After a period in that the lesions had apparently healed based on radiographs, the appearance of a sinus tract and the observation of recurrence of the apical periodontitis lesions on both roots as shown by CBCT led to indication for a new surgery.

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Abstract
Objective: Radiographic “J-shaped” lesions can be present in teeth without vertical root fractures (VRF). The objective of this study was to assess the recommended treatment plan in this type of case.
Methods: Radiographs and clinical data from fifteen necrotic or endodontically-treated teeth with radiographic/tomographic “J-shaped” or “halo” endodontic lesions were presented during a lecture to 323 evaluators for treatment selection. The selection of treatments (endodontic therapy, periodontal therapy, endo-perio combined treatment or extraction) and the influence of patient/tooth-related factors in treatment decision planning were statistically compared.

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Abstract
Objective. This case-control study compared the outcome of the nonsurgical root canal treatment/retreatment of teeth with small and large apical periodontitis lesions. Other factors associated with the outcome of the treatment of teeth with apical periodontitis were also assessed.
Methods. Ninety-six patients (48 cases and 48 controls) were selected from 240 treated teeth from 206 individuals, and paired for age and tooth type. An experienced operator treated all teeth over a period of 23 years. Cases were treated/retreated in a single visit using irrigation with 2.5% sodium hypochlorite. The clinical and radiographic outcome was classified as healed, healing or diseased. Healed cases were considered as success and diseased cases were considered as failures. Healing cases consisted of teeth with lesions that decreased in size and were regarded as failure in a rigid criterion or as success in a lenient criterion.

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