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BACKGROUND: The purpose of this article was to Evaluate the influence of sealer on the outcome of non-surgical endodontic treatment or retreatment of permanent teeth with apical periodontitis (PROSPERO registration: CRD42020205951). METHODOLOGY: A systematic review of original clinical studies was carried out following PRISMA guidelines to answer whether the type of sealer used in endodontic treatment or retreatment influences the repair of apical periodontitis determined by clinical and radiographic parameters. Electronic searches were performed in PubMed, Embase, Web of Science, Scopus, and the Cochrane Library database, until May 2023. Gray literature and a hand search of reference lists were also performed. The risk of bias was assessed using Cochrane RoB2 for randomized trials and the Newcastle-Ottawa Scale (NOS) for prospective and retrospective cohort and case-control studies. RESULTS: Among 1046 studies, a total of 819 were selected by title and abstract, resulting in 23 for full-text review. In total, 11 studies met the inclusion criteria (1467 patients/teeth with apical periodontitis). The quality assessment using RoB2 included five randomized control trials, of which four had medium risk and one had a low risk of bias. According to the NOS scale, five studies were classified as low risk and one study was considered as medium risk of bias. The sealer type and obturation techniques varied, and the mean follow-up time was 3.7 years. Most studies used two-dimensional radiographic criteria to assess the treatment outcome sealers and not cements. Eight studies did not find significant differences when comparing cements. The healing rates ranged from 56.7% to 90%. CONCLUSIONS: The results of this review support that the current endodontic sealers do not seem to influence the treatment outcome of permanent teeth with apical periodontitis. Although the studies had medium and low risk of bias, the results should be interpreted with caution. More randomized studies of long-term outcomes comparing filling materials are needed to strengthen this claim and allow for a meta-analysis.

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Abstract The purpose of this article was to Evaluate the influence of sealer on the outcome of non-surgical endodontic treatment or retreatment of permanent teeth with apical periodontitis (PROSPERO registration: CRD42020205951). Methodology: A systematic review of original clinical studies was carried out following PRISMA guidelines to answer whether the type of sealer used in endodontic treatment or retreatment influences the repair of apical periodontitis determined by clinical and radiographic parameters. Electronic searches were performed in PubMed, Embase, Web of Science, Scopus, and the Cochrane Library database, until May 2023. Gray literature and a hand search of reference lists were also performed. The risk of bias was assessed using Cochrane RoB2 for randomized trials and the Newcastle-Ottawa Scale (NOS) for prospective and retrospective cohort and case-control studies. Results: Among 1046 studies, a total of 819 were selected by title and abstract, resulting in 23 for full-text review. In total, 11 studies met the inclusion criteria (1467 patients/teeth with apical periodontitis). The quality assessment using RoB2 included five randomized control trials, of which four had medium risk and one had a low risk of bias. According to the NOS scale, five studies were classified as low risk and one study was considered as medium risk of bias. The sealer type and obturation techniques varied, and the mean follow-up time was 3.7 years. Most studies used two-dimensional radiographic criteria to assess the treatment outcome sealers and not cements. Eight studies did not find significant differences when comparing cements. The healing rates ranged from 56.7% to 90%. Conclusions: The results of this review support that the current endodontic sealers do not seem to influence the treatment outcome of permanent teeth with apical periodontitis. Although the studies had medium and low risk of bias, the results should be interpreted with caution. More randomized studies of long-term outcomes comparing filling materials are needed to strengthen this claim and allow for a meta-analysis.

Resumo O objetivo deste artigo foi avaliar a influência do cimento no resultado do tratamento ou retratamento endodôntico não cirúrgico de dentes permanentes com periodontite apical (registro PROSPERO: CRD42020205951). Metodologia: Uma revisão sistemática de estudos clínicos originais foi realizada seguindo as diretrizes PRISMA para responder se o tipo de cimento usado no tratamento ou retratamento endodôntico influencia a reparação da periodontite apical determinada por parâmetros clínicos e radiográficos. Pesquisas eletrônicas foram realizadas no PubMed, Embase, Web of Science, Scopus e no banco de dados Cochrane Library, até maio de 2023. A literatura cinza e uma pesquisa manual das listas de referências também foram realizadas. O risco de viés foi avaliado usando Cochrane RoB2 para os estudos randomizados e Newcastle-Ottawa Scale (NOS) para coorte prospectiva e retrospectiva e estudos de caso-controle. Resultados: Entre 1.046 estudos, um total de 819 foram selecionados por título e resumo, resultando em 23 para revisão de texto completo. No total, 11 estudos preencheram os critérios de inclusão (1.467 pacientes/dentes com periodontite apical). A avaliação de qualidade usando RoB2 incluiu cinco estudos randomizados de controle, dos quais quatro tinham risco médio e um tinha baixo risco de viés. De acordo com a escala NOS, cinco estudos foram classificados com baixo risco e um estudo foi considerado com médio risco de viés. O tipo de cimento e as técnicas de obturação variaram, e o tempo médio de acompanhamento foi de 3,7 anos. A maioria dos estudos utilizou critérios radiográficos bidimensionais para avaliar o resultado do tratamento. Oito estudos não encontraram diferenças significativas ao comparar os cimentos. As taxas de reparação variaram de 56,7% a 90%. Conclusões: Os resultados desta revisão suportam que os cimentos endodônticos atuais não parecem influenciar o resultado do tratamento de dentes permanentes com periodontite apical. Embora os estudos tiveram médio e baixo risco de viés, os resultados devem ser interpretados com cautela. Mais estudos randomizados de resultados de longo prazo comparando materiais de obturação são necessários para fortalecer essa afirmação e permitir uma meta-análise.

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OBJECTIVE: The effects of brushing on shaping with three different instruments were assessed in oval canals. DESIGN: Mandibular incisors were assigned to 6 groups (n = 12/group) according to the system, each one with or without brushing: Reciproc Blue, VDW.Rotate, and Race EVO. Micro-computed tomography was performed before and after preparation. RESULTS: Brushing strokes caused no increase in canal volume, surface area, and structure model index independently of the system (p > 0.05), except for RaCe EVO in the full canal surface area (p < 0.05). Brushing did not increase the prepared areas (p > 0.05), except for Reciproc in the apical canal (p < 0.05). Reciproc with no brushing exhibited less pericervical dentin than with brushing (p < 0.05), while RaCe EVO with brushing resulted in less remaining dentin (p < 0.05). CONCLUSIONS: The brushing motion had no effects on the overall shaping performance of the 3 instruments tested. An exception was the increase in prepared surface area in the apical canal segment when the Reciproc instrument was used with brushing strokes.

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The aim of this study was to investigate the internal root canal anatomy of maxillary and mandibular premolars in a Brazilian subpopulation, in order to establish the prevalence of the different configurations proposed by Vertucci. Three hundred and ninety-eight cone-beam computed tomography scans were collected from a private imaging clinic database in Rio de Janeiro, including 217 maxillary and 226 mandibular scans. A total 1316 premolars (594 maxillary and 722 mandibular) were evaluated using an image viewer, and classified according to Vertucci. Two calibrated examiners determined the frequency of each morphological Type. A third examiner reviewed discordant cases. The Kappa test was applied to verify inter-rater agreement, and Fisher's Exact Test to verify gender-related differences. The most frequent root canal configurations of maxillary first and second premolars were Type IV (73.86%) and Type I (47.18%), respectively. Type I was the most prevalent in mandibular first and second premolars (80.59% and 95.86%, respectively). Only Types I and VIII presented a statistically significant difference between sexes. Type I was more frequent in females and Type VIII in males. A highly significant frequency of Type I was found in both mandibular first and second premolars, whereas the most frequent maxillary premolar root canal configuration was Type IV for first premolars and Type I for second premolars.

O presente estudo teve como objetivo investigar a anatomia interna de pré-molares superiores e inferiores em uma subpopulação brasileira para estabelecer a prevalência das diferentes configurações propostas por Vertucci. Trezentos e noventa e oito exames de tomografia computadorizada de feixe cônico foram coletados de um banco de dados de uma clínica privada de imagem no Rio de Janeiro, incluindo 217 exames maxilares e 226 mandibulares. Um total de 1.316 pré-molares (594 superiores e 722 inferiores) foram avaliados usando um visualizador de imagens e categorizados de acordo com a classificação de Vertucci. Dois examinadores calibrados determinaram a frequência de cada tipo morfológico. Um terceiro examinador revisou os casos discordantes. O teste Kappa foi aplicado para verificar a concordância entre os avaliadores e o Teste Exato de Fisher para verificar diferenças relacionadas ao gênero. A configuração do canal radicular mais frequente dos primeiros e segundos pré-molares superiores foi Tipo IV (73,86%) e Tipo I (47,18%), respectivamente. O tipo I foi o mais prevalente nos primeiros e segundos pré-molares inferiores (80,59% e 95,86%, respectivamente). Os tipos I e VIII foram os únicos que apresentaram diferença estatisticamente significativa entre os sexos. O tipo I foi mais frequente nas mulheres e o tipo VIII nos homens. Uma frequência altamente significativa do Tipo I foi encontrada em ambos os primeiros e segundos pré-molares inferiores, enquanto a configuração do canal radicular dos pré-molares superiores mais frequente foi o Tipo IV para os primeiros pré-molares e o Tipo I para os segundos pré-molares.

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ABSTRACT The aim of this study was to investigate the internal root canal anatomy of maxillary and mandibular premolars in a Brazilian subpopulation, in order to establish the prevalence of the different configurations proposed by Vertucci. Three hundred and ninety-eight cone-beam computed tomography scans were collected from a private imaging clinic database in Rio de Janeiro, including 217 maxillary and 226 mandibular scans. A total 1316 premolars (594 maxillary and 722 mandibular) were evaluated using an image viewer, and classified according to Vertucci. Two calibrated examiners determined the frequency of each morphological Type. A third examiner reviewed discordant cases. The Kappa test was applied to verify inter-rater agreement, and Fisher's Exact Test to verify gender-related differences. The most frequent root canal configurations of maxillary first and second premolars were Type IV (73.86%) and Type I (47.18%), respectively. Type I was the most prevalent in mandibular first and second premolars (80.59% and 95.86%, respectively). Only Types I and VIII presented a statistically significant difference between sexes. Type I was more frequent in females and Type VIII in males. A highly significant frequency of Type I was found in both mandibular first and second premolars, whereas the most frequent maxillary premolar root canal configuration was Type IV for first premolars and Type I for second premolars.

RESUMO O presente estudo teve como objetivo investigar a anatomia interna de pré-molares superiores e inferiores em uma subpopulação brasileira para estabelecer a prevalência das diferentes configurações propostas por Vertucci. Trezentos e noventa e oito exames de tomografia computadorizada de feixe cônico foram coletados de um banco de dados de uma clínica privada de imagem no Rio de Janeiro, incluindo 217 exames maxilares e 226 mandibulares. Um total de 1.316 pré-molares (594 superiores e 722 inferiores) foram avaliados usando um visualizador de imagens e categorizados de acordo com a classificação de Vertucci. Dois examinadores calibrados determinaram a frequência de cada tipo morfológico. Um terceiro examinador revisou os casos discordantes. O teste Kappa foi aplicado para verificar a concordância entre os avaliadores e o Teste Exato de Fisher para verificar diferenças relacionadas ao gênero. A configuração do canal radicular mais frequente dos primeiros e segundos pré-molares superiores foi Tipo IV (73,86%) e Tipo I (47,18%), respectivamente. O tipo I foi o mais prevalente nos primeiros e segundos pré-molares inferiores (80,59% e 95,86%, respectivamente). Os tipos I e VIII foram os únicos que apresentaram diferença estatisticamente significativa entre os sexos. O tipo I foi mais frequente nas mulheres e o tipo VIII nos homens. Uma frequência altamente significativa do Tipo I foi encontrada em ambos os primeiros e segundos pré-molares inferiores, enquanto a configuração do canal radicular dos pré-molares superiores mais frequente foi o Tipo IV para os primeiros pré-molares e o Tipo I para os segundos pré-molares.

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Dens invaginatus or dens in dente is a developmental dental anomaly resulting from an invagination of the enamel organ into the dental papilla during odontogenesis. Radiographically, it is usually seen as a radiolucent invagination surrounded by a radiopaque area (enamel) limited to the tooth crown or extending into the root. Because the invagination is opened to the oral cavity, it can retain saliva, food remnants, and bacteria. In conditions where the enamel lining of the invagination is naturally absent or lost because of caries, bacterial cells and products can diffuse from the invagination through the dentin tubules to reach the pulp and cause disease. Management of teeth with dens invaginatus includes preventive sealing or filling of the invagination, or if the pulp is affected, therapeutic options include vital pulp therapy, nonsurgical root canal treatment, apexification or regenerative endodontic procedures, periradicular surgery, intentional replantation, or extraction. It is recommended that the invagination be always approached, regardless of the type of dens invaginatus. The root canal should be treated whenever the pulp is irreversibly inflamed or necrotic. Endodontic management of teeth with dens invaginatus is often tricky because of its anatomic complexity, and special and customized strategies should be devised. This review discusses the endodontic implications of this anomaly and the current treatment recommendations based on anatomic, pathological, and technologic considerations.

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This article shows the follow-up of several cases of maxillary sinusitis of dental (usually endodontic) origin, with different manifestations, diagnostic challenges, and outcomes.Cases from 14 patients from 3 countries and treated by 7 different endodontists are presented, all of them with inflammatory sinus changes represented by mucositis, osteoperiostitis, and/or partial/full obstruction. All cases showed dental and/or sinus signs/symptoms that resolved after dental management. In 13 cases, the sinus condition had an endodontic origin, 4 of them concurrently with periodontal involvement. In 1 case, sinusitis was caused by trauma to the face. All cases but 1 had a satisfactory response of the periradicular tissues and maxillary sinus to treatment that consisted of root canal therapy, root amputation, extraction, or trauma management.The successful management of most cases reported in this article emphasizes the importance of endodontics as a specialty engaged in saving teeth and promoting health not only in the oral cavity but also in other areas that may be affected by infections of endodontic origin, including the maxillary sinus.

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INTRODUCTION: This study evaluated the microbiological conditions of the apical root canal system of teeth with posttreatment apical periodontitis and correlated them with observations from cone-beam computed tomographic (CBCT) imaging, micro-computed tomographic (micro-CT) imaging, and histopathology. METHODS: Root apices were obtained from 36 root canal-treated teeth subjected to periradicular surgery. CBCT examination was available before surgery. The apical root specimens were scanned in a micro-CT device and then cryopulverized. The powder was subjected to DNA extraction for real-time polymerase chain reaction quantification of total bacteria, Streptococcus species, members of the phylum Actinobacteria, and Enterococcus faecalis. Microbiological findings were evaluated for associations with CBCT, micro-CT, and histopathologic data. An association between lesion size and the proportion of unfilled apical canal system volume was also assessed. RESULTS: All cryopulverized specimens were positive for total bacteria. Actinobacteria and streptococci occurred in 35 and 33 specimens, respectively, and were usually dominant in the community. Actinobacteria counts were 2.23 times higher in granulomas than in cysts. Streptococci were significantly more present in small lesion cases. E. faecalis was detected in only 7 samples, always as a dominant community member. The association of total bacteria, streptococci, and Actinobacteria counts with the unfilled canal volume was significant in the univariate analyses but not confirmed in the adjusted analyses. Large lesions were significantly associated with a higher volume of unfilled apical canals. CONCLUSIONS: Bacterial infection occurred in all root apices, with high prevalence and dominance of Actinobacteria and streptococci. The volume of the unfilled apical canal system was significantly associated with the lesion size and possibly with bacterial counts. Findings illustrate the need to thoroughly disinfect and fill the apical root canal of infected teeth during endodontic therapy.

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INTRODUCTION: This study assessed the cleaning, shaping, and disinfection abilities of 2 instrumentation systems in molar root canals using a novel correlative analytical approach. METHODS: The root canals from extracted mandibular and maxillary molars with apical periodontitis were pair matched according to anatomic similarities as determined by micro-computed tomographic analysis and prepared with either XP-endo Shaper (FKG Dentaire, La Chaux-de-Fonds, Switzerland) (n = 16) or Reciproc Blue (VDW, Munich, Germany) (n = 16) instruments and 2.5% sodium hypochlorite irrigation. Pre- and postpreparation micro-computed tomographic scans were used to identify and calculate the unprepared surface areas (shaping), which were histobacteriologically evaluated for the presence of residual bacteria (disinfection) and pulp tissue remnants (cleaning) in each canal third. RESULTS: Unprepared canal surface areas for XP-endo Shaper and Reciproc Blue in the full canal length were approximately 26% and 19% (P < .05), respectively (30% and 23% in the apical part of the canal, P > .05). Preparation with Reciproc Blue resulted in 37.5% canals free of bacteria in all sections examined and 56% in the apical sections only. XP-endo Shaper resulted in 44% canals free of bacteria in all sections, and 56% in the apical part of the canal only. Pulp tissue remnants were not observed in 31% (all canal sections) and 50% (apical canal sections) of specimens from both instrument systems. No significant differences were observed between instruments when comparing the amount of pulp tissue remnants and the number of cases negative for bacteria and tissue remnants (P > .05). CONCLUSIONS: Although the Reciproc Blue instrument had superior shaping ability in comparison with XP-endo Shaper, both systems performed similarly in cleaning and disinfecting root canals. Irregular canals and difficult-to-reach areas were not thoroughly cleaned and disinfected by any of the tested systems.

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INTRODUCTION: The impact of minimally invasive endodontic procedures on root canal disinfection has not been determined. This ex vivo study compared root canal disinfection and shaping in teeth with contracted or conventional endodontic cavities. METHODS: Mandibular incisors with oval-shaped canals were selected and anatomically matched based on micro-computed tomographic (micro-CT) analysis and distributed into 2 groups. Conservative and conventional access cavities were prepared, and the canals were contaminated with a pure culture of Enterococcus faecalis for 30 days. Root canal preparation in both groups was performed using the XP-endo Shaper instrument (FKG Dentaire, La Chaux-de-Fonds, Switzerland) and 2.5% sodium hypochlorite irrigation. Intracanal bacteriologic samples were taken before and after preparation, and DNA was extracted and subjected to quantitative polymerase chain reaction. Micro-CT scans taken before and after preparation were used for shaping evaluation. Bacteriologic data were analyzed by the Poisson regression model and the chi-square test with Yates correction. Micro-CT data were analyzed by the Wilcoxon, Mann-Whitney, and Student t tests with the significance level set at 5%. RESULTS: All initial samples were positive for E. faecalis. After preparation, the number of bacteria-positive samples was significantly higher in the contracted cavity group (25/29, 86%) than in the conventional cavity group (14/28, 50%) (P < .01). Intergroup quantitative comparison showed that the reduction in bacterial counts was also significantly higher in the group of conventional cavities (P < .01). Micro-CT data revealed no significant difference in the amount of unprepared areas between groups. CONCLUSIONS: Our findings showed that although shaping using an adjustable instrument was similar between groups, disinfection was significantly compromised after root canal preparation of teeth with contracted endodontic cavities.

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OBJECTIVES: To evaluate and compare irrigant distribution throughout the root canal system of mesial roots of mandibular molars after application of distinct adjunctive irrigant activation procedures. MATERIALS AND METHODS: Fifteen extracted mandibular molars presenting Fan's type II, III, or IV isthmus configurations were selected. The canals were initially enlarged and cleaned. The same specimens were subjected to conventional positive pressure irrigation (PPI) followed by adjunctive irrigation approaches: passive ultrasonic irrigation (PUI), mechanical activation with the XP-endo Finisher instrument, and a control group in which the irrigant remained in the canal with no activation. Retention time for the irrigant was the same for all groups. Sodium hypochlorite mixed with a contrast medium (Omnipaque 300) was used as the irrigant. Before and immediately after the adjunctive irrigation, micro-computed tomographic (micro-CT) scans were taken to evaluate the volume of the entire root canal system that was filled by the irrigant. An exclusive analysis was also done for the isthmus area. RESULTS: Analysis of the entire root canal system showed that the XP-endo Finisher instrument promoted better distribution of the irrigant than PUI and the control group (p < 0.01). PUI was not significantly different from the control group (p > 0.05). A separate analysis of the isthmus area showed no significant difference between the adjunctive irrigation methods and the control (p > 0.05). CONCLUSIONS: The XP-endo Finisher instrument promoted better distribution of irrigant throughout the root canal system, especially in the apical canal segment, when compared to PUI. However, the tested approaches did not differ as to the ability to drive irrigants into the isthmus area. CLINICAL RELEVANCE: This study highlighted that the XP-endo Finisher instrument presented a better performance to distribute irrigant throughout the root canal system, especially in the apical canal segment compared to positive pressure irrigation and PUI.

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INTRODUCTION: This ex vivo study evaluated the intracanal bacterial reduction promoted by chemomechanical preparation using a single-file technique varying the volume, concentration, and retention time of sodium hypochlorite (NaOCl) irrigation in comparison with a multifile system. METHODS: Palatal roots from extracted maxillary first molars were selected and anatomically matched based on microcomputed tomographic analysis for group distribution. The canals were contaminated with a fresh mixed bacterial culture grown in anaerobiosis and recently obtained from a tooth with apical periodontitis. Specimens were divided into 4 groups of 24 each according to the following preparation protocols: REC-6LOW (Reciproc R50 instrument [VDW, Munich, Germany], 6% NaOCl, low irrigant volume), REC-2.5LOW (R50, 2.5% NaOCl, low irrigant volume), REC-2.5HI (R50, 2.5% NaOCl, high irrigant volume), and BR-2.5HI (BioRaCe [FKG Dentaire, LaChaux-de-Fonds, Switzerland], 2.5% NaOCl, high irrigant volume). The total time of preparation was recorded. Intracanal bacteriologic samples were taken before and after preparation; DNA was extracted and subjected to quantitative polymerase chain reaction. RESULTS: Bacteria were detected in 22 initial samples from the REC-2.5LOW group and in 23 from the other groups. Intragroup analysis showed that all tested preparation protocols were highly effective in significantly reducing the intracanal bacterial counts (P < .001). Intergroup comparison of bacterial reduction levels revealed a statistically significant difference between BR-2.5HI and REC-2.5LOW (P < .05). Counts of bacteria were 2.5 times significantly higher in REC-2.5LOW compared with BR-2.5HI. No other significant differences were found in quantitative findings (P > .05). CONCLUSIONS: The concerted effects of multiple instruments, the high volume of irrigation, and the long retention time of NaOCl irrigant had a positive influence on intracanal disinfection during chemomechanical preparation.

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AIM: In the present study, we compared the transportation of three different instrumentation systems in different levels of standardized artificial curved canals. METHODS: Sixty epoxy resin blocks containing simulated canals were divided into three groups (n = 20) according to the instrument used for canal preparation: Reciproc (REC), Reciproc Blue (REC Blue), and XP-endo Shaper (XPS). Pre- and post-instrumentation digital images of each specimen were superimposed by Photoshop software to evaluate the different amount of transportation. The Kruskal-Wallis and Wilcoxon were the non-parametric tests applied for the intergroup and intragroup analyses, respectively. The significance level was set at 5%. RESULTS: The XPS showed significantly less canal transportation than REC Blue at five levels (P < 0.05) and significantly less canal transportation at seven evaluated levels when compared with the REC (P < 0.05). REC Blue showed significant less canal transportation than REC at four of the eight evaluated levels (P < 0.05). All evaluated instruments showed a significantly higher amount of resin removal toward the inner wall compared to the outer wall of the curvature (P < 0.001). CONCLUSION: Although the XPS showed significantly less canal transportation than REC and REC Blue, all systems produced transportation from the original canal anatomy.

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In this case series, bacterial reduction promoted by antimicrobial photodynamic therapy (PDT) used during endodontic surgery was evaluated. Cases were also followed up, and the surgical outcome was reported. The study consisted of 19 teeth with posttreatment apical periodontitis that were consecutively treated by endodontic surgery. After apicoectomy, the root end was treated with PDT using methylene blue as the photosensitizer. Bacteriologic samples were taken from both the cut root surface and the root-end cavity before and after PDT. Samples were analyzed for the total bacterial and Streptococcus group counts using quantitative real-time polymerase chain reaction. EndoSequence BC-RRM Putty (Brasseler, Savannah, GA) was used as the root-end filling. Patients were followed up, and the surgical outcome was evaluated. The reduction in bacterial counts after the PDT approach was analyzed using the nonparametric Wilcoxon signed rank test. PDT significantly reduced the total bacterial and streptococcal counts in both root-end cavities and resected root surfaces (P < .05). The success rate for 15 teeth that were available for recall after 12 to 21 months was 93% under a loose evaluation criterion and 73% under a rigid one. Used during endodontic surgery, PDT significantly enhanced disinfection of the cut surface area and root-end cavity. Cases treated with PDT showed a high healing rate.

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INTRODUCTION: The present study evaluated the cleaning and shaping ability of 3 instrumentation systems in oval canals of extracted vital teeth using a correlative analytic approach. METHODS: Oval distal canals from 33 freshly extracted mandibular molars with pulp vitality were scanned by micro-computed tomographic (micro-CT) imaging for sample selection. Specimens matched by anatomic similarities were distributed into 3 experimental groups according to the instrument system to be evaluated: the Self-Adjusting File (SAF; ReDentNOVA, Ra'anana, Israel), TRUShape (Dentsply Sirona, Tulsa, OK), and XP-endo Shaper (FKG Dentaire, La Chaux-de-Fonds, Switzerland). The irrigant was 5.25% sodium hypochlorite heated at 37°C. After rescanning with micro-CT imaging, the unprepared surface areas were identified, measured, and then histologically evaluated for the amount of pulp remnants in each root third. RESULTS: When the apical 4-mm canal segment was evaluated, the SAF exhibited significantly less unprepared areas than the XP-endo Shaper (P < .05), and there were no significant differences for the other comparisons (P > .05). Analysis of the full canal length showed no statistically significant differences between the 3 tested systems (P > .05). Likewise, the tested systems did not differ significantly in cleaning the unprepared walls (P > .05). CONCLUSIONS: There was no significant difference in the amount of unprepared surface areas between the 3 instrument systems, except for the comparison between the SAF and XP-endo Shaper in the apical 4-mm segment. None of them prepared 100% of the root canal walls. The cleaning ability of the 3 systems was similar.

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Acute fatty liver of pregnancy is an uncommon and potentially fatal disorder usually found in the third trimester of pregnancy and the early days postpartum. It is characterized by a micro vesicular stheatosis of the liver, which is reversible with complete regression of the disease. We present two clinical cases, in the first one the patient developed encephalopathy and hypoglycemia in her third day post cesarean section; the patient underwent surgical exploration because of a subaponeurotic hematoma and the diagnosis was confirmed by liver biopsy. The patient presented spontaneous resolution of the disease and was discharged home on her 21st day after delivery. The second case was a patient on her 37th week of pregnancy that arrived to the emergency room complaining of malaise, nausea and vomit, her laboratory analyses were remarkable hypoglycemia and hyperbilirubinemia. She underwent elective pregnancy termination with a favorable maternal and fetal outcome towards spontaneous resolution. It is critical to diagnose and treat this disease in a expedite manner in order to have a favorable maternal and fetal outcome. The mortality rate has decreased dramatically from 80% in 1965 to 100% survival in 1999 according to the latest reviews. This regression of the symptoms and signs along with normalization of the laboratory values has driven some authors to call this disease as the "reversible peripartum liver failure".

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La presencia de algún estoma concomitante con el embarazo no es un evento frecuente, no existe mucha literatura al respecto, por lo que puede haber dudas de manejo al enfrentarnos a una paciente con estas características. Dentro de las causas encontramos a la colitis ulcerativa, trauma con lesión de recto, fístulas rectovaginales, etc. El manejo se lleva a cabo en conjunto con un especialista en colon y recto. Se debe estar familiarizado con las principales complicaciones que se pueden presentar como la obstrucción, prolapso del estoma, cambios en la luz del estoma y sangrado. La vía del parto es de preferencia por vía vaginal, reservando la operación cesárea únicamente para indicaciones obstétricas. La reconexión se puede llevar a cabo en el puerperio. La paciente debe recibir una educación adecuada del manejo de los estomas.

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El síndrome de ogilvie es una complicación quirúrgica mayor. Se define como una dilatación severa del colon proximal (ciego, colon ascendente y transverso), sin evidencia de aire en el colon distal, generalmente consecutivo a un procedimiento quirúrgico abdominal o un parto normal. La causa es desconocida pero se ha asociado a una inhibición simpática de la contractilidad del colon. Presentamos un caso de una paciente post operada de cesárea que presentó este problema en el postoperatorio inmediato, así como una revisión de la literatura. Hacemos énfasis en la importancia de la sospecha clínica y un diagnóstico temprano mediante el uso de placas simples de abdomen, así mismo, realizamos una descripción de un abordaje relativamente nuevo que debe estar presente en nuestro armamentario como ginecoobstetras, esto es, la descompresión mediante el uso de una sonda nasogástrica auxiliados por colonoscopia. Este es un tratamiento invasor mínimo si se compara con los tratamientos previos existentes, del cual se pueden beneficiar de manera importante estas pacientes.

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