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   Table of Contents - Current issue
January-April 2023
Volume 13 | Issue 1
Page Nos. 1-133

Online since Wednesday, January 11, 2023

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Root and root canal morphology of permanent mandibular premolars in Saudi Arabian population: A literature review p. 1
Roqayah Aljuailan
Introduction: Thorough knowledge of the teeth's root and root canal morphology is vital before obtaining access to endodontic therapy. This study aimed to undertake a comprehensive literature review of the root and root canal anatomy of the mandibular premolars in several provinces of Saudi Arabia. Materials and Methods: The PubMed and Scopus databases were screened for relevant literature. Included studies reported data on the number of roots, root canals, canal configurations, and anatomical variations of mandibular premolars in the Saudi population. Gender morphological differences and bilateral symmetry have also been reviewed, along with case reports of anomalies. Results: Fifteen studies that fulfilled the inclusion criteria were included. The weighted average of single-rooted teeth is 91.4% of the mandibular first premolar and 96.7% of the second premolar. Studies of the internal canal morphology revealed that two or more canals were found in 21.5% of the first premolar and 7.1% of the second premolar. Type I Vertucci canal configuration is the most prevalent in mandibular premolars. The multi-rooted or multi-canalled system variants were frequently reported in the clinical case reports. Conclusion: Mandibular first premolars have a higher incidence of multi-canal system than second premolars, hence clinicians should be attentive to the possibility of an extra canal in these teeth. Few studies are available that discuss the root canal morphology of mandibular premolars in the Saudi population, and further studies with a larger sample size covering Saudi Arabia's provinces are indicated.
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Preoperative nonsteroidal anti-inflammatory drugs on the success of inferior alveolar nerve block in irreversible pulpitis: An overview of systematic reviews p. 9
Alpa Gupta, Kritika Aneja, Jitesh Wadhwa, Vivek Aggarwal, Sejal Sidhu, Namrata Mehta
Introduction: The inflammatory conditions of pulp often lead to pain which is managed by adequate anesthesia. Achieving optimum anesthethic effect in such conditions is difficult; therefore, various supplemental techniques have been used to enhance the effect. Premedication is one such technique vastly studied. This study aimed to critically analyze the systematic reviews, including their respective meta-analyses, to summarize the data regarding the role of nonsteroidal anti-inflammatory drugs (NSAIDs) on the success of inferior alveolar nerve block (IANB) in patients with irreversible pulpitis. Materials and Methods: The protocol was formulated using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, and the formulated PICO question was “Is there any effect of oral premedication with NSAIDs on the anesthetic success of IANB in irreversible pulpitis?” The reviews were analyzed using a measurement tool to assess systematic reviews (AMSTAR). Results: Twelve reviews were selected, out of which three were finally included for detailed analysis and their AMSTAR scores were 'high.' Individual meta-analyses results pointed toward the anesthetic success of IANB with NSAIDs as oral premedication. Conclusion: The current overview justifies the use of NSAIDs by highlighting the supporting and conflicting data of each systematic review.
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Comparative evaluation of the effect of endodontic access and subsequent restorations on crown retention: A narrative review of an in vitro study p. 22
Reem Mahmoud, Arruh Almolhem, Sawsan Alomari, Rahaf Babader, Faisal Alghamdi
Studies suggest that endodontic access cavity (EAC) can decrease the retention of crowns. However, there is no clear evidence that restoring EAC effects on crown retention. Thus, the main objective of this narrative review is to assess several materials applied for restoring EAC to different crowns in anterior or posterior teeth, as well as the effect of each material on crown retention. An electronic search for studies published until December 31, 2021, was conducted using the four databases: Scopus, PubMed, Web of Science, and Google Scholar. Researchers selected in vitro studies that investigated the crown retention before and after resorting EAC of anterior or posterior teeth. Exclusively, in vitro studies were considered for assessment. Five papers were selected for the final analysis from the 126 identified during the initial search. Our outcomes illustrated that no significant differences in outcomes between the restorative materials after the endodontic treatment. The findings of this narrative review suggest that crown retention can increase after restoring endodontic access cavities. Finally, the available data indicated that restoring EAC could increase the crown retention more than the original crown. Nevertheless, the prefabricated crown resistance could be more affected by the type of restorative material used inside the EAC following endodontic treatment than retention. Additional clinical and radiological measures are needed.
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Effective management of mandibular second premolar with root anomalies: Review of literature with case analysis p. 28
Ashwaq Faia Asiri
The enigma of successful treatment of mandibular second premolars with taurodontism has been explored for very long due to its rarity of occurrence. This case report aimed to enumerate the successful nonsurgical endodontic management of left mandibular second premolar #35 with three roots and taurodontism. A 34-year-old Saudi male patient with a noncontributory medical history was referred from the prosthodontic department for nonsurgical root canal treatment of tooth #35. Clinical examination revealed rotated clinical crown with caries related to tooth #35. Pulp sensibility cold test of the tooth showed no response, with the absence of pain on percussion and/or visible pocket depth. Radiographic examination showed long and deep pulp chamber and rotated and curved roots with broken apical lamina dura. The tooth was diagnosed with necrotic pulp and asymptomatic apical periodontitis. After making an access to the pulp chamber, two orifices were easily detected while the third one was found by the aid of surgical microscope. The canals were cleaned and shaped using ProTaper Gold file and then obturated with BioCeram Sealer and Gutta-Percha points, using hydraulic bonded obturation technique. Tooth immediately received the final crown. Clinical and radiographical examination after a 3-month follow-up revealed successful peri-apical healing with no symptoms. A literature search was organized to review the past publications about management of mandibular second premolar with taurodontism or anomalies in the root canal system. The search was focused on cases reported in Medline, Scopus, and Google Scholar databases. The conclusion of the seven selected studies and reported cases revealed that proper visualization with advanced microscopes or computer imaging radiographs, negotiation of the root canals, and efficient instrumentation and obturation enhance endodontic success.
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Assessment of quality of life among dental practitioners using magnification devices during nonsurgical root canal treatment in the Kingdom of Saudi Arabia: A cross-sectional study p. 36
Nezar Mohammed Boreak, Afnan Yahya Shabi, Hamed Ahmed Ali Alshawkani, Walaa Aqeel Ageeli, Zainab Mousa Madhhali, Abdulrahman Saeed Al Juman, Ahmed Ali Shibli, Hussain Hassan Najmi
Introduction: This study was conducted to assess the effect of magnification devices (MDs) during nonsurgical root canal treatment (RCT) on quality of life (QOL) among dental professionals of the Kingdom of Saudi Arabia. The dental practitioners performing endodontic treatment were evaluated for ergonomic, postural, psychological, and financial issues associated with and without the use of MDs. Materials and Methodology: A total of 1650 dental professionals (general dentists and endodontists) were recruited from public and private sectors of Saudi Arabia from October 2021 to December 2021. The World Health Organization's QOL assessment questionnaire (WHOQOL-BREF) was administered to conduct the study. The questionnaire addressed four domains of QOL which included physical, psychological, procedural, and financial. Statistical analysis was done by SPSS software® version 23.0. Descriptive analysis, ANOVA test, and unpaired t-test were used. Results: All dental professionals completed the survey. 41.5% reported the use of MDs out of which dental loupe was most commonly used. Work-related musculoskeletal disorders were the most frequent physical difficulty which was faced by 61.5% of dental practitioners while performing RCT. 80% of DPs revealed that MDs improve manual abilities while performing RCT. MDs also relieved psychological, physical, and postural stress by 49.2%, 64.6%, and 63%, respectively. Further 72% of the dental professionals reported improved quality of work after the usage of MD. Conclusion: MDs are commonly used by dental professionals during RCT in Saudi Arabia. It is believed that its use can lead to a better ergonomic, postural, and psychological state of these dental professionals.
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Selection of the best endodontic treatment option using data mining: A decision tree approach p. 44
Alireza Akbarzadeh Baghban, Farid Zayeri, Mohammad Jafar Eghbal, Ardavan Parhizkar, Saeed Asgary
Introduction: The presence of postendodontic pain is an important issue, which can affect the patients' quality of life. Appropriate treatment selection, based on specific characteristics (e.g., clinical test results and patients' demographics), may reduce postendodontic pain. We aimed to evaluate the relationship of data mining algorithms in longitudinal data of postendodontic pain and treatment allocation to predict the best treatment option. Materials and Methods: The pain data of an original multicenter randomized clinical trial with two study arms, pulpotomy with mineral trioxide aggregate (PMTA) (n = 188) and root canal therapy (RCT) (n = 168), were used. The linear mixed-effects model and predictive algorithms were fitted in accordance with the personal characteristics of patients and diagnostic test results to determine the best treatment option. Using SPSS 23, SAS 9.1, and WEKA 3.6.9, the preferred treatment was identified via comparing the areas below the receiver operating characteristic curves and identifying the most appropriate algorithm. In addition, a decision tree was used to allocate the best type of treatment modality to reduce posttreatment pain. Results: For <18-year-old patients with irreversible pulpitis (IP) based on cold test and >18-year-old patients whose electrical pulp test (EPT) exhibited IP, the chosen treatment would be RCT (P < 0.05). However, for >18-year-old patients with IP based on cold test and <18-year-old patients whose EPT revealed IP, the recommended treatment would be PMTA (P < 0.05). Conclusions: The decision tree model seems to be able to predict the reduction of postendodontic pain in ~65% of patients if they receive optimal treatment.
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Effect of various volume syringes on solution delivery time using conventional irrigation technique in 0.04 tapered preparations of single straight root canals: An ex vivo study p. 51
Kavalipurapu Venkata Teja, Sindhu Ramesh, Sahil Choudhari, Olcay Özdemir, Krishnamachari Janani, Jerry Jose, Kaligotla Apoorva Vasundhara, Gopi Battineni
Introduction: The important aspect of endodontic treatment is root canal irrigation. Although agitation systems proved to have enhanced irrigant wall interactions, syringe needle-based delivery systems still play a significant role during the preparatory phases of root canal treatment. The current study aimed to evaluate the time taken for the irrigant delivery during conventional syringe irrigation using different volume syringes in different root canal preparations. Materials and Methods: Two hundred extracted single-rooted premolars with approximately round canals were randomly instrumented to preferred apical preparation sizes using 0.4 tapered Hyflex-CM rotary Ni-Ti instruments and randomly divided as follows: Group I, instrumentation to size 40, 0.04 taper (n = 50); Group II, instrumentation to size 30, 0.04 taper (n = 50); Group III, instrumentation to size 25, 0.04 taper (n = 50); and Group IV, instrumentation to size 20, 0.04 taper (n = 50). Fifty operators were chosen for the experimentation. They were asked to irrigate the prepared specimens using different volume syringes. The entire irrigant delivery time was recorded by a head nurse using a stopwatch, and the values were calibrated and statistically analyzed. Results: Group I recorded significantly lesser time for irrigant delivery during manual syringe needle irrigation (P = 0.005) compared to other groups. Conclusion: Irrigation delivery time was less in 40/0.04 taper preparations, using 1 ml volume syringes.
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Does periodontal ligament removal using natural proteolytic enzymes alter the surface structure and microhardness of cementum of avulsed tooth? An in vitro analysis p. 57
Sonali Taneja, Chetna Dudeja, Vidhi Kiran Bhalla, Punya Taneja
Introduction: Surface treatment of avulsed tooth must be directed towards the debridement of necrotic periodontal fibers while having no effect on the cementum microhardness. The role of proteolytic enzymes on the periodontal ligament (PDL) surface and hardness of cementum has not been investigated in the literature. Aim: The present study aimed to evaluate the effect of 5.25% sodium hypochlorite (NaOCl), 10% bromelain, 10% papain and 10% panzyme on root surface topography and microhardness of avulsed teeth. Materials and Methods: Forty healthy premolars were freshly extracted and randomly allocated into five treatment groups based on the surface agent employed; Group 1: 50 ml saline, Group 2:20 ml of 5.25% NaOCl, Group 3: 20 ml of 10% bromelain enzyme, Group 4: 20 ml of 10% papain enzyme, and Group 5: 20 ml of 10% mixed panzyme enzyme. The specimens were then subjected to confocal laser scanning microscopy and scanning electron microscopic examination. Supplemental set of freshly extracted forty premolars were decoronated longitudinally and one-half from each specimen was submitted for Vickers microhardness testing before and after application of the above-mentioned agents. Statistical Analysis: Intragroup comparison of mean percentage hardness reduction was assessed using paired t-test. Results: Treatment with NaOCl led to complete removal of PDL fibers with the presence of cracks and crazes on the root surface along with a significant reduction in microhardness. Bromelain and papain revealed regular and even distribution, while few PDL fibers were evident with papain. Panzyme revealed a shiny surface with minute cracks and a significant reduction in microhardness. Conclusion: Ten percentage bromelain for 10 min was effective in the removal of necrotic PDL fibers and preserved the cementum integrity better.
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Influence of technical quality and coronal restoration on periapical health of root canal treatment performed by Malaysian undergraduate students p. 63
Norazlina Mohammad, Faizah Abdul Fatah, Azlan Jaafar, Siti Hajar Omar, Aimi Amalina Ahmad, Abdul Azim Asy Abdul Aziz, Aws Hashim Ali Al-Kadhim
Introduction: Root canal treatment (RCT) and its coronal restoration should be regularly assessed to ensure a successful treatment outcome. The aim of the current study is to evaluate the relationship between the obturation technical quality and coronal restoration in the clinical and radiographic outcome of RCT provided by Malaysian undergraduate students. Materials and Methods: A total of 143 root-treated teeth from 136 patients were evaluated through clinical examinations and periapical radiographs with a mean follow-up period of 2.4 (standard deviation = 1.59) years. The quality of the coronal restoration was classified according to modified United States Public Health Service criteria and the technical quality of the obturation was assessed based on two variables: length and density. Periapical status was evaluated according to periapical index scores. Results: About 64% of the teeth were classified as healthy with a significant reduction of apical periodontitis from 70.3% preoperatively to 36% at reassessment (P < 0.001). About 92.1% of obturation was of acceptable length, whereas 5% underfilled and 2.9% overfilled. Teeth with acceptable obturation length were five times less likely associated with apical periodontitis than the inadequately filled ones. 90% of canals had adequate obturation density with no significant association to apical periodontitis. Teeth restored with intracoronal restorations had 50% more chance of developing apical periodontitis. Inadequately restored teeth and teeth with poor obturation quality were associated with three times more likely apical periodontitis occurrence. The quality of endodontic treatment and the coronal restoration significantly influenced the periapical status (P < 0.001). Conclusion: The radiographic obturation quality and coronal restorations of the RCTs performed by the undergraduate students in a Malaysian public dental school were acceptable in 63.8% of cases with a 64% favorable outcome.
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Comparison of root canal transportation and centering after instrumentation through conservative and traditional access cavities using different file systems: An in vitro study p. 73
Samer Abbas Kadhim, Anas Falah Mahdee, Ahmed Hamid Ali
Introduction: While conservative access preparations could increase fracture resistance of endodontically treated teeth, it may influence the shape of the prepared root canal. The aim of this study was to compare the prepared canal transportation and centering ability after continuous rotation or reciprocation instrumentation in teeth accessed through traditional or conservative endodontic cavities by using cone-beam computed tomography (CBCT). Materials and Methods: Forty extracted intact, matured, and 2-rooted human maxillary first premolars were selected for this study. Teeth were equally divided into two groups according to the access cavity design (traditional or conservative). Each group (n = 20) was further subdivided according to instrumentation technique (n = 10) into rotary 2 shape and reciprocation R-motion file subgroups. The teeth were scanned pre and post instrumentation using Planmeca ProMax to obtain two CBCT images for each sample. Images were analyzed and root canal transportation and centering ability were calculated for both buccal and palatal roots at three levels from their apices (3, 5 to 7 mm). Results: Although conservative access cavities showed more canal transportation and less centering ability than the traditional one, there was no statistically significant difference (P > 0.05) between them at all levels. Furthermore, no statistically significant difference has been identified in the same parameter between the two instrumentation techniques (continuous rotation and reciprocation) (P > 0.05). However, longer instrumentation time was measured in the conservative group compared to traditional. Conclusion: The size of endodontic access cavity has no effect on root canal transportation and centering ability when instrumentation was performed using 2 shape and R-motion file systems.
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Evaluation and comparison of transportation and centering ability of various pathfiles in the second mesiobuccal canal of maxillary first molars p. 80
Maryam Gharechahi, Ali Bagherpour, Shima Behzadi, Mohammad Mehdi Gharechahi, Maryam Peighoun
Introduction: In root canal treatment, the glide path process is considered a primary action to increase the safety and efficiency of nickel–titanium rotary files and prevent preparation errors. The present study aimed to evaluate and compare different glide paths in terms of transportation and centering ability of the curved, narrow second mesiobuccal (MB2) canal of maxillary first molars using cone-beam computed tomography (CBCT). Materials and Methods: First, periapical radiographs and CBCT were obtained from extracted maxillary first molars, and 125 teeth, whose mesiobuccal root curve was in the medium range (a curve angle of 20°–40°) and had separate MB2 canal, were selected. However, teeth <17 mm and more than 21 mm in length were excluded from the study. Afterward, the access cavity was prepared with a round diamond bur, and the MB2 canal was negotiated using a manual size 6–8 C-pilot. In the next stage, were randomly divided to five groups of 25, and each group was prepared by using one of the files of ProGlider, R-Pilot, Hyflex EDM, WaveOne Gold Glider, and C-Pilot. Following that, CBCT was taken from all teeth again, and the levels of canal transportation and centering ability were evaluated at five levels (distances of furcation, 1 and 2 mm from the furcation, the crest of the curvature, and 1 mm from the apex). Results: In this study, there was no statistically significant difference in canal transportation and centering ability among five PathFile systems in all sections (P > 0.05). Conclusions: All five PathFile systems carry out Glide path preparation similarly and appropriately in terms of canal transportation and centering ability.
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Preeruptive intracoronal resorption: A cone-beam computed tomography study p. 88
Kendra Clark, Mehrnaz Tahmasbi, Robert A Augsburger, Poorya Jalali
Introduction: Preeruptive intracoronal resorption (PEIR) is described as the cavitation of intracoronal dentin just below the dentinoenamel junction in the coronal portion of an unerupted tooth. The aim of this study was to analyze cone-beam computed tomography (CBCT) scans of teeth affected by PEIR and report the radiographic findings. Materials and Methods: In this retrospective study, a total of 26 CBCT scans including 33 PEIR-affected teeth were evaluated. The following data were documented: age, sex, affected tooth, presence and location of enamel/cementum disruption, lesion extension, radiographic distance of lesion to the pulp, pericoronal radiolucency, and periapical radiolucency. Results: Third molars were the primary teeth affected (88%). A radiographic disruption of the external surface of the tooth was noted in all cases. Disruption of the enamel only was observed in 29 cases, followed by disruption of enamel and cementum in two cases, and disruption of the cementum only in two cases. Twenty-one cases (64%) showed lesions extending to or above the cementoenamel junction (CEJ), and 12 cases (36%) displayed lesions extending below the CEJ. In 21 cases, the lesion progressed close to the root canal system, leaving <1 mm of dentin. However, due to the limitations of CBCT imaging, resorptive pulpal exposure could not be accurately determined. One case exhibited a pericoronal radiolucency, whereas none of the 33 cases displayed signs of a periapical radiolucency. Conclusion: These data suggest that PEIR is a form of external resorption. CBCT is a viable tool for the identification of cases with PEIR, and for determining the extent of the resorptive defect.
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Dental health-care professionals' awareness and knowledge of sterilization and disinfection practices for new, unused endodontic files and gutta-percha in Jeddah, Saudi Arabia p. 94
Khalid Merdad, Maram Alnaffaie, Rawan Balbaid, Asmaa Nakity, Faisal Alghamdi, Dania Sabbahi, Saad Al Nazhan
Introduction: The proper protocol for the sterilization of instruments is essential in dental practice; especially because some clinicians think that new files directly from the manufacturers are already sterile and can be used directly on patients without the standard sterilization. Therefore, the aim of this study is to analyze the dental levels of professionals and their auxiliary staffs concerning awareness, knowledge, attitudes, and behaviors about sterilizing endodontic instruments and gutta-percha. Materials and Methods: This cross-sectional study was conducted in Jeddah, Saudi Arabia, using an online, randomly distributed survey for dental health-care practitioners. The survey questions were about the participants' demographics, knowledge, attitudes, and behaviors about sterilization techniques for endodontic files and gutta-percha. Data analysis consisted of simple descriptive statistics presented in frequency tables and percentages. Results: Of the 197 dental health-care practitioners surveyed, the majority (84.7%) stated that they use files directly from the manufacturer's packages, while only 15.3% reported sterilizing the new endodontic files before using them with patients. As for gutta-percha, 23.4% of the participants answered that they disinfected it before obturation. About 60% of the participants were unaware that the sterilization's expiry date was printed on the endodontic file packages. Conclusions: The results indicated that the majority of dental practitioners and students do not practice an effective sterilization protocol for endodontic files and gutta-percha. Based on these results, this study recommends that more education about sterilization protocols should be added to the infection control curriculum.
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Management of odontogenic cutaneous sinus tract referred from dermatology and ENT clinics using cone-beam computed tomography: A case series p. 100
Khalid Merdad
An odontogenic cutaneous sinus tract (OCST) is an uncommon finding caused by prolonged periapical inflammation. Patients typically seek treatment from dermatology and ENT clinics due to a lack of intraoral symptoms and the presence of a cutaneous lesion. Misdiagnosis in certain circumstances may result in ineffective treatment. This current article describes four cases of recurrent OCST that were initially misdiagnosed and treated with surgical excision and orally administered antibiotics, without healing. These cases were referred to the endodontic clinic and diagnosed noninvasively using cone-beam computed tomography. The cases were managed by nonsurgical endodontic treatment, followed by dermatologic treatment protocol to prevent scar formation and healing was observed with a 3-year follow-up. These cases emphasize the importance of considering dental infection as a primary etiologic factor in OCST. Referral for dental care management is essential for diagnosis, treatment, and follow-up.
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Endodontic management of unusual extraoral cutaneous sinus tract p. 108
Mohammad A Alshammari, Fahad M Alzoubi
Chronically, draining cutaneous sinus tracts are a common manifestation of pulpal necrosis with periapical pathosis that requires endodontic treatment to heal. However, it is frequently misdiagnosed with cutaneous lesions and incorrectly treated. A clinical case of an 8-year-old girl presented with an extraoral cutaneous sinus tract of the right submandibular region after long-term pus drainage was misdiagnosed by her dermatologist. The odontogenic origin of the sinus tract was made by tracing an unusual pathway of the sinus tract utilizing cone-beam computed tomography. The clinical and radiographic examination revealed a necrotic pulp, with chronic periapical abscess and cutaneous drainage of the immature mandibular right first molar. Endodontic therapy and mineral trioxide aggregate apexification were performed. The cutaneous sinus tract showed signs of healing after 1 month from treatment initiation and complete radiographic healing was noted after 18th month recall. Cutaneous extraoral sinus tracts of endodontic origin can be easily misdiagnosed and mistreated. Utilizing cone-beam computed tomography to trace the sinus tract revealed an unusual pathway confirming the odontogenic origin of the sinus tract. Correct treatment resulted in regaining the patient her self-confidence, saving the tooth, and healing of the facial sinus tract.
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Chitosan-modified mineral trioxide aggregate for pulp capping applications p. 116
K Sai Vaishnavi, Saravana Karthikeyan Balasubramanian, Sekar Mahalaxmi
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Author's reply p. 118
Ashraf M Abu-Seida
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Effect of bioceramic sealers against planktonic Enterococcus faecalis p. 120
Saravana Karthikeyan Balasubramanian, VC Divya
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11th Saudi Endodontic Society International Conference 2022 p. 122
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Workshops p. 125

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Winning Poster p. 131

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SIDC 2023: The Saudi International Dental Conference p. 132
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