Damiano Pasqualini

Background: This study compared the antibacterial efficacy of iVac and conventional syringe-and-needle irrigation, used with an identical standardized antimicrobial irrigant regimen, by evaluating bacterial viability and the depth of membrane-compromised bacterial cells within dentinal tubules. Methods: Forty-two extracted human teeth were instrumented, sterilized, and inoculated with Enterococcus faecalis ATCC 29212. Specimens were randomly assigned to iVac irrigation (n = 20) or conventional 30G syringe-and-needle irrigation (n = 20). Both protocols employed the same irrigation sequence consisting of 5% NaOCl, 10% EDTA, 5% NaOCl, and saline. After treatment, the teeth were sectioned, stained with the BacLight viability kit, and analyzed by confocal laser scanning microscopy (CLSM) to determine the mean proportion of red staining (MPRS) and mean penetration depth (MPD) defined as the depth within dentinal tubules at which PI-associated red fluorescence corresponding to membrane-compromised bacterial cells was detected in the coronal, middle, and apical thirds. Statistical significance was set at p < 0.05. Results: No significant difference in mean proportion of red staining (MPRS) was found between the two groups (p = 0.24). In contrast, mean penetration depth (MPD) was significantly greater with iVac overall (p = 0.021), particularly in the coronal and middle thirds (p = 0.015 and p = 0.032, respectively). No significant difference was observed in the apical third (p = 0.12). Conclusions: Under the present experimental conditions, the iVac and conventional syringe-and-needle irrigation protocols resulted in comparable overall bacterial viability outcomes. However, the iVac protocol was associated with a significantly greater depth of membrane-compromised bacterial cells within dentinal tubules, particularly in the coronal and middle thirds.

Aim: A growing body of research supports an association between periapical inflammation and an increased risk of various systemic effects. However, there is currently no scientific evidence demonstrating a causal relationship between this inflammation and changes in epithelial or endothelial permeability in patients with apical periodontitis (AP). This study aimed to evaluate the potential association between AP, circulating inflammatory cytokines known to affect cellular permeability, and serum proteins associated with an impaired cellular barrier permeability. Additionally, we investigated the effect of endodontic treatment on in vitro endothelial barrier integrity. Methodology: A total of 27 patients with AP and 27 healthy control subjects were enrolled. AP patients underwent root canal treatment and were followed up at 6 and 12 months post‐treatment. Serum levels of human ZO‐1, Claudin‐5, and VE‐cadherin were measured using enzyme‐linked immunosorbent assays (ELISA). An in vitro model of the microvascular endothelial blood–brain barrier (hCMEC/D3 cells) was used to assess the biological activity of patient sera on barrier function and cellular permeability. Results: At baseline, patients with AP showed significantly higher serum levels of ZO‐1 and Claudin‐5 compared with controls ( p < 0.001), whereas VE‐cadherin levels did not differ significantly between groups. Serum ZO‐1 and Claudin‐5 levels progressively decreased at 6 and 12 months following root canal treatment. In adjusted analyses, the baseline between‐group differences for ZO‐1 and Claudin‐5 remained significant after adjustment for BMI and smoking status. ZO‐1 and Claudin‐5 levels showed moderate correlations with IL‐1β and IL‐6 in the AP group at baseline. In vitro, exposure to baseline AP sera increased endothelial permeability, indicating barrier disruption, while sera collected after treatment did not impair barrier integrity. Moreover, cellular ZO‐1 expression remained stable in cells treated with control sera but was markedly reduced after exposure to sera from untreated AP patients (t0), whereas post‐treatment sera (t6 and t12) restored ZO‐1 expression to control levels. Conclusions: Systemic inflammation in patients with apical periodontitis to deranged endothelial barrier function. Successful endodontic treatment was associated with reduced levels of inflammatory cytokines and the restoration of serum and cellular proteins essential for barrier integrity.

Background: Extended reality (XR) technologies, encompassing augmented reality (AR), virtual reality (VR), and mixed reality (MR), are increasingly used in endodontic education and practice. A gap exists regarding understanding of XR's applications and limitations among endodontic educators and practitioners. Objectives: This narrative review aims to (A) explain the technical foundations of AR, VR, and MR systems; (B) review current applications of XR in endodontic education and clinical practice; (C) examine limitations and barriers to adoption; and (D) outline future directions. Method: An overview of the technical foundations of XR was provided. A comprehensive electronic search was conducted across PubMed, Scopus, and Web of Science databases to identify papers on applications of XR in endodontics. After screening, 33 articles met the inclusion criteria and were subjected to full‐text review. The main features of the studies were extracted, and a narrative summary was prepared. Results: The review shows that XR technologies have been applied in endodontic education for training in visualisation of root canal anatomy, access cavity preparation, and microsurgical procedures, with most studies demonstrating improved comprehension and procedural accuracy. Haptic feedback systems and head‐mounted displays enable realistic training that surpasses traditional methods of education. However, most applications remain educational, with few clinical studies involving real patients. Challenges include hardware costs, technical setup complexity, data security concerns and lack of standardisation. Conclusions: When thoughtfully implemented, XR has the potential to improve endodontic education, support clinical workflow and enhance the overall practice of endodontics. Coordinated efforts among clinicians, educators, engineers and regulators are needed to validate these technologies, develop practical implementation standards and integrate XR into routine endodontic education and care.

Digital technologies, such as artificial intelligence (AI), virtual reality (VR), and haptic simulation, are rapidly reshaping oral health education. Traditional phantom head and clinic-based teaching remain essential but no longer suffice alone for digital-native learners or for regulators who increasingly view digital competence as mandatory. Post-COVID evidence suggests immersive and hybrid approaches can enhance motivation, deepen learning, support well-being, and strengthen clinical competence when thoughtfully embedded into curricula. Done well, this integration can foster safer, patient-centered digital care. Sustainability concerns around traditional, resource-intensive methods are also growing; digital tools can reduce material waste and resource use, aligning dental education with the United Nations 2030 Agenda for Sustainable Development. However, access to these innovations is uneven, raising concerns about a digital divide in graduate readiness and patient care. Networks such as the American Dental Education Association (ADEA), the Association for Dental Education in Europe (ADEE), the Haptic and AI Digital Education Network for Excellence and Research (HAiDENERS) show how collaboration and benchmarking can democratize advanced simulation. Together with active communication involving global research bodies and industry, these developments enable a hybrid, evidence-informed, and equitable training ecosystem whose ultimate goal is improved, safer, and more predictable oral health care worldwide.

The above article, published eFirst in the European Journal of Dentistry in August 2025 (doi: 10.1055/s-0045-1810611), has been updated to reflect the correct name of its sixth author, David P. Rice. It was previously listed incorrectly as David R. Rice. The article has now been corrected accordingly. Article published online: 23 December 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

This study investigates the bactericidal efficacy and penetration ability inside dentinal tubules of calcium hydroxide (CH) and a modified tri-antibiotic paste (ciprofloxacin, metronidazole, clarithromycin) (TAP) during regenerative endodontic procedures (REPs). The blood clot serving as a biological scaffold was introduced into the root canal to assess its influence on bacterial regrowth. Forty-four human extracted teeth were infected with E. faecalis and divided in four experimental groups (N = 10) with positive and negative controls (N = 4). Samples were treated with either CH or TAP as intracanal dressing. Bacterial viability and depth of penetration were evaluated using confocal laser scanning microscopy (CLSM) after fluorescent vital staining. The same analysis was performed with or without blood clot exposure and the data were analyzed by one-way ANOVA and a post hoc Bonferroni test (p < 0.05). TAP demonstrated significantly stronger bactericidal activity than CH (p = 0.008). However, its efficacy significantly decreased in the presence of blood clot (p = 0.032). CH showed a moderate antibacterial effect, with its efficacy reduced in the presence of blood. Blood clot exposure consistently reduced the bactericidal efficacy in both groups (p = 0.01) and the dye penetration in CH group (p = 0.041). In conclusion, TAP demonstrated superior antibacterial performance compared to CH and blood clot exposure seemed to decrease antimicrobial efficacy and depth of disinfection during REPs.

Background: The integration of artificial intelligence (AI), virtual reality (VR) and haptic technologies is revolutionising dental education, offering transformative opportunities to enhance skill acquisition, ergonomic awareness and student well‐being. These tools offer immersive, repeatable and personalised learning experiences, addressing challenges such as underdeveloped manual dexterity in digitally literate students and post‐COVID disruptions in hands‐on training. Aim: This letter aims to highlight the transformative potential of AI‐driven adaptive feedback paired with VR and haptic simulators in creating risk‐free environments for mastering complex procedures, while advocating for strategies to reduce clinical errors and promote sustainability by minimising reliance on physical resources. Discussion: Despite their potential, barriers such as high costs, resistance to change, logistical complexities and insufficient longitudinal evidence hinder widespread adoption. These challenges perpetuate educational disparities, particularly in low‐resource regions, and necessitate targeted strategies such as cost‐effective models, faculty retraining and international collaboration. The rise of digitally native educators and global initiatives, such as the Digital, VR‐Haptic Thinkers network, signals a shift toward future‐ready curricula that prioritise equity, sustainability and innovation. As mandated by the EU's 2024 directive, digital dentistry knowledge is now a fundamental component of basic dental training. Conclusion: To fully harness these technologies, stakeholders must address evidence gaps, validate cognitive benefits and align curricula with modern learner expectations. This letter calls for urgent collaboration among educators, institutions and industry to overcome barriers, ensuring dental education evolves to meet 21st‐century demands for equitable, high‐quality oral healthcare delivery.

Background/Objectives: The purpose of the study is to determine and compare the accuracy and efficiency of two dynamic navigation systems (DNS)—Navident (ClaroNav, Canada) and X-Guide (Nobel Biocare, Switzerland)—vs. a free-hand (FH) approach in performing endodontic microsurgery (EMS) on human cadavers. Methods: a total of 119 roots of six cadavers were randomly divided into three groups (Navident/X-Guide/FH). The cadavers’ jaws were scanned pre-operatively with computed tomography. The DICOM data were uploaded and digitally managed with software interfaces for registration, calibration, and virtual planning of EMS. Osteotomy was performed under DNS control and using a dental operating microscope (FH control group). Post-operative scans were taken with same settings as preoperative. Accuracy was then determined by comparing pre- and post-scans of coronal and apical linear, angular deviation, angle, length, and depth of apical resection. Efficiency was determined by measuring the procedural time of osteotomy, apicectomy, retro-cavity preparation, the volume of substance, and cortical bone loss, as well as iatrogenic complications. Outcomes were also evaluated in relation to different operators’ skill levels. Descriptive statistics and inferential analyses were conducted using R software (4.2.1). Results: DNS demonstrated better efficiency in osteotomy and apicectomy, second only to FH in substance and cortical bone loss. Both DNS approaches had similar accuracy. Experts were faster and more accurate than non-experts in FH, apart from resection angle, length and depth, and retro-cavity preparation time, for which comparison was not statistically significant. The Navident and X-guide groups had similar trends in increasing efficiency and accuracy of EMS. All complications in the FH group were performed by non-experts. The X-guide group demonstrated fewer complications than the Navident group. Conclusions: Both DNS appear beneficial for EMS in terms of accuracy and efficacy in comparison with FH, also demonstrating the decreasing gap of skill expertise between experts and novice operators. Through convenient use X-guide diminishes the level of iatrogenic complications compared to Navident.

Integrating digital, virtual reality (VR), and haptic technologies into dental education transforms training by fostering immersive, student-centered environments. These tools bridge theoretical knowledge and clinical practice, enhancing psychomotor skills, reducing anxiety, and enabling standardized assessments in risk-free settings. The Digital, VR, and Haptic Thinkers Network drives global collaboration and innovation. Drawing on insights from a 2025 conference at Queen Mary University of London, this commentary explores advancements, challenges, and future directions for VR-haptic integration in dental curricula. Results from global implementations, including improved manual dexterity and procedural precision, as well as enhanced pulpotomy performance, demonstrate a significant educational benefit. In clinical dentistry, VR-haptic simulators enhance patient outcomes by facilitating precise skill development for procedures in restorative dentistry and endodontics, thereby reducing errors in real-world practice. Combining these technologies with traditional methods is proposed to prepare competent, confident dental professionals while addressing educational disparities. Rigorous validation, strategic curriculum integration, and interdisciplinary collaboration are recommended to maximize impact.

Objectives: The primary aim of this randomised clinical trial was to compare the one year clinical and radiographic outcome of mature permanent central incisors with periapical radiolucencies in adolescents after root canal retreatment using two regenerative endodontic procedures (REPs) with revitalization using induced blood clot formation (BC) or platelet-rich fibrin (PRF) evaluated with cone-beam computed tomography (CBCT). The secondary aim was to assess the responses of the teeth to thermal and electric pulp tests. Materials and methods: Fifty-four root filled maxillary central incisors with post-treatment endodontic disease and periapical radiolucencies in 48 adolescents were allocated into two groups (n = 27) using permuted block randomisation. The teeth in one group were root canal retreated with induced BC formation and teeth in the other with PRF. At baseline and at one year, teeth were evaluated clinically and radiographically using periapical radiographs and CBCT scans. Changes in the maximum diameter and volume of the periapical lesions were assessed and pulp sensibility was assessed at one year using thermal and electrical tests. Differences in lesion diameter and volume between the two groups were tested using the Mann–Whitney U test. A linear regression model explored the relationship between independent variables and lesion size. The significant level was set at 5%. Results: Reduction in periapical lesion size in the BC and PRF techniques occurred in 85% and 100% of teeth, respectively, with no significant difference. In the BC group, the mean lesion volume diminished from 0.33 ± 0.18 cm³ to 0.13 ± 0.20 cm³, while the mean volume of lesions in the PRF group decreased from 0.27 ± 0.16 cm³ to 0.04 ± 0.06 cm³ with no significant difference between the groups (P > 0.05). Significantly more teeth responded positively to thermal (P = 0.028) and electric (P = 0.032) tests in the PRF group compared to the BC group. Conclusions: REPs using BC or PRF techniques when retreating root canal-treated mature permanent central incisors in adolescents with apical radiolucencies had comparable clinical and radiographic outcomes one year following treatment associated with significantly more positive responses to thermal and electric pulp tests in the PRF group. Clinical relevance: Retreatment of mature permanent teeth with apical periodontitis using regenerative endodontic procedures (REPs) is a new and promising approach. REPs with platelet-rich fibrin (PRF) and revascularization techniques provided high and comparable clinical and radiographic success rates.