The patient reported on in this article is a student in dentistry and his parents are both dentists. They referred their son to a good endodontist, who then referred the case to me. As always, peers are more than welcome in either of my practices, in Rome and London, so when I treated this case, I had three dentists watching me, a future dentist on the chair, placing a great deal of pressure on me.
The 22-year-old male patient had a history of trauma to his maxillary incisors and arrived at my practice with symptoms related to tooth #21. The tooth, opened in an emergency by the patient’s mother, was tender when prodded, with a moderate level of sensitivity on the respective buccal gingiva. Sensitivity tests were negative for the other central incisor (tooth #12 was positive), and a periapical radiograph showed radiolucency in the periapical areas of both of the central incisors. The apices of these teeth were quite wide and the length of teeth appeared to exceed 25 mm.
My treatment plan was as follows: root canal therapy with two apical plugs with a calcium silicate-based bioactive cement. The patient provided his consent for the treatment of the affected tooth and asked to have the other treated in a subsequent visit.
After isolating with a rubber dam, I removed the temporary filling, and then the entire pulp chamber roof with a low-speed round drill. The working length was immediately evaluated using an electronic apex locator and a 31 mm K-type file. The working length was determined to be 28 mm.
As can be seen in the photographs, the canal was actually quite wide, so I decided to only use an irrigating solution and not a shaping instrument. Root canals are usually shaped so that there will be enough space for proper irrigation and a proper shape for obturation. This usually means giving these canals a tapered shape to ensure good control when obturating. With open apices, a conical shape is not needed, and often there is enough space for placing the irrigating solution deep and close to the apex.
Fig. 1: Pre-operative radiograph
Fig. 2: Intraoperative radiograph of apical plug of tooth #21.
Fig. 3: Post-operative radiograph.
Fig.4: EDDY in action.
Fig. 5: Intraoperative radiograph of apical plug of tooth #11 (after 6 months from the first treatment).
Fig. 6: Post-operative radiograph.
Fig. 7: Four months follow-up radiograph.
I decided to use only some syringes containing 5 per cent sodium hypochlorite and EDDY, a sonic tip produced by VDW, for delivery of the cleaning solution and to promote turbulence in the endodontic space and shear stress on the canal walls in order to remove the necrotic tissue faster and more effectively. After a rinse with sodium hypochlorite, the sonic tip was moved to and from the working length of the canal for 30 seconds. This procedure was repeated until the sodium hypochlorite seemed to become ineffective, was clear and had no bubbles. I did not use EDTA, as no debris or smear layer was produced.
I suctioned the sodium hypochlorite, checked the working length with a paper point and then obturated the canal with a of 3 mm in thickness plug of bioactive cement. I then took a radiograph before obturating the rest of the canal with warm gutta-percha. I used a compomer as a temporary filling material.
The symptoms resolved, so I conducted the second treatment only after some months, when the tooth #11 became tender. Tooth #21 had healed. I performed the same procedure and obtained the same outcome (the four-month follow-up radiograph showed healing).
The ultimate reason why root canals fail is bacteria. If our mouths were sterile there would be no decay or infection, and damaged teeth could, in ways, repair themselves. So although we can attribute nearly all root canal failure to the presence of bacteria, I will discuss five common reasons why root canals fail, and why at least four of them are mostly preventable.
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LONDON, England: Although dietary interventions have been associated with reduced systemic inflammation, their relevance to periodontal disease remains unclear. To address this gap, researchers at King’s College London have investigated whether a fasting-mimicking diet can affect clinical parameters and inflammatory biomarkers in patients with periodontitis. The findings point to a possible effect on inflammation after non-surgical periodontal therapy.
Lead author Dr Giuseppe Mainas, a research assistant at King’s College London. (Image: Dr Giuseppe Mainas)
“Over the last decade, increasing evidence has shown that periodontitis is not simply a local oral disease, but a chronic inflammatory condition associated with systemic health. At the same time, fasting-mimicking diets have attracted considerable scientific interest because of their potential effects on inflammation and metabolic regulation. We wanted to investigate whether these benefits could also be observed in periodontal patients undergoing conventional treatment,” lead author Dr Giuseppe Mainas, a research assistant at King’s, told Dental Tribune International.
He added: “Lifestyle interventions represent a potentially accessible approach that could complement existing periodontal therapies. Understanding how nutrition influences periodontal inflammation could open new avenues for more holistic patient management.”
The study was a multicentre feasibility randomised controlled pilot trial involving 27 systemically healthy adults with Stage III–IV periodontitis recruited from university dental clinics across Spain. The participants were divided into two groups: one group followed three five-day cycles of a restrictive, fasting-mimicking diet while the control group maintained their usual diet. The fasting-mimicking diet followed was a short-term, low-calorie dietary regimen designed to reproduce some of the physiological effects of fasting while allowing limited food intake. Blood and crevicular fluid samples, clinical parameters and patient-reported outcomes were assessed over the six-month study period.
The study found that a fasting-mimicking diet was feasible and appeared safe in this patient group as an adjunct to non-surgical periodontal treatment. It also showed a reduction in inflammatory biomarkers, but it did not produce clear improvements in periodontal clinical outcomes compared with the control group.
“Patients undergoing repeated cycles of a fasting-mimicking diet showed changes in both systemic and local inflammatory biomarkers following periodontal treatment. In particular, we observed reductions in selected inflammatory biomarkers together with changes in inflammatory markers detected in crevicular fluid,” Dr Mainas explained.
Senior author Prof. Luigi Nibali, head of the Centre for Host–Microbiome Interactions at King’s College London. (Image: Prof. Luigi Nibali)
Senior author Prof. Luigi Nibali, head of the Centre for Host–Microbiome Interactions at King’s, also highlighted patient adherence as evidence of the intervention’s feasibility: “Patients were able to complete the dietary intervention with very high adherence, suggesting that such an approach can realistically be implemented in a periodontal setting.”
“Our findings suggest that future periodontal care may extend beyond conventional mechanical treatment alone. While professional cleaning and oral hygiene remain the foundation of periodontal therapy, lifestyle interventions such as dietary modification may represent promising adjunctive strategies to support inflammation control. The study also reinforces the concept that oral health and general health are closely interconnected and should not be considered separately,” Dr Mainas noted.
Despite the encouraging findings, the researchers emphasised that the evidence is exploratory and that larger studies are needed to confirm the results. However, Prof. Nibali believes that dentistry could benefit from a more personalised and multidisciplinary approach to periodontal therapy. “Although fasting-mimicking diets are not ready to be routinely prescribed for periodontal patients, this research provides a foundation for future studies investigating how nutritional interventions can be integrated into comprehensive periodontal care,” Prof. Nibali concluded.
The study builds on long-standing research by King’s into the relationship between oral inflammation and wider health. Last year, researchers at King’s reported an association between the Mediterranean diet and less severe periodontal disease.
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The ultimate reason why root canals fail is bacteria. If our mouths were sterile there would be no decay or infection, and damaged teeth could, in ways, repair themselves. So although we can attribute nearly all root canal failure to the presence of bacteria, I will discuss five common reasons why root canals fail, and why at least four of them are mostly preventable.