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Suhr Villefrance J, Kirkevang LL, Wenzel A, Væth M, Matzen LH. Long-term prognosis for teeth with external cervical resorption based on periapical images and cone beam CT: A clinical study. Int Endod J 2024. [PMID: 38976489 DOI: 10.1111/iej.14122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/10/2024]
Abstract
AIM To evaluate whether supplemental information from CBCT changed long-term prognosis for teeth with external cervical resorption (ECR) compared to periapical (PA) images. Furthermore, to assess predictive findings in PA images and evaluate which findings in CBCT affected the long-term prognosis of teeth with ECR. METHODOLOGY One hundred and ninty-four patients, mean age 41.2, range 13-81, having 244 teeth with ECR were included. An initial long-term prognosis determined either good or poor was established based on intraoral images. Afterwards, the patients underwent CBCT, and final long-term prognosis was decided. From the PA images and CBCT, ECR using Heithersay's classification system, pulp involvement and extension of ECR was assessed. In CBCT, the number of surface lesion(s) was additionally assessed. Descriptive statistics evaluated changes in long-term prognosis after CBCT. Logistic regression analyses tested if findings in PA images and CBCT affected the long-term prognosis. RESULTS Based on CBCT, out of 244 teeth the long-term prognosis was assessed to be poor for 173 (70.9%) teeth and good for 71 (29.1%) teeth. The long-term prognosis changed in 76 (31.1%) teeth after CBCT; 5 (2.0%) changed from poor to good, and 71 (29%) changed from good to poor long-term prognosis. In 81 (33.2%) teeth the H-class increased, and in 10 (4.1%) teeth the H-class decreased after assessing CBCT. In 70 (28.7%) teeth, there was a change from no pulp involvement to involvement of the pulp after CBCT; eight (3.3%) teeth changed in the opposite direction. H-class 2 and 4 in PA images significantly increased the probability for a change in long-term prognosis compared to an H-class 3 (p < .05). H-class 4, pulp involvement, ECR in the oral 1/3 of the root, and more than two surface lesions seen in CBCT significantly influenced a poor long-term prognosis (p < .05). CONCLUSIONS Supplemental information from CBCT changed long-term prognosis in almost one third of teeth with ECR. In most cases, the long-term prognosis changed from good to poor. H-class 3 in PA images had a significant influence on change in long-term prognosis. Several findings in CBCT influenced a poor long-term prognosis.
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Affiliation(s)
- Julie Suhr Villefrance
- Section for Oral Radiology and Endodontics, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Lise-Lotte Kirkevang
- Section for Oral Radiology and Endodontics, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Ann Wenzel
- Section for Oral Radiology and Endodontics, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Michael Væth
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Louise Hauge Matzen
- Section for Oral Radiology and Endodontics, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
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Thibault É, Dhalla S, Deporter D. Management of cervical external root resorption following connective tissue grafting. Clin Adv Periodontics 2024; 14:90-94. [PMID: 37366238 DOI: 10.1002/cap.10255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/25/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Cervical external root resorption (CERR) is not a common occurrence, but can result in a hopeless tooth prognosis. Its etiology is poorly understood and its management can be challenging. The present case report describes the late presentation and management of CERR at both maxillary first premolar teeth following connective tissue grafting (CTG) procedures including use of citric acid as a chemical root surface conditioner. METHODS AND RESULTS A 55-year-old female was diagnosed with bilateral external cervical root resorption of both maxillary first premolar teeth 28 years after CTG procedures that had included the use of citric acid root conditioning. As both teeth were asymptomatic, the patient opted for repair of the lesions via full-thickness flap elevation, meticulous removal of all granulation tissue, and restoration of the lesions with a resin-modified glass ionomer. A 2-year follow-up has been completed with no significant complications to report. CONCLUSIONS CERR usually develops asymptomatically and is found by chance in radiographs. Its etiology is unclear, but may appear some years after soft tissue grafting to manage gingival recession. Early detection is key to be able to repair the lesions with minimal intervention.
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Affiliation(s)
- Émilie Thibault
- Discipline of Periodontology, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Suraya Dhalla
- Discipline of Periodontology, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Douglas Deporter
- Discipline of Periodontology, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
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Rai A, Koirala B, Dali M, Shrestha S. Delayed replantation of avulsed permanent maxillary central incisor: Case report with 6-year follow-up. Clin Case Rep 2024; 12:e8487. [PMID: 38328488 PMCID: PMC10847390 DOI: 10.1002/ccr3.8487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/10/2024] [Accepted: 01/25/2024] [Indexed: 02/09/2024] Open
Abstract
Replantation should be attempted in any case of avulsion, be it immediate or delayed. Retention of the replanted tooth helps in preservation of adjacent alveolar bone. Despite the occurrence of replacement resorption, the tooth can stay healthy and functional in the arch for a longer duration.
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Affiliation(s)
- Amita Rai
- Department of Pediatric and Preventive DentistryPeople's Dental College and HospitalKathmanduNepal
| | - Bandana Koirala
- Department of Pedodontics and Preventive DentistryCollege of Dental Surgery, B.P. Koirala Institute of Health SciencesDharanNepal
| | - Mamta Dali
- Department of Pedodontics and Preventive DentistryCollege of Dental Surgery, B.P. Koirala Institute of Health SciencesDharanNepal
| | - Sneha Shrestha
- Department of Pedodontics and Preventive DentistryCollege of Dental Surgery, B.P. Koirala Institute of Health SciencesDharanNepal
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Ghabraei S, Bolhari B, Hashemi N, Gharehchahi H. Conservative management of an advanced external cervical resorption with internal approach using bio-ceramic materials: A case report. Clin Case Rep 2024; 12:e8378. [PMID: 38161643 PMCID: PMC10753636 DOI: 10.1002/ccr3.8378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Key clinical message A successful management of an advanced external cervical resorption using a conservative approach with CBCT, dental operating microscope, and a new bio-ceramic material. Abstract External cervical resorption (ECR) is a pathologic condition that is initiated on the external aspect of the root, below the epithelial attachment in the cervical position. This article will report a case of external cervical resorption (ESR) in an advanced stage, which was asymptomatic and was incidentally detected in a follow-up radiograph after the end of orthodontic treatment. Cone-beam computed tomography (CBCT) was prescribed to accurately diagnose the resorptive lesion and differentiate it from internal root resorption (IRR), and the final diagnosis was Heithersay's class IV ECR. Considering the health of the periodontium and the absence of attachment loss, it was decided to use a conservative internal approach to the management of this case. After the treatment, the patient was asymptomatic and the radiographic examinations showed no signs of peri-radicular pathology during the follow-up period. With the correct case selection and the availability of the appropriate materials and equipment such as a dental operating microscope (DOM) and bio-ceramic materials, the internal approach can be a successful and minimally invasive treatment, even for the management of advanced ECR cases.
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Affiliation(s)
- Sholeh Ghabraei
- Department of Endodontics, School of DentistryTehran University of Medical SciencesTehranIran
| | - Behnam Bolhari
- Department of Endodontics, School of DentistryTehran University of Medical SciencesTehranIran
| | - Nasim Hashemi
- Department of Endodontics, School of DentistryTehran University of Medical SciencesTehranIran
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Bardini G, Orrù C, Ideo F, Nagendrababu V, Dummer P, Cotti E. Clinical management of external cervical resorption: A systematic review. AUST ENDOD J 2023; 49:769-787. [PMID: 37702252 DOI: 10.1111/aej.12794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/14/2023]
Abstract
This review investigated whether any therapeutic options influenced the outcome of treatment for teeth with external cervical resorption. Out of 870 articles identified by an electronic search, 60 clinical case reports and six case series were included. No randomised clinical trials were found. Risk of bias was assessed using Joanna Briggs Institute's tools. External surgical intervention was the preferred method of accessing the lesions. Removal of resorptive tissue was most often achieved mechanically. Bioactive endodontic cements were the preferred materials for restoring teeth. The outcome measures were based on clinical and radiographic parameters. Of the cases included in the review, no specific treatment approach had a superior outcome in relation to Heithersay's classification. Furthermore, due to the absence of randomised clinical trials, and the low level of evidence associated with case reports/case series, it was not possible to define the optimum clinical treatment for external cervical resorption.
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Affiliation(s)
- Giulia Bardini
- Department of Conservative Dentistry and Endodontics, University of Cagliari, Cagliari, Italy
| | - Cristiano Orrù
- Department of Conservative Dentistry and Endodontics, University of Cagliari, Cagliari, Italy
| | - Francesca Ideo
- Department of Conservative Dentistry and Endodontics, University of Cagliari, Cagliari, Italy
| | - Venkateshbabu Nagendrababu
- Department of Preventive and Restorative Dentistry, College of Dental Medicine, University of Sharjah, Sharjah, UAE
| | - Paul Dummer
- School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Elisabetta Cotti
- Department of Conservative Dentistry and Endodontics, University of Cagliari, Cagliari, Italy
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Huang J, Walsh RM, Witherspoon DE, Khalighinejad N, Tam EC, Jalali P, He J. The prevalence, characteristics, and risk factors of external cervical resorption: a retrospective practice-based study. Clin Oral Investig 2023; 27:5595-5604. [PMID: 37493728 DOI: 10.1007/s00784-023-05180-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVES External cervical root resorption (ECR) is a poorly understood and aggressive form of resorption. The purpose of this study was to examine the prevalence, characteristics, and risk factors associated with the occurrence of ECR in patients seeking endodontic care from private practice settings. MATERIALS AND METHODS Records of 343 patients with 390 teeth diagnosed with ECR were identified from 3 private endodontic practices from 2008 to 2022. The patients' demographic information, systemic conditions, and dental history were recorded. The characteristics of the cases including Heithersay classification, pulpal and periapical status, and their management were documented. The association between case severity and potential predisposing factors was examined using chi-square analysis. RESULTS The overall prevalence of ECR among patients seeking endodontic care was low (< 1%). However, there was a greater than twofold increase in the pooled prevalence from 2016 to 2021 (0.99%) compared to the data from 2010 to 2015 (0.46%). The most commonly affected teeth were anterior teeth (48.7%). Class II (30.0%) and class III (45.4%) defects were the most often identified. Patients with a history of trauma or orthodontic treatment were significantly more likely to be diagnosed with severe cervical resorption (class III or IV) (p < 0.05). CONCLUSIONS There has been an increase in the prevalence of ECR in patients seeking endodontic care. A history of orthodontic treatment and traumatic dental mechanical injuries may predict the severity of resorption. CLINICAL RELEVANCE The upward trend in the occurrence of ECR warrants close monitoring of the patients at high risk of developing the condition to facilitate early detection and management.
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Affiliation(s)
- Jenny Huang
- Department of Endodontics, Texas A&M University College of Dentistry, 3302 Gaston Ave., Dallas, TX, 75246, USA
| | - Ryan M Walsh
- Department of Endodontics, Texas A&M University College of Dentistry, 3302 Gaston Ave., Dallas, TX, 75246, USA
| | | | | | - Esther C Tam
- Department of Endodontics, Texas A&M University College of Dentistry, 3302 Gaston Ave., Dallas, TX, 75246, USA
| | - Poorya Jalali
- Department of Endodontics, Texas A&M University College of Dentistry, 3302 Gaston Ave., Dallas, TX, 75246, USA
| | - Jianing He
- Department of Endodontics, Texas A&M University College of Dentistry, 3302 Gaston Ave., Dallas, TX, 75246, USA.
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Suhr Villefrance J, Wenzel A, Kirkevang LL, Væth M, Christensen J, Matzen LH. Early detection of external cervical resorption in posterior teeth: a radiographic, cross-sectional study of an adolescent population. Dentomaxillofac Radiol 2023; 52:20220223. [PMID: 36331310 PMCID: PMC9974234 DOI: 10.1259/dmfr.20220223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/15/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To establish the prevalence and severity of external cervical resorption (ECR) in posterior teeth observed in bitewing (BW) radiographs in an epidemiological study of a 17-year-old patient population from community dentistry. Furthermore, to assess the potential predisposing factors for ECR. METHODS Posterior BWs from 5596 patients (2717 females, 2879 males; mean age 17.8 years) were assessed by three observers in order to detect ECR (using Heithersay's classification system, severity classes 1-4). When ECR was suspected, cone beam CT (CBCT) was offered to verify diagnosis. Prevalence was estimated based on ECR suspected in BWs and finally in CBCT. Possible predisposing factors (orthodontic treatment, trauma, and periodontal disease) were recorded and assessed for association with ECR. RESULTS In 41 patients, ECR was suspected in BWs (suspected prevalence 0.73%). 32 patients accepted CBCT examination, of which eight were verified to have ECR (final prevalence 0.18%). In 24 patients, other disease entities and abnormal tooth morphology, that had mimicked ECR in BWs, excluded ECR in CBCT. ECR severity ranged from class 1-3 in BW and 2-4 in CBCT. All but one case had not been diagnosed by the patient's community dentist. No statistically significant association between predisposing factors and ECR was identified. CONCLUSIONS ECR had low prevalence in this adolescent population, as observed in both BWs and CBCT. Still, early detection of ECR is important for treatment prognosis, and attention should be paid to this disease entity when assessing BWs obtained for other diagnostic purposes. CBCT may subsequently aid in verifying the disease.
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Affiliation(s)
- Julie Suhr Villefrance
- Section for Oral Radiology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Ann Wenzel
- Section for Oral Radiology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Lise-Lotte Kirkevang
- Section for Oral Radiology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Michael Væth
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Louise Hauge Matzen
- Section for Oral Radiology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
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Rodríguez Mazón M, Garcia-Font M, Doria G, Durán-Sindreu F, Abella F. Influence of Cone-beam Computed Tomography in clinical decision-making among different specialists in External Cervical Resorption lesions: a before-after study. J Endod 2022; 48:1121-1128. [PMID: 35690274 DOI: 10.1016/j.joen.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/30/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Inadequate management of external cervical resorption (ECR) lesions may impact the treatment outcome. This study aimed to ascertain the influence of cone-beam computed tomography (CBCT) in clinical decision-making choices in cases of ECR among dentistry specialists (endodontics, prosthodontics, oral surgery, periodontics orthodontics, and general dentistry). A secondary objective was to evaluate the self-reported level of difficulty in choosing a treatment plan before and after viewing the CBCT images. METHODS Sixty examiners from different specialties were chosen to evaluate 12 cases of ECR lesions. Each case included clinical photographs, digital periapical (PA) radiographs, and a small-volume CBCT scan. In the first assessment, the examiners were given all the relevant information of each case, except the CBCT scan. Each examiner was asked to select 1 of the proposed treatment options and assess the difficulty of decision making. Four weeks later, the examiners randomly reviewed the same 12 cases with additional information from the CBCT data. RESULTS After the CBCT evaluation, the clinicians changed their treatment plan in 72.2% of the cases (P < .05). The self-reported level of difficulty in choosing a treatment changed in all groups after evaluating the CBCT scans (P< .05). After viewing the CBCT scan, the extraction option increased significantly in all groups (P < .05). CONCLUSIONS CBCT scan had a significant impact on clinical decision-making in cases of ECR evaluated by different specialists.
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Affiliation(s)
- Marta Rodríguez Mazón
- Departments of Endodontics. Universitat International de Catalunya, School of Dentistry, Sant Cugat del Valles, Barcelona, Spain
| | - Marc Garcia-Font
- Departments of Endodontics. Universitat International de Catalunya, School of Dentistry, Sant Cugat del Valles, Barcelona, Spain.
| | - Guillermo Doria
- Departments of Endodontics. Universitat International de Catalunya, School of Dentistry, Sant Cugat del Valles, Barcelona, Spain
| | - Fernando Durán-Sindreu
- Departments of Endodontics. Universitat International de Catalunya, School of Dentistry, Sant Cugat del Valles, Barcelona, Spain
| | - Francesc Abella
- Departments of Endodontics. Universitat International de Catalunya, School of Dentistry, Sant Cugat del Valles, Barcelona, Spain
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Suhr Villefrance J, Kirkevang LL, Wenzel A, Væth M, Matzen LH. Impact of cone beam CT on diagnosis of external cervical resorption: the severity of resorption assessed in periapical radiographs and cone beam CT. A prospective clinical study. Dentomaxillofac Radiol 2022; 51:20210279. [PMID: 34520244 PMCID: PMC8802697 DOI: 10.1259/dmfr.20210279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES To compare the severity of external cervical resorption (ECR) observed in periapical (PA) images and cone beam CT (CBCT) using the Heithersay classification system and pulp involvement; and to assess inter- and intraobserver reproducibility for three observers. METHODS CBCT examination was performed in 245 teeth (in 190 patients, mean age 40 years, range 12-82) with ECR diagnosed in PA images. Three observers scored the severity of ECR using the Heithersay classification system (severity class 1-4) and pulp involvement (yes/no) in both PA images and CBCT. Percentage concordance and κ-statistics described observer variation in PA images and CBCT for both inter- and intraobserver reproducibility. RESULTS For all three observers, the ECR score was the same in the two modalities in more than half of cases (average 59%; obs1: 54%, obs2: 63%, obs3: 61%). However, in 38% (obs1: 44%, obs2: 33%, obs3: 36%) of the cases, the observers scored more severe ECR in CBCT than in PA images (p < 0.001). The ECR score changed to a less severe score in CBCT only in 3% (obs1: 1%, obs2: 4%, obs3: 4%). For pulp involvement, 14% (obs1: 7%, obs2: 20%, obs3: 15%) of the cases changed from "no" in PA images to "yes" in CBCT. In general, κ values were higher for CBCT than for PA images for both the Heithersay classification score and pulp involvement. CONCLUSIONS ECR was generally scored as more severe in CBCT than PA images using the Heithersay classification and also more cases had pulp involvement in CBCT.
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Affiliation(s)
- Julie Suhr Villefrance
- Section for Oral Radiology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Lise-Lotte Kirkevang
- Section for Oral Radiology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Ann Wenzel
- Section for Oral Radiology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Michael Væth
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Louise Hauge Matzen
- Section for Oral Radiology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
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Ferreira MD, Barros-Costa M, Costa FF, Freitas DQ. The prevalence and characteristics of external cervical resorption based on cone-beam computed tomographic imaging: a cross-sectional study. Restor Dent Endod 2022; 47:e39. [DOI: 10.5395/rde.2022.47.e39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/12/2022] [Accepted: 05/10/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Matheus Diniz Ferreira
- Division of Oral Radiology, Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP), Sao Paulo, Brazil
| | - Matheus Barros-Costa
- Division of Oral Radiology, Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP), Sao Paulo, Brazil
| | - Felipe Ferreira Costa
- Department of Oral Diagnosis, São Paulo Dental School, University of São Paulo (USP), São Paulo, Brazil
| | - Deborah Queiroz Freitas
- Division of Oral Radiology, Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP), Sao Paulo, Brazil
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Aminoshariae A, Azarpazhooh A, Diogenes AR, Fouad AF, Glickman GN, Kishen A, Letra AM, Levin L, Roda RS, Setzer FC, Tay FR, Hargreaves KM. Insights into the June 2021 Issue of the JOE. J Endod 2021; 47:849-851. [PMID: 34045041 DOI: 10.1016/j.joen.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Amir Azarpazhooh
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Anibal R Diogenes
- University of Texas Health San Antonio School of Dentistry, San Antonio, Texas
| | - Ashraf F Fouad
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Anil Kishen
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Ariadne M Letra
- University of Texas Health Science Center at Houston School of Dentistry, Houston, Texas
| | | | | | - Frank C Setzer
- University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
| | - Franklin R Tay
- The Dental College of Georgia, Augusta University, Augusta, Georgia
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