JOE Review: Covering Early-2026
By Dr. Keriann Jimenez
da Silva-Filho JE, Rodrigues-Lima AC, et al. Cemental Tear: Systematic Review and Thematic Analysis of Clinical and Imaging Features with a Proposed Diagnostic Framework. J Endod, 2026;52,202-211.
Methods: This systematic review and thematic analysis looked at clinical characteristics, diagnosis, management, and outcomes of cemental tears (CT). Electronic databases were searched for published human case reports and case series describing CT. Included studies reported clinical and/or radiographic findings with confirmed diagnoses. Information collected included patient demographics, tooth type, signs and symptoms, imaging characteristics, diagnostic methods, treatment approaches, and clinical outcomes.
Results: Cemental tear was identified as a rare and underdiagnosed condition, most commonly occurring in older patients and affecting posterior teeth. Clinical presentation can mimic vertical root fracture or localized periodontal disease i.e. isolated deep probing depths, sinus tracts, and localized bone loss. Radiographic features were variable and often nonspecific, occasionally showing radiopaque fragments or J-shaped radiolucencies. Definitive diagnosis was frequently delayed and often required surgical exploration for direct visualization of detached cementum. The most common treatment was surgical removal of the cemental fragment with periodontal debridement. Outcomes were generally favorable when the fragment was removed and defects were appropriately managed; however, delayed diagnosis and extensive periodontal destruction were associated with poorer prognosis.
Conclusions: Cemental tear is an underrecognized condition that can mimic vertical root fracture and periodontal lesions, contributing to frequent misdiagnosis. Because clinical and radiographic findings are often inconclusive, surgical exploration may be necessary for definitive diagnosis. Early recognition and removal of the cemental fragment are critical for optimal healing and tooth preservation. Clinicians should include cemental tear in the differential diagnosis of isolated periodontal defects or VRF-like presentations, particularly in older patients.
Methods: Clinical case report/series evaluating the occurrence and management of a separated endodontic instrument that migrated beyond the root canal system. Clinical and radiographic examinations, including CBCT, were used to assess the position of the fragment and its relationship to adjacent anatomical structures, particularly the mandibular canal. Treatment planning focused on diagnosis, risk assessment for neurologic involvement, and selection of an appropriate management strategy. The patient had NSRCT #31 in private practice where an instrument was separated seven years prior and was referred to an endodontic program at a University Hospital (Kanagawa Hospital, Japan) and found that the instrument had migrated out of the tooth and into the mandibular canal. The patient’s medical history was significant for chronic myeloid leukemia. The Semmes-Weinstein monofilament test was used for quantitative sensory.
Results: A separated endodontic instrument in a mandibular molar can migrate into the mandibular canal, posing a risk for neurologic complications. Radiographic evaluation revealed displacement of the fragment beyond the root apex into close proximity or direct involvement with the inferior alveolar nerve. There was a minimal difference in tactile sensitivity according to the Semmes-Weinstein monofilament testing (0.1 g on the affected side vs 0.55 g on the contralateral side), and there were no clinically significant neurological symptoms that developed as a result. Management strategies depend on the location of the fragment and symptoms e.g. monitoring, surgical intervention. Follow-up radiography at 8 years showed continued migration toward the inferior mandibular border without symptom development. This case emphasizes the importance of careful assessment prior to intervention due to the potential for nerve injury.
Conclusion: Separated endodontic instruments may migrate into the mandibular canal and create a risk for neurologic complications. Accurate diagnosis and appropriate imaging is critical for identifying the position of the fragment and guiding treatment decisions. Clinicians should exercise caution and consider proximity to vital structures when determining whether to intervene or monitor. Early recognition and appropriate referral or surgical planning is essential to minimize the risk of permanent nerve injury.
Methods: Clinical study to quantify and compare the density and phenotype of sensory innervation in symptomatic vs asymptomatic apical periodontitis (AP) lesions, and to evaluate the expression of nociceptive voltage-gated Na channels in relation to clinical symptoms. Two soft tissue biopsy samples were collected during endo surgery from patients w/ persistent AP,10 of which were symptomatic and 10 asymptomatic, for a total of 40 biopsy samples. Protein extraction and ELISA were used to quantify β-tubulin III (a neural axon marker), Nav1.8, and Nav1.9, normalized to total protein content. Immunohistochemistry and confocal microscopy were performed to qualitatively assess nerve fiber density and co-localization of nociceptive markers.
Results: Symptomatic AP lesions demonstrated a 6x increase in innervation density compared with asymptomatic lesions. Expression of the nociceptive Na+ channels Nav1.8 and Nav1.9 was significantly higher in symptomatic cases. Immunohistochemical analysis revealed dense networks of nerve fibers in symptomatic lesions, predominantly composed of nociceptive fibers expressing Nav1.8, whereas asymptomatic lesions exhibited sparse innervation. These findings were independent of histopathologic lesion type.
Conclusion: Symptomatic AP is characterized by significantly increased sensory innervation and upregulation of nociceptive Na channels Nav1.8 and Nav1.9. These neural changes likely contribute to pain perception and may explain difficulties in achieving profound LA in symptomatic AP cases.
Dr. Keriann Jimenez is a member of the AAE’s Resident and New Practitioner Committee.