PurposePainful diabetic neuropathy (PDN) is a variant of diabetic peripheral neuropathy which is highly prevalent and distressing in diabetic patients. Despite its high burden, the optimal treatment of PDN has remained a clinical challenge. To explain the emergence and maintenance of PDN, increasing attention has been focused on dimensions of inflammation and oxidative toxic stress (OTS). Accordingly, the aim of this study was to investigate the effects of oral N-acetylcysteine (NAC), an agent with known anti-oxidant and anti-inflammatory effects, as an adjunct therapy in patients suffering from PDN.Patients and methods113 eligible patients with type 2 diabetes suffering from PDN were randomly assigned to either the pregabalin + placebo or pregabalin + NAC group for 8 weeks (pregabalin at a dose of 150 mg per day, NAC and matched placebo at doses of 600 mg twice a day). Mean pain score was evaluated at baseline, week 1, 2, 4, 6, and 8 of the study based on the mean 24 hr average pain score, using an 11-point numeric rating scale (NRS). As secondary efficacy measures, mean sleep interference score (SIS) resulting from PDN, responder rates, Patient Global Impression of Change (PGIC), Clinical Global Impression of Change (CGIC), and safety were also assessed. Additionally, serum levels of total antioxidant capacity (TAC), total thiol groups (TTG), catalase activity (CAT), glutathione peroxidase (GPx), superoxide dismutase (SOD), nitric oxide (NO), and malondialdehyde (MDA) were assessed at baseline and at the end of the study.ResultsNinety patients completed the eight-week course of the study. The decrease in mean pain scores and mean sleep interference score in pregabalin + NAC group was greater in comparison with pregabalin + placebo group (p value<0.001 in both conditions). Moreover, more responders (defined as ≥50% reduction in mean pain score from baseline to end-point) were observed in the pregabalin + NAC group, in comparison with pregabalin + placebo group (72.1% vs 46.8%). More improvement in PGIC and CGIC from baseline to the end of the study was reported in pregabalin + NAC group. Oral NAC had minimal adverse effects and was well tolerated in almost all patients. Furthermore, in respect to OTS biomarkers, adjuvant NAC significantly decreased serum level of MDA and significantly increased serum levels of SOD, GPx, TAC, and TTG.ConclusionThe pattern of results suggests that compared to placebo and over a time period of 8 weeks, adjuvant NAC is more efficacious in improving neuropathic pain associated with diabetic neuropathy than placebo. Ameliorative effects of NAC on OTS biomarkers demonstrated that NAC may alleviate painful symptoms of diabetic neuropathy, at least in part by its antioxidant effects.

Introduction: During endodontic treatment the variety of mandibular sectorial in the form of an extra lingual (radix entomolaris) or buccal root (radix paramolaris) can often cause difficulties. In other words, awareness and understanding of this unusual root, and its canal morphology, are factors that can affect the outcome of root canal treatment. Case Presentation: A 30-year-old male patient with a history of severe, throbbing, constant pain in the lower mandibular molars was referred to the department of endodontics of Hamedan Dental university. The patient's medical history was noncontributory. The buccal object rule (same-lingual opposite-buccal technique) confirmed the additional root as a distolingual root (radix entomolaris). Following the evaluation of vitality tests, we began endodontic treatment for this patient, after administration of local anesthesia using 2% lidocaine with 1:80,000 epinephrine (Daroupakhsh, Tehran, Iran) and rubber dam isolation. The working length was determined by a Root ZX apex locator (Dentaport ZX, J Morita) and later confirmed by parallel periapical radiograph. Canals were shaped in a crown down fashion with Protaper Nickel Titanium rotary instruments (Dentsply, Maillefer) under copious irrigation with 2.5% sodium hypochlorite and lubrication with RC-Prep. After drying the canals with paper points, the master gutta-percha points were fitted within the canals and confirmation radiography was taken. The root canal system was obturated with the cold lateral compaction technique. Conclusions:This case is about a mandibular molar with radix entomolaris and the radiographic exploration and endodontic order. Clinicians should be aware of these unusual root morphologies in the mandibular molars. The initial diagnosis of a radix entomolaris or paramolaris before root canal treatment is important to facilitate the endodontic procedure.