Outcome of one-visit and two-visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation

The choice of one-visit versus two-visit root canal therapy for necrotic teeth with apical periodontitis is a source of current debate. The primary objective of this randomized controlled clinical trial was to compare radiographic evidence of periapical healing after root canal therapy completed in one visit or two visits with an interim calcium hydroxide/chlorhexidine paste dressing. Ninety-seven patients met the inclusion criteria and consented to participate in this study. Patients were randomly assigned to either the one-visit or two-visit group, and root canal therapy was performed with a standardized protocol. Patients in the two-visit group received an intracanal dressing of calcium hydroxide/chlorhexidine paste. Sixty-three patients, 33 in the one-visit group and 30 in the two-visit group, were evaluated at 12 months. The primary outcome measure was change in apical bone density by using the periapical index (PAI). Secondary outcome measures were proportion of teeth healed or improved in each group. Both groups exhibited equally favorable periapical healing at 12 months, with no statistically significant differences between groups.     

Radiographic follow-up of periapical status after endodontic treatment of teeth with and without apical periodontitis

Objectives

The aim was to assess objectively the rate of changes in periapical status after endodontic treatment in relation to preoperative radiographic status (Periapical Index Score, PAI) and to tooth type.

Material and methods

Radiographic data from a total of 1,410 teeth in seven prospective clinical studies was pooled. The periapical status was evaluated blindly using the PAI scoring system. The longest follow-up period was 4 years; intervals between controls varied from 3 months to 1 year.

Results

Teeth with preoperative PAI score 1 maintained excellent periapical health throughout. Teeth with preoperative PAI score 2 showed some impairment in health over the first 6 months, but improved to approach 95 % healthy teeth at 2 years of observation. Teeth with PAI 3–5 at the start showed significant improvement at 3 months; 27 % were considered healthy (PAI 1 or 2) increasing to 41 % after 1 year. Improvement of periapical status was slower in PAI groups 4 and 5 compared with PAI 3 during the first year. After 2 years, improvement continued similarly in all preoperative PAI 3–5 groups of teeth. Upper lateral incisors showed the poorest healing rate.

Conclusions

Healing of pre-existing periapical lesions is most pronounced from 3 months to 2 years. Teeth with initially healthy periapical structures predictably maintain good periapical health. Maxillary teeth, especially lateral incisors, showed poorer healing rates than mandibular teeth.

Clinical relevance

Radiographic healing rates may vary among tooth groups within the dentition. Periapically healthy teeth that are root filled may not need postoperative controls.     

Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms

AIM: The purpose of the present study is to evaluate the healing of periapical lesions of teeth with positive and negative canal cultures at the time of obturation, and to evaluate the periapical healing of teeth treated in one visit (without) or in two visits with an interappointment dressing of calcium hydroxide. METHODOLOGY: Thirty-nine patients received root-canal treatment. In the first visit, teeth were instrumented, and 18 of these teeth were filled (after microbiological sampling) with calcium hydroxide in sterile saline. The other 21 teeth were obturated with gutta-percha and AH-26 sealer after microbiological sampling. Four weeks later, the teeth with calcium hydroxide were accessed again and after microbiological sampling they were obturated with gutta-percha and AH-26 sealer. Healing of periapical radiolucency was recorded over a period up to 4.5 years. RESULTS: In both the treatment groups, the size of the periapical lesions reduced significantly during the follow-up period. Complete radiographic healing was observed in 81% of the cases in the one-visit group, and in 71% of the cases in the two-visit group. The probability of success increased continuously over time for both treatment groups. Seven out of eight cases (87.5%) that showed a positive root-canal culture at the time of obturation healed. The number of colony forming units (CFU) in six out of eight positive canals was <10(2) CFU mL(-1). CONCLUSIONS: Within the limitations of this study, no significant differences in healing of periapical radiolucency was observed between teeth that were treated in one visit (without) and two visits with inclusion of calcium hydroxide for 4 weeks. The presence of a positive bacterial culture (CFU<10(2)) at the time of filling did not influence the outcome of treatment.     

Mineral Trioxide Aggregate as Apical Plug in Teeth with Necrotic Pulp and Immature Apices: A 10-year Case Series

Introduction

This 10-year study evaluated the clinical and radiologic outcomes of teeth with necrotic pulp, immature apices, and periapical lesions treated with the mineral trioxide aggregate (MTA) apical plug technique.

Methods

Seventeen single-rooted immature teeth with necrotic pulp and periapical lesion from 17 patients treated between January 2001 and December 2001 were included in this study. Apical obturation on all teeth included in the study was completed in 2 visits: first using calcium hydroxide as an interappointment intracanal medication and a second visit for the creation of the artificial apical barrier with MTA. The outcome, based on clinical and radiographic criteria, was assessed by 2 calibrated investigators using the periapical index (PAI). The Friedman test was used to verify the differences between baseline and the 1-, 5-, and 10-year PAI scores.

Results

Of the 17 patients treated, 1 patient dropped out at 5 years. At the 10-year follow-up, 15 teeth were healed (PAI ≤2), and 1 tooth had been extracted because of the presence of a longitudinal root fracture. The PAI score exhibited a significant decrease between baseline and 1 year and between 1 and 5 years. The difference between 5 and 10 years was not significant.

Conclusions

The apical plug with MTA was a successful and effective technique for long-term management of this group of teeth with necrotic pulps with immature root development and periapical lesions.     

Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: a clinical review

AIM: To evaluate clinically and radiographically the long-term clinical outcome of nonsurgical root canal treatment using calcium hydroxide in teeth with large cyst-like periapical lesions. SUMMARY: A total of 42 mature anterior teeth with large periapical lesions ranging in size from 7 to 18 mm in diameter were included in this study. Fluid samples from the lesions contained cholesterol crystals, which were identified by light microscopy. After adequate draining, the teeth were treated endodontically using calcium hydroxide as the intracanal medicament. All cases were followed up for a period of 2-10 years. Complete healing was observed in 73.8% and incomplete healing in a further 9.5% of cases. KEY LEARNING POINTS: Root canal treatment using calcium hydroxide as an antibacterial dressing was successful in healing large cyst-like periapical lesions. This study suggests that the size of a periapical lesion is not a major determining factor in the decision to perform conventional root canal treatment or surgical removal of the lesion. Even large cyst-like periapical lesions containing cholesterol crystals can heal following nonsurgical root canal treatment.     

Clinical efficacy of treatment procedures in endodontic infection control and one year follow-up of periapical healing

The objective was to evaluate the clinical efficacy of chemomechanical preparation of the root canals with sodium hypochlorite and interappointment medication with calcium hydroxide in the control of root canal infection and healing of periapical lesions. Fifty teeth diagnosed with chronic apical periodontitis were randomly allocated to one of three treatments: Single visit (SV group, n = 20), calcium hydroxide for one week (CH group n = 18), or leaving the canal empty but sealed for one week (EC group, n = 12). Microbiological samples were taken to monitor the infection during treatment. Periapical healing was controlled radiographically following the change in the periapical index at 52 wk and analyzed using one-way ANOVA. All cases showed microbiological growth in the beginning of the treatment. After mechanical preparation and irrigation with sodium hypochlorite in the first appointment, 20 to 33% of the cases showed growth. At the second appointment 33% of the cases in the CH group revealed bacteria, whereas the EC group showed remarkably more culture positive cases (67%). Sodium hypochlorite was effective also at the second appointment and only two teeth remained culture positive. Only minor differences in periapical healing were observed between the treatment groups. However, bacterial growth at the second appointment had a significant negative impact on healing of the periapical lesion (p < 0.01). The present study indicates good clinical efficacy of sodium hypochlorite irrigation in the control of root canal infection. Calcium hydroxide dressing between the appointments did not show the expected effect in disinfection the root canal system and treatment outcome, indicating the need to develop more efficient inter-appointment dressings.     

Evaluation of periapical lesion healing by correction of gray values

The purpose of this study was to compare two methods for evaluating periapical healing in humans: the periapical index (PAI) and a gray value correction method. Fifty human teeth with a periapical lesion were endodontically treated. Radiographs, with a special aluminum device, were taken postoperatively, after 3 months and after 6 months. The PAI was recorded at each period of time, and a Kruskall and Wallis test was performed to compare the three groups. After scanning, the size of the lesion and its gray value were recorded. The aluminum device allowed the gray values to be equalized. An analysis of variance followed by a Duncan test was performed to compare the three groups. The teeth that showed no sign of healing according to the PAI were separately analyzed by an analysis of variance and a Duncan test. The PAI (n = 50) showed signs of periapical healing over time (p < 0.01). The analysis of variance, based on gray value evaluation (n = 50), also showed signs of periapical healing over time (p < 0.002). The analysis of variance of teeth with the same PAI over time (n = 15 at 3 months, and n = 5 at 6 months), based on gray value evaluation showed statistically significant differences among the 3 groups (p < 0.02). These results show that the gray level correction method is powerful and may reduce the risks of false negative responses during assessment of treatment results or epidemiological studies.     

Endodontic treatment of teeth with apical periodontitis using calcium hydroide: a long-term study

Abstract The aim of this study was to evaluate clinically and radiographically the long-term results of endodontic therapy. A total of 172 mature teeth with periapical radiolucencies with and without symptoms were treated endoclontically using calcium hydroxide paste as the intracanal medicament and a calcium hydroxide containing root canal sealer. In 58 teeth, the dressing-was accidentally or intentionally extruded into the lesions. All cases were followed up for a period of 2–5 years. The teeth in which the dressing was extruded did not show a different healing pattern from the ones treated conventionally. The complete healing rate for all cases was 80.8% while incomplete healing had taken place in 7.6% of the cases.     

The Dynamics of Periapical Lesions in Endodontically Treated Teeth That Are Left without Intervention: A Longitudinal Study

Introduction

The long-term dynamics of periapical lesions in endodontically treated teeth is not fully elucidated, thus presenting a clinical dilemma regarding the need for an intervention. The aim of the study was to retrospectively evaluate the long-term dynamics of periapical lesions that were left without intervention in endodontically treated teeth.

Methods

Periapical status surveys of patients treated in a public dental clinic were retrospectively evaluated for the presence of periapical lesions in endodontically treated coronally restored teeth. The dynamics of the included periapical lesions was evaluated based on the periapical index (PAI) score changes between 2 consecutive periapical surveys of at least a 4-year interval. The influence of various factors on lesion dynamics was statistically evaluated.

Results

The study cohort consisted of 74 patients with a total of 200 endodontically treated teeth having periapical lesions that fulfilled the inclusion criteria. Fifty-seven (28.5%) lesions remained unchanged, 103 (51.5%) lesions worsened (PAI score increased), and 40 (20%) lesions improved (PAI score decreased). Poor root canal filling and poor restoration were found to adversely affect the long-term dynamics of the periapical lesions (P < .05). Age, sex, and the presence of a post had no statistically significant influence on lesion dynamics (P > .05).

Conclusions

Poor root canal filling and poor restoration may adversely affect the long-term dynamics of periapical lesions that are left without intervention in endodontically treated teeth. Therefore, in cases of poor root canal filling or poor restoration, further intervention may be indicated.     

地塞米松-氢氧化钙糊剂用于根管封药的临床研究

目的 观察地塞米松-氢氧化钙糊剂应用于根管封药的临床疗效。方法 选择240例根尖周炎病例，随机分观察组(地塞米松-氢氧化钙糊剂组)对照组(甲醛甲酚组)各120例，观察封药一周后的临床疗效。结果 两组效果有显著差异，地塞米松-氢氧化钙糊剂根管封药显效率(90．8％)优于甲醛甲酚根管封药(66．7％)。结论 地塞米松-氢氧化钙糊剂应用于根管封药能有效预防和降低根管治疗期间疼痛和水肿的发生。     

Effect of QMix as final irrigation protocol on periapical healing after single-visit root canal treatment: A randomised controlled clinical trial

The aim of this study was to evaluate radiographic periapical repair after endodontic treatment using QMix or NaOCl irrigation in single-rooted teeth with apical periodontitis. In this randomised clinical trial, 60 patients were selected and randomised into two groups (n = 30). After instrumentation of root canals, QMix or NaOCl was used as a final irrigation and the canals obturated with gutta-percha and AH Plus sealer. All the participants were recalled after 12 months and 15 patients were lost to the study so 45 patients were evaluated radiographically according to periapical index (PAI) scores. A significant decrease was seen in PAI scores after 1 year in all patients (p < 0.001). In the QMix and NaOCl group, absence or reduction of radiolucency was observed in 23 of 25 teeth (92%) and 20 of 20 teeth (100%), respectively. There was no significant difference between two groups according to the decrease in PAI score (p = 0.508). Root canal treatments with or without QMix irrigation contributed equally to periapical healing.     

Healing of apical periodontitis after endodontic treatment: a comparison between a silicone-based and a zinc oxide-eugenol-based sealer

AIM: To assess the treatment results up to 1 year after endodontic treatment of apical periodontitis using a silicone-based sealer in comparison with Grossman's sealer, and to compare the results at 3 months after treatment with the 12-month follow-up to assess the prognostic value of a 3-month control. METHODOLOGY: A total of 199 teeth were treated at three centres. The sealer was randomly chosen at the time of filling. Treatment results were evaluated clinically and radiographically 3 and 12 months after root-canal filling. The periapical status was evaluated using the periapical index (PAI). RESULTS AND CONCLUSIONS: Average PAI scores decreased from 3.43 at start to 2.21 at 12 months for Grossman's sealer and from 3.40 to 2.26 for the silicon-based material. No significant difference between the groups at start or any of the follow ups was seen. The 3-month control was adequate in establishing significant healing in both groups. The improvement of the periapical condition continued at the 12-month examination.     

氢氧化钙应用于根管封药的临床研究

目的：观察氢氧化钙甘油糊剂用于根管封药的临床疗效。方法：选择244例慢性根尖周炎病例，随机分观察组（氢氧化钙甘油糊剂组）124例、 对照组（甲醛甲酚组）120例，观察封药一周后的临床疗效和细菌培养结果。结果：两组的临床效果有显著差异（P＜0．01）。Ca(OH2)组67．7％一次封药后即可行根管充填，FC组为40％，Ca(OH2)组治疗期间未产生疼痛，FC组则有8．3％产生疼痛，平均封药次数Ca(OH2)组1．38次，FC组1．76次，细菌培养结果与此呈正相关。结论：氢氧化钙甘油糊剂在杀灭微生物、减少治疗期间疼痛和 减低对根尖周组织和刺激性方面效果优良。     

The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study

AIM: To assess the outcome of apexification using mineral trioxide aggregate (MTA). METHODOLOGY: Fifty-seven teeth with open apices on 50 patients referred for root canal treatment received an apexification procedure in one appointment with MTA by the same operator. Patients were recalled at 6 months, 12 months and every year thereafter. Blind to the treatment record, two examiners assessed the pre-treatment, post-treatment and control radiographs of the study patients in a dark room using a magnifier. Each apex visible on the radiographs was scored with the periapical index (PAI), and the size of the apical lesion was measured. The presence of an apical bridge was also noted. Kappa-Cohen test was used for examiners calibration. The paired t-test was used for statistical analysis of apical healing. RESULTS: Forty-three cases were included with at least 12 months follow-up. When considering the PAI score and the decrease in size of the apical lesion, healing occurred in 81% of cases. CONCLUSION: Apexification in one step using an apical plug of MTA can be considered a predictable treatment, and may be an alternative to the use of calcium hydroxide.     

USAGE OF CHLORHEXIDINE AS A FINAL IRRIGANT IN ONE-VISIT ROOT CANAL TREATMENT IN COMPARISON WITH CONVENTIONAL TWO-VISIT ROOT CANAL TREATMENT IN MANDIBULAR MOLARS: A RANDOMIZED CLINICAL TRIAL

ObjectivesThe effectiveness of 1-visit root canal treatment (RCT), especially for teeth with large periapical lesions, are still being debated. Although, the use of chlorhexidine (CHX) as a final irrigant have been recommended to provide an optimized approach in 1-visit RCT, there is limited knowledge about the outcome of 1-visit RCT using CHX as the final irrigant.AimThe aim of this randomized clinical trial was to evaluate the healing of mandibular molar teeth with large periapical lesions after RCT that was completed in 1 visit using 2% CHX as a final irrigant, comparing the results with a conventional 2-visit RCT as a control group.MethodologyThis study is a prospective, parallel-designed, and single-blinded randomized clinical trial. One-hundred asymptomatic mandibular molar teeth with large periapical lesions were randomly assigned to 2 groups. All teeth were instrumented with Reciproc files with 2.5% sodium hypochloride (NaOCl) and 5% ethylenediaminetetraacetic acid (EDTA) as irrigants. In the intervention group, half of the teeth were treated in 1 visit, receiving an additional final rinse with 2% CHX before obturation; the other half of the teeth, however, were treated in 2 visits with calcium hydroxide (CH) dressings, in the control group. All root canals were obturated with Reciproc gutta-percha cones and AH Plus root canal sealer. All patients were recalled and investigated clinically and radiographically for 48 months. Periapical healing was evaluated statistically using the Mann-Whitney U test, followed by the Friedman and the Wilcoxon tests (α = 0.05).ResultsDuring the 48-month follow-up process, 86 teeth (44 in 1-visit and 42 in 2-visit group) were examined. There were no significant differences between the 2 groups regarding the radiographic healing rates (1-visit group 91% and 2-visit group 88%) (P > .05).ConclusionIn this study, 1-visit RCT using 2% CHX as final irrigant in asymptomatic mandibular molars with large periapical lesions produced favorable healing results, similar to 2-visit root canal treatment with calcium hydroxide.     

Vitapex治疗根尖囊肿的临床疗效分析

目的:比较Vitapex糊剂作为根管消毒药物治疗较大根尖囊肿的临床疗效。方法:将临床诊断为根尖囊肿的52例患牙随机分为两组,每组26例,以氢氧化钙糊剂为对照组,根管内封氢氧化钙1周后即AH-plus糊剂和牙胶尖充填,6个月和12个月复诊。Vitapex糊剂为实验组,根管内封Vitapex 6个月,复诊时再以AH-plus糊剂牙胶尖充填,继续观察6个月,即12个月时复诊。比较6个月复诊及12个月复诊时实验组及对照组的治疗效果。结果:6个月复诊时,氢氧化钙组的成功率为73.1%,Vitapex组的成功率为76.9%。两组间无显著性差异。12个月复诊时,氢氧化钙组的成功率为69.2%,Vitapex组的成功率为92.3%,两组间有显著性差异。结论:根尖囊肿采取Vitapex多次封药,可以促进根尖病变愈合,提高疗效。     

Long-term outcome of primary non-surgical root canal treatment

Aim

The aim of this study is to examine the survival distributions of primary root canal treatment using interval-censored data and to assess the factors affecting the outcome of primary root canal treatment, in terms of periapical healing and tooth survival.

Materials and methods

About one tenth of primary root canal treatment performed between January 1981 and December 1994 in a dental teaching hospital were systematically sampled for inclusion in this study. Information about the patients' personal particulars, medical history, pre-operative status, treatment details, and previous review status of the treated teeth, were obtained from dental records. Patients were recalled for examination clinically and radiographically. Treatment outcomes were categorized according to the status for periapical healing and tooth survival. The event time was interval-censored and subjected to survival analysis using the Weibull accelerated failure time model.

Results

A total of 889 teeth were suitable for analysis. Survival curves of both outcome measures (periapical healing and tooth survival) declined in a non-linear fashion with time. Median survival of the treated teeth was 119?months (periapical healing) and 252?months (tooth survival). Age, tooth type, pre-operative periapical status, occlusion, type of final restoration, and condition of the tooth/restoration margin were significant factors affecting both periapical healing and tooth survival. Apical extent and homogeneity of root canal fillings had a significant impact towards periapical healing (p?<?0.05), but not tooth survival.

Conclusion

The longevity of treated teeth based on tooth survival was considerably greater than that of periapical healing. Both outcome measures were affected by a number of socio-demographic, pre-, intra-, and post-operative factors.

Clinical relevance

Root canal-treated teeth may continue to function for a considerable period of time even though there may be radiographic periapical lesion present. Decision for extraction may be due to reasons other than a failure of the periapical tissues to heal.     

Leaving the pulp chamber open for drainage has no effect on the complications of root canal therapy.

In this retrospective study the effects of different kinds of emergency treatments on flare-ups and other complications were examined. A total of 197 teeth received emergency treatment after diagnosis at the beginning of the root canal therapy; in 103 the pulp chamber was left open for drainage of pus, 35 were treated with dexamethasone sodium phosphate, and 59 with various other medicaments, followed by routine root canal treatment. In all, 404 teeth received root canal treatment without emergency treatment. If symptoms occurred during treatment, flare-up was said to be present. If a periapical radiolucency was found, long-term calcium hydroxide treatment was used: no sign of periapical healing radiographically after 6 months was described as a complication. The percentage of teeth with no complications varied from 72.2% (dexamethasone) to 78.9% (other modification) and the results showed no differences between the groups in the teeth with no complications, flare-ups or other complications. The number of bacteria detected with Gram's staining was higher in the teeth which were left open. In conclusion, leaving the pulp chamber open for drainage had no effect on the incidence of flare-ups or other complications.     

Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions

AIM: This prospective clinical study explored the influence of calcium hydroxide as an interappointment dressing on the healing of periapical lesions associated with pulpless teeth that had not been endodontically treated previously. This was achieved by comparing the prognosis after a two-visit root canal treatment with that following a one-visit treatment. METHODOLOGY: Seventy-three patients were recruited having one tooth with an endodontically induced lesion. Of these patients, 67 could be re-examined. Calcium hydroxide was placed in the instrumented root canals of 31 teeth for at least one week and the treatment finished at the second visit. Thirty-six teeth were root canal treated at one visit. The criteria for success were the absence of signs and symptoms indicating an acute phase of periapical periodontitis and radiographically a periodontal ligament space of normal width. Methods for event time analysis were used to evaluate and compare the prognosis of both treatment approaches. RESULTS: The probability that complete periapical healing will take place increased continuously with the length of the observation period. In both treatment groups the likelihood that the root canal treatment yields a success within an observation time of five years exceeded 90%. A statistically significant difference between the two treatment groups could not be detected. CONCLUSIONS: From a microbiological perspective, one-visit root canal treatment created favourable environmental conditions for periapical repair similar to the two-visit therapy when calcium hydroxide was used as antimicrobial dressing. One-visit root canal treatment is an acceptable alternative to two-visit treatment for pulpless teeth associated with an endodontically induced lesion.     

Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta-percha. A retrospective clinical study.

A material of 885 luxated, non-vital incisors was evaluated radiographically with respect to healing of periodontal tissues including inflammatory root resorption and occurrence of ankylosis and cervical root fractures. The results were assessed after completion of calcium hydroxide treatment and 4 years after filling of the root canal with gutta-percha. After treatment with calcium hydroxide, periapical healing occurred in 95% of the teeth. Four years after filling with gutta-percha, periapical healing was present in 91% of the teeth. In the remaining teeth, recurrent or persistent periapical radiolucency was more frequent in overfilled than adequately filled teeth (P = 0.0001). There was no difference between immature and mature teeth. Inflammatory root resorption healed in 192 of 197 teeth (97%); in 5 teeth it developed into ankylosis. Ankylosis occurred in 13 teeth, all of which were intruded into the alveolar bone at the time of injury. The frequency of cervical root fractures was markedly higher in immature than mature teeth (P greater than 0.0001). Among immature teeth, the frequency of fractures was dependent on the stage of root development (chi 2 = 31.6) and ranged from 77% in teeth with the least to 28% in teeth with the most developed roots. The frequency of fractures was also related to the defects after healing of inflammatory root resorption in the cervical area of the root, significant at P less than 0.0001.