Apexogenesis after initial root canal treatment of an immature maxillary incisor – a case report

Aim To present a case where a traumatized, immature tooth still showed capacity for continued root development and apexogenesis after root canal treatment was initiated based on an inaccurate pulpal diagnosis. Summary Traumatic dental injuries may result in endodontic complications. Treatment strategies for traumatized, immature teeth should aim at preserving pulp vitality to ensure further root development and tooth maturation. A 9‐year‐old boy, who had suffered a concussion injury to the maxillary anterior teeth, was referred after endodontic treatment was initiated in tooth 21 one week earlier. The tooth had incomplete root length, thin dentinal walls and a wide open apex. The pulp chamber had been accessed, and the pulp canal instrumented to size 100. According to the referral, bleeding from the root made it difficult to fill the root canal with calcium hydroxide. No radiographic signs of apical breakdown were recorded. Based on radiographic and clinical findings, a conservative treatment approach was followed to allow continued root development. Follow‐up with radiographic examination every 3rd month was performed for 15 months. Continued root formation with apical closure was recorded. In the cervical area, a hard tissue barrier developed, which was sealed with white mineral trioxide aggregate (MTA). Bonded composite was used to seal the access cavity. At the final 2 years follow‐up, the tooth showed further root development and was free from symptoms. Key learning points

• ? Endodontic treatment of immature teeth may result in a poor long‐term prognosis.
• ? The pulp of immature teeth has a significant repair potential as long as infection is prevented.
• ? Treatment strategies of traumatized, immature permanent teeth should aim at preserving pulp vitality to secure further root development and tooth maturation.
• ? Radiographic interpretation of the periapical area of immature teeth may be confused by the un‐mineralized radiolucent zone surrounding the dental papilla.

     

The success of endodontic therapy--healing and functionality

Current, relevant knowledge on the outcome of endodontic therapy is key to clinical decision making, particularly when endodontic treatment is weighed against tooth extraction and replacement. Inherent to reviewing the outcome is a definition of "success" in relation to the goals of therapy. As the specific goal set out by the individual patient may either be healing/prevention of disease (apical periodontitis) or just functional retention of the tooth, the potential for both healing and functionality is reviewed. Based on selected follow-up studies that offer the best evidence, the chance of teeth without apical periodontitis to remain free of disease after initial treatment or orthograde retreatment is 92 percent to 98 percent. The chance of teeth with apical periodontitis to completely heal after initial treatment or retreatment is 74 percent to 86 percent, and their chance to be functional over time is 91 percent to 97 percent. Thus there does not appear to be a systematic difference in outcome between initial treatment and orthograde retreatment. The outcome of apical surgery is less consistent than that of the nonsurgical treatment. The chance of teeth with apical periodontitis to completely heal after apical surgery is 37 percent to 85 percent, with a weighted average of approximately 70 percent. However, even with the lower chance of complete healing, the chance for the teeth to be functional over time is 86 percent to 92 percent. Considering the favorable outcome, conservative endodontic therapy, both nonsurgical and surgical, is definitely justified and should be attempted when a good restorative and periodontal prognosis is projected, unless the patient is not motivated to retain the tooth.     

Interaction between endodontics and periodontics

Endodontic–periodontal lesions present challenges to the clinician regarding diagnosis, treatment planning and prognosis. Etiologic factors, such as bacteria and viruses, as well as contributing factors, such as trauma, root resorptions, perforations, cracks and dental malformations, play an important role in the development and progression of such lesions. Treatment and prognosis of endodontic–periodontal lesions vary, depending on the etiology, pathogenesis and correct diagnosis of each specific condition. This chapter will appraise the interrelationship between endodontic and periodontal lesions and provide biological and clinical evidence for diagnosis, prognosis and decision‐making in the treatment of these conditions.     

The endo‐perio lesion: a critical appraisal of the disease condition

Endodontic–periodontal lesions present challenges to the clinician as far as diagnosis and prognosis of the involved teeth are concerned. Etiologic factors such as bacteria, fungi, and viruses as well as various contributing factors such as trauma, root resorptions, perforations, and dental malformations play an important role in the development and progression of such lesions. Treatment and prognosis of endodontic–periodontal diseases vary and depend on the cause and the correct diagnosis of each specific condition. This article will appraise the interrelationship between endodontic and periodontal diseases and provide biological and clinical evidence of significance for diagnosis, prognosis, and decision‐making in the treatment of these conditions.     

Undergraduate education in endodontology at two European dental schools

The aim of this study was to compare the courses in endodontics and to assess the treatment quality in the student clinics in two dental schools, in Malmö, Sweden and Paris, France. A further aim was to improve the curriculum development in Paris 5 and Malmö by testing student exchange programmes. The comparison was based on the guidelines for undergraduate education set up by the European Society of Endodontology (ESE) [Int. Endod. J. 25 (1992) 169] and on the criteria formulated by Qualtrough and Dummer [Int. Endod. J. 30 (1997) 234]. The latter criteria covered the following aspects: educational methods, the timing of endodontic teaching, pre‐clinical practical exercises, student assessment, recommended literature, clinical/practical procedures, the education of the staff and number of students per teacher. The quality guidelines for endodontic treatment set up by the ESE [Int. Endod. J. 27 (1994) 115] were used for the assessment of the quality of the treatment. The following aspects were covered: history, diagnosis and treatment planning, records, infection control, root‐canal treatment, assessment of endodontic treatment. The undergraduate education in endodontics was fundamentally similar in Paris 5 and Malmö. The main differences observed were related to:

• ? Educational methods: In Malmö, problem‐based learning and in Paris 5, traditional.
• ? Assessment of student performance. In Malmö, self‐assessment and in Paris 5, credits for clinical/practical procedures.
• ? Clinical/practical procedures relating to infection control. Aseptic treatment regimens were more meticulously performed in Malmö than in Paris 5.
• ? Assessment (follow‐up) of all endodontic treatments was a routine only in Malmö.

     

影响牙周-牙髓联合病变预后的相关因素研究进展

牙周-牙髓联合病变是牙周炎的伴发病变之一,因其治疗方法复杂,疗程相对较长,预后难以确定,给口腔科医生的临床诊治带来了巨大的挑战。该文对影响牙周-牙髓联合病变预后的相关因素研究进展作一综述。     

Salvaging a tooth with a deep palatogingival groove: an endo-perio treatment--a case report

AIM: To describe the diagnosis and management of tooth 22 with a necrotic pulp and severe periodontal destruction associated with a deep palatogingival groove extending to the root apex. SUMMARY: Palatogingival grooves are uncommon in maxillary lateral incisors, but when present may contribute to the pathogenesis of periodontal and endodontic lesions. In the present case, the prognosis was considered poor, as the patient presented with a deep probing defect, advanced bone loss and grade III mobility of tooth 22. Root canal treatment was performed, followed by periodontal surgery, during which the groove was conditioned and sealed with conventional glass-ionomer cement and the osseous defect filled with indigenously prepared hydroxyapatite. The 18 month post-operative follow up showed substantial resolution of the osseous defect with gain in attachment and decreased tooth mobility. KEY LEARNING POINTS: Teeth with deep palatogingival grooves may be significantly compromised with severe periodontal and periapical bone loss. Following thorough evaluation, the careful application of endodontic and periodontal surgical procedures may restore satisfactory function.     

Recommendations for using regenerative endodontic procedures in permanent immature traumatized teeth

Abstract –  The regeneration of immature permanent teeth following trauma could be beneficial to reduce the risk of fracture and loss of millions of teeth each year. Regenerative endodontic procedures include revascularization, partial pulpotomy, and apexogenesis. Several case reports give these procedures a good prognosis as an alternative to apexification. Care is needed to deliver regenerative endodontic procedures that maintain or restore the vitality of teeth, but which also disinfect and remove necrotic tissues. Regeneration can be accomplished through the activity of the cells from the pulp, periodontium, vascular, and immune system. Most therapies use the host’s own pulp or vascular cells for regeneration, but other types of dental stem cell therapies are under development. There are no standardized treatment protocols for endodontic regeneration. The purpose of this article is to review the recent literature and suggest guidelines for using regenerative endodontic procedures for the treatment of permanent immature traumatized teeth. Recommendations for the selection of regenerative and conventional procedures based on the type of tooth injury, fracture type, presence of necrosis or infection, periodontal status, presence of periapical lesions, stage of tooth development, vitality status, patient age, and patient health status will be reviewed. Because of the lack of long‐term evidence to support the use of regenerative endodontic procedures in traumatized teeth with open apices, revascularization regeneration procedures should only be attempted if the tooth is not suitable for root canal obturation, and after apexogenesis, apexification, or partial pulpotomy treatments have already been attempted and have a poor prognosis.     

Factors Related to the Outcomes of Cracked Teeth after Endodontic Treatment

IntroductionCracked teeth are a common clinical finding; however, their presence renders diagnosis and prognosis unreliable. The purpose of this research was to assess the correlations of multiple factors on the prognosis of cracked teeth that had undergone endodontic treatment.MethodsA total of 3680 patients who received endodontic treatment by an advanced postdoctoral education program in endodontics with follow-up records of at least 1 year were assessed. From this sample, 62 patients met the inclusion criteria and were included in the final analysis. The factors being evaluated included demographics, clinical symptoms and signs, radiographic findings, and restoration type. Statistical analysis was then completed using the chi-square and Fisher exact tests.ResultsThe mean follow-up period was 23.3 months, with an overall tooth success rate of 75.8%. The success rates differed significantly when the patient had an existing preoperative periapical lesion, lacked a proper permanent restoration on the treated tooth, or had a post placed after root canal treatment. Data analysis showed that restoring the tooth after endodontic treatment was the single most important factor for prognosis. In fact, the endodontically treated teeth with definitive full-coverage restorations had a 2-year success rate of 93.6%.ConclusionFull-coverage restorations should be considered an important part of the treatment plan for cracked teeth treated endodontically.     

Extraoral endodontic treatment, odontotomy and intentional replantation of a double maxillary lateral permanent incisor: case report and 6-year follow-up

AIM: To describe combined endodontic, surgical and orthodontic treatment of a maxillary lateral incisor fused with a supernumerary. SUMMARY: Double tooth is a dental irregularity consequent to fusion of two or more teeth or dental gemination. The teeth most commonly involved are deciduous, but in 0.1% of cases permanent teeth are affected, in which case aesthetic, functional and periodontal problems can result. This paper reports a clinical case of a double tooth in the position of the maxillary right lateral permanent incisor. Combined orthodontic, endodontic and surgical treatment (intentional replantation) allowed the tooth to be retained without periodontal compromise and with a positive orthodontic result both immediately and 6 years following intervention. *A conservative approach that addresses periodontal, pulpal and tooth tissues, can result in the retention of a double tooth. *Maintenance of the root and alveolar bone in young adults at least until full skeletal maturation should be the main treatment objective.     

Tooth extraction decision model in periodontitis patients

Objective: The purpose of this study was to build, around several types of input data, a decision analysis model for dental extraction strategy in periodontitis patients. Materials and methods: The decision analysis was based on the following scenario: a fictitious adult chronic periodontitis patient with no chief complaint, being referred to make a decision of extraction on one single tooth presenting a periodontal defect that may affect the decision‐making process. A decision tree was used to identify the treatment options within the next 5 years. Scientific evidences were based on probabilities given by a literature analysis using a systematic approach. Clinical expertize was based on subjective utilities (SUs) assigned by an experts' panel. Expected utilities (EUs) were used to rank the following options: no treatment (EU₁) or periodontal treatment (EU₂); extraction followed by a tooth‐supported fixed partial denture – FPD – (EU₃) or an implant‐supported single crown – ISC – (EU₄). Results: The robustness analysis calculation indicates that the probability of tooth survival needed to be equal to 0.78 in order that the passive option becomes optimal. However, EU₁ was impossible to calculate due to the lack of available probabilities. The EU intervals were 79–96, 86–89 and 94–95 for EU₂, EU₃ and EU₄, respectively. Consequently, the FPD option is dominated by the ISC option, and it is not possible to conclude to a difference between the periodontal and the ISC therapy. Conclusions: Within the limits of this model, tooth extraction followed by FPD is the worst strategy compared with ISC or periodontal therapies. To cite this article:
Popelut A, Rousval B, Fromentin O, Feghali M, Mora F, Bouchard P. Tooth extraction decision model in periodontitis patients.
Clin Oral Impl Res. 21 , 2010; 80–89.     

Single-session treatment of a major complication of dens invaginatus: a case report.

Dens invaginatus is a dental malformation that may give rise to several complications. Caries of the invagination can severely weaken the whole tooth, making it susceptible to fracture. Subgingival fractures are major complications threatening tooth survival and usually require periodontal/orthodontic/prosthetic treatment if long-term viability is to be ensured. This article describes a case of single-session restoration of a fractured invaginated tooth by means of endodontic treatment followed by fragment reattachment.     

儿童全脱出牙外伤的序列治疗

牙全脱出是儿童时期非常严重的牙外伤之一，通常应对其进行序列治疗，包括应急处理、诊间治疗及长期随访。在外伤发生地，将脱出的牙齿即刻再植或正确地保存患牙并及时就诊能够取得较好的预后。因此，相应的科普宣传和指导至关重要。诊间的治疗计划需要考虑牙周、牙髓的处理和辅助性治疗。牙周治疗计划的制定应根据患牙是否已再植、再植操作是否正确、是否有咬合创伤及牙槽骨是否骨折等，采取相应的处理。而牙髓治疗需根据牙根发育程度、离体时间、保存介质等决定治疗方案。对于根尖未闭合的恒牙，需要慎重权衡牙根吸收的风险与牙髓血运重建的可能性。此外，长期的随访、及时处理并发症也是重要的环节。文章就以上内容做一详细阐述，以期为临床诊疗提供参考。     

Immediate self‐replantation of an avulsed permanent mandibular incisor – a case report

Abstract – Background: Approximately 50% of children under the age of 15 years are subjected to various kinds of injuries in the orofacial region. In the permanent dentition, the most severe dental injury affects the surrounding alveolar bone structure and leads to loss of the tooth. The current literature emphasizes that the awareness of appropriate triage procedures following dental trauma is unsatisfactory and that delay in treatment is the single most influential factor affecting prognosis. Results: This case report presents the immediate self‐replantation of a right lateral mandibular incisor of a 12‐year‐old male patient following a traumatic avulsion. The same patient had earlier, aged 10 years, experienced a trauma leading to the loss of all four maxillary incisors. The missing incisors were replaced by a removable acrylic denture. Having the requisite experience from the earlier accident, the child performed on himself an immediate replantation of the tooth at the site of the accident. After avulsion, the tooth was not splinted timely nor was an endodontic procedure carried out and no antibiotics were prescribed. The first dental examination after the trauma was performed 6 months later and since then, radiographic follow‐up has been introduced. One year after the trauma, following the late endodontic treatment performed 6 months after reimplantation, the tooth is asymptomatic and stable. Conclusions: Immediate self‐replantation of an avulsed tooth is the best treatment choice, even without any other proceeding treatment. However, the healing process should be followed up to allow for the treatment of the early signs of pulpal necrosis and/or root resorption.     

Multidisciplinary approach to the rehabilitation of a crown fracture with glass-fibre-reinforced composite: a case report

Traumatic tooth injuries are common in children. When permanent teeth are involved, it can be a challenge to save these teeth. This clinical case study describes the multidisciplinary treatment of a complex crown fracture and luxation of a right maxillary incisor along with esthetic management. After periodontal surgery including guided bone regeneration and endodontic treatment, we used a glass-fibre-reinforced composite post to increase retention and distribute stress along the root. The restoration was completed using composite in an incremental technique. During follow-up appointments, clinical and radiographic examinations revealed no root canal or periodontal problems, suggesting the efficacy of the treatment in retaining the fractured tooth. Periodontal surgery with endodontic treatment is an alternative treatment for severe trauma in permanent teeth.     

Endodontic prognosis assessment

There are several variables which must be considered before initiating endodontic treatment, including assessing the feasibility of endodontic treatment, addressing past, present and future periodontal concerns, determining the restorability of the tooth, and detecting root fractures. If these parameters are not carefully evaluated, then short- or long-term endodontic success may be questionable. Endodontic prognosis assessment is often subjective, based on objective finding, but ultimately determined by the experience of the operator. Although dentists must rely upon evidence-based research to determine the best modality of treatment, good clinical judgment and experience may override the most objective findings. This article discusses the objective and subjective criteria which must be evaluated for determining the potential prognosis of endodontic treatment.     

Different treatment strategies are applied to patients with the same periodontal status in general dentistry

Objective. To analyse how general dental practitioners (GDPs) and dental hygienists judge and plan to treat patients with different periodontal conditions. Materials and methods. Seventy-seven GDPs and 50 dental hygienists in a Swedish county, Halland, participated in a questionnaire study. The response rate was 94%. The questionnaire consisted of four simulated patient cases and an attached answer sheet. The patient cases had different periodontal status, ranging from healthy to moderate bone loss with general inflammation. The clinicians judged the periodontal status as healthy or diseased. If judged as diseased the clinicians suggested a diagnosis, selected treatment options and estimated the number of treatment sessions for each patient case. The clinicians were compared to each other regarding their judgement, as healthy or diseased, diagnostics and treatment. Results. Three out of four patients were judged both as healthy and diseased by different clinicians. If judged as diseased the patients were diagnosed as having gingivitis or periodontitis. Regardless of the clinicians' former judgement and diagnostics there were no differences (p > 0.05) in the selected treatment options but there was a difference (p < 0.05) in the suggested number of treatment sessions. Conclusions. Clinicians' judgement of the same periodontal condition, as healthy or diseased, varies, which partly results in different treatment decisions considering the number of treatment sessions. The suggested number of treatment sessions varied also between clinicians even if they judged and diagnosed the condition likewise. The willingness to treat and suggested treatment options were not influenced by the variation in judgement and diagnostics.     

Squamous cell carcinoma presenting as an endodontic-periodontic lesion

BACKGROUND: Regardless of advances in diagnosis and treatment during the past 40 years, the overall 5-year survival rates for oral and oropharyngeal squamous cancers have only slightly improved and remain around 50%. Thus, the early diagnosis and treatment of carcinoma by health care providers are essential in achieving a good prognosis. We report a case of invasive squamous cell carcinoma that presented as a benign endodontic-periodontic lesion with a 7-mm periodontal pocket on tooth #15 in a 40-year-old, non-smoking woman. The subsequent management of the case is also discussed. The study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000. METHODS: Our patient was seen for a comprehensive periodontal examination including a periodontal charting, occlusal analysis, study casts, electronic pulp test for tooth #15, and complete mouth periapical radiographs. As there was a periapical radiolucency, an endodontic consultation was obtained. A periodontal flap surgical procedure was performed on teeth #13 to #15, and as there was bone erosion into the maxillary sinus, a biopsy of the soft tissue was submitted to the local hospital for histological analysis. RESULTS: The biopsied lesion was diagnosed as invasive, moderately differentiated squamous cell carcinoma with focal spindle and clear cell differentiation (grade II to III of IV). Bone invasion was also identified. The treatment of the carcinoma involved a hemimaxillectomy with the removal of the maxillary left posterior teeth. The patient remained free of tumor for 5 years after the initial presentation. CONCLUSIONS: Patient education and periodic oral cancer examinations by dental professionals are necessary to reduce diagnostic delay and improve prognosis. This case report emphasizes the important role of dental professionals, especially periodontists and endodontists, of being aware that squamous cell carcinoma may manifest itself clinically and/or radiographically as a common periodontal or endodontic lesion.