Relationship between periapical and periodontal status

Abstract The purpose of the present investigation was to explore possible relationships between clinical periodontal status in periodontally involved teeth with and without endodontic infection. The investigation was conducted as a retrospective study on a consecutive referral population. The periapical conditions in endodontically-involved single-rooted teeth from a selected patient sample were evaluated and correlated to their periodontal status. There was a significant correlation between periapical pathology and vertical bony destructions. An intra-individual comparison between pocket depth in teeth with and without periapical pathology showed that periapical pathology was significantly correlated to an increased pocket depth in the absence of a vertical bony destruction. It was concluded that an endotontic infection, evident as a periapical radiolucency. promotes periodontal pocket-formation on an instrumented marginal root surface and, consequently, should be regarded as a risk factor in periodontitis progression and be given appropriate consideration in periodonlal treatment planning.     

Microorganisms from canals of root-filled teeth with periapical lesions

AIM: The objective of the present study was to identify the microbial flora within root canals of teeth with failed root-canal treatment and to determine the association of the various species with clinical features. METHODOLOGY: Sixty root-filled teeth with persisting periapical lesions were selected for this study. During nonsurgical endodontic re-treatment, the root-filling material was removed and the canals were sampled. Microbial sampling, isolation and species determination were performed using advanced microbiological techniques for anaerobic species. The association of microbiological findings with clinical features was investigated. RESULTS: Microorganisms were recovered from 51 teeth. In most cases, one or two strains per canal were found. Of the microbial species isolated, 57.4% were facultative anaerobic species and 83.3% Gram-positive microorganisms. Enterococcus faecalis was the most frequently recovered bacterial species. Obligate anaerobes accounted for 42.6% of the species and the most frequently isolated genera was Peptostreptococcus. which was associated with clinical symptoms (P < 0.01). Significant associations were also observed between: (a) pain or history of pain and polymicrobial infections or anaerobes (P < 0.05): (b) tenderness to percussion and Prevotella intermedia/P. nigrescens (P < 0.05); (c) sinus and Streptococcus spp. (P < 0.001) or Actinomyces spp. (P < 0.01); (d) coronally unsealed teeth and Streptococcus spp. or Candida spp. (both with P < 0.01). CONCLUSION: The microbial flora in canals after failure of root-canal treatment were limited to a small number of predominantly Gram-positive microbial species. Facultative anaerobes, especially E. faecalis, were the most commonly isolated microorganisms, however, polymicrobial infections and obligate anaerobes were frequently found in canals of symptomatic root-filled teeth.     

Healing of periapical lesions of pulpless teeth after endodontic treatment with controlled asepsis

Abstract Using a careful anaerobic bacteriological technique, bacteria were shown to be eliminated from infected root canals before the endodontic treatment was finished by root filling. Healing of the periapical lesions of the teeth was followed for 2–5 yr. The majority of the 79 lesions healed completely or decreased in size in such a way that they could be expected to heal. In 5 cases there was no or only an insignificant decrease in the size of the lesions. Two of these lesions were shown to contain bacteria of the species Actinomyces or Arachnid. In another case there were dentin chips in the periapical tissue. Periapical lesions which fail to heal in spite of careful bacteriological monitoring of the endodontic treatment may in some cases be due to an establishment of the bacteria outside the root canal in the periapical tissue. In these sites, the bacteria are inaccessible to conventional endodontic treatment.     

Endodontic treatment of teeth associated with a large periapical lesion

AIM: To report the healing of a large periapical lesion following non-surgical root canal treatment. SUMMARY: A 12-year-old male with a large periapical lesion around the apices of his mandibular incisors is described. The lesion formed after trauma to the mandibular anterior teeth 5 years previously. During root canal treatment, chlorhexidine gluconate was used for irrigation, and calcium hydroxide was used both for the intracanal dressing and as a base of the root canal sealer. Periapical healing was observed 3 months after obturation and continued at the 12-month review. Key learning points Root canal treatment, including the use of chlorhexidine gluconate and calcium hydroxide for infection control, led to substantial healing of a large periapical lesion. This report confirms that large periapical lesions can respond favourably to non-surgical treatment.     

Endodontic management of immature teeth with spontaneous apical closure and periapical lesions: case series and review of the literature

Spontaneous apical closure in non‐vital immature teeth has been rarely encountered and outcome of non‐surgical endodontic treatment of related teeth associated with periapical lesions has not yet been adequately elucidated. The aim of this article was to report endodontic management of spontaneous apical closure of infected untreated immature teeth with periapical lesions and to review previously proposed mechanisms for the development of spontaneous hard tissue barrier. Three patients were referred at different time intervals to the endodontic clinic for treatment of their maxillary anterior incisors with acute or chronic apical periodontitis . Dental histories indicated that related teeth had been subjected to trauma approximately 12–18 years previously. Radiographically, the involved teeth exhibited incomplete root formation with spontaneous apical closure and were associated with an apical radiolucency. After biomechanical preparation, calcium hydroxide paste was applied and was changed once or twice within 3 months. All canals were then filled with gutta‐percha and AH Plus and the follow‐up period was 16–50 months; both clinical and radiographic examinations revealed adequate function, the absence of clinical symptoms and significant healing of the periapical radiolucency.     

Periodontal healing of replanted dog teeth stored in Viaspan, milk and Hank's balanced salt solution

Abstract This study examined, histologically, periodontal healing and root resorption of replanted dogs teeth stored in Viaspan for different time periods and compared these healing patterns to those after storage in milk or Hank's balanced salt solution (HBSS). Seventy-two beagle incisors were endodontically treated, extracted, randomly divided and placed in Viaspan or milk for 6, 12, 24 and 36 h, and Viaspan or HBSS for 36, 48, 72 and 96 h, after which they were replanted. Four negative control teeth were immediately replanted while four positive controls were allowed to dry for one hour before replantation. All replanted teeth were splinted for 14 days. Two months after replantation the clogs were killed and the teeth histologically examined for healing of the supporting tissues. For Viaspan neither replacement nor inflammatory root resorption was seen after 6 and 12 h storage. A statistically significant rise in the incidence of replacement resorption was seen at 24, 36 and 48 h which decreased again at 72 and 96 h to levels equal to storage for 6 and 12 h. The occurrence of inflammatory root resorption was low and significantly increased only at 48 h after which it decreased significantly again. Viaspan proved superior to milk as a storage medium. Teeth stored in HBSS showed healing results similar to those stored in Viaspan.     

Endodontic infection and calcium hydroxide-treatment. Effects on periodontal healing in mature and immature replanted monkey teeth

Abstract Large experimental defects with marginal communication, and small isolated experimental defects were created on the root surfaces of extracted monkey lateral incisors with either open or closed apices. The pulp tissue was either infected or removed, and calcium hydroxide placed in the root canal. The teeth were then replanted and the healing pattern evaluated histomorphometrically after 20 weeks. From the results, it was concluded that (1) an intrapulpal infection promotes marginal epithelial down-growth on a denuded dentin surface irrespective of tooth developmental stage, and that (2) the periodontal healing potential after calcium hydroxide-treatment appears to be higher in teeth with open apices compared with teeth with closed apices, where ankylosis was promoted as opposed to teeth with open apices where significantly more reparative cementum was found.     

Periodontal healing of extracted dogs' teeth air-dried for extended periods and soaked in various media

Abstract The aim of this study was to determine the periodontal healing of replanted dogs’ teeth which, after extended extra-oral dry times, had been soaked in various media before replantation. Incisors and premolars of beagle dogs were root canal treated, extracted and bench dried. The teeth were grouped according to dry times of 30, 45 and 60 minutes. Each group of teeth was soaked in one of three media, Hank's balanced salt solution, Via Span (Belzer UW-CSS, Dupont Pharmaceuticals), or Conditioned Medium (supernatant of confluent culture of human gingival fibroblasts) for 30 minutes before replantation. Controls consisted of teeth extracted and replanted without drying or soaking (negative control), and bench-dried teeth replanted without soaking in the media (positive control). The dogs were killed 6 months after replantation of the teeth, which were prepared for histologic evaluation. Five um cross-sections (every 70 Jim) of the root and surrounding tissue were evaluated for healing/resorption according to Andreasen's criteria. The best healing occurred for the roots which had been immediately replanted. Healing in the positive control groups decreased with increased dry time. For the 30–minute dry time groups, soaking in media had no beneficial effect on periodontal healing compared with the controls. Soaking in ViaSpan resulted in an increased healing incidence for both the 45- and 60- minute bench-dried groups while soaking in the other media had no consistent beneficial effect. It appears from this study that an avulsed tooth that has been left dry for 30 minutes should be replanted immediately without soaking. However, teeth that have been dry for 45 or 60 minutes would benefit from soaking for 30 minutes in ViaSpan.     

Influence of residual bacteria on periapical tissue healing after chemomechanical treatment and root filling of experimentally infected monkey teeth

The purpose of this study was twofold: first, to determine the influence on the healing of the periapical tissues when selected bacterial strains and combinations thereof remain after root canal treatment; and, second, the relationship to healing of the quality of the root filling. In eight monkeys, 175 root canals, previously infected with combinations of four or five bacterial strains and with radiographically verified apical periodontitis, were endodontically treated, bacteriologically controlled, and permanently obturated. After 2-2.5 yr, the periapical regions were radiographically and histologically examined. Of these teeth, 48 root canals were also examined for bacteria remaining after removal of the root fillings. When bacteria remained after the endodontic treatment, 79% of the root canals showed non-healed periapical lesions, compared with 28% where no bacteria were found. Combinations of residual bacterial species were more frequently related to non-healed lesions than were single strains. When no bacteria remained, healing occurred independently of the quality of the root filling. In contrast, when bacteria remained, there was a greater correlation with non-healing in poor-quality root fillings than in technically well-performed fillings. In root canals where bacteria were found after removal of the root filling, 97% had not healed, compared with 18% for those root canals with no bacteria detected. The present study demonstrates the importance of obtaining a bacteria-free root canal system before permanent root filling in order to achieve optimal healing conditions for the periapical tissues.     

Periodontal healing after replantation of intentionally rotated teeth with healthy and denuded root surfaces

Abstract – The purpose of the study was to evaluate periodontal healing after replantation of intentionally rotated teeth with healthy and denuded root surfaces. Ten teeth with hopeless prognoses because of extensive alveolar bone loss and deep pockets extending to the apexes only on one or two surfaces, but with a healthy periodontal apparatus on the other surfaces, were selected. A mucogingival flap was elevated and the teeth were extracted carefully so as not to damage the healthy remnant of the periodontal membrane remaining on the root surfaces. Thorough extra‐oral debridement was performed on the contaminated root surface and the remnant was carefully conserved. Retrofilling was also done to eliminate an endodontic cause of attachment loss. The teeth were horizontally rotated and then replanted so that the healthy root would face the connective tissue at the initially periodontally involved sites, and the root planed surfaces, which had been periodontally involved, would face the surfaces of the alveolar sockets at initially healthy sites. The teeth were splinted with adjacent teeth. Clinical parameters and radiographic examination were performed pre‐operatively, and at 3 or 6 months, 1, 2, and 3 years postoperatively. One tooth was extracted 1.5 years postoperatively due to reduced support and the treatment strategy of the patient. The other nine teeth were well maintained without any discomfort for the whole maintenance period of 3 years. In all teeth, areas that previously had no pocketing but were now against denuded root surfaces maintained the previous pocket depth readings. In areas where a deep pocket was present but now had a root surface with healthy periodontium, a distinct decrease of mean pocket depth was observed at the first reexamination 3 months postoperatively. The mean radiographic alveolar bone level increased from 0.3% to 45.3% in 2 years and was thereafter maintained for the entire observation period. Loss of periodontal space and possible root resorption were observed in only one case without other ankylotic symptoms. These results suggest that the healing without ankylosis of an extensive denuded root surface may occur by mechanisms other than the maintenance of a viable periodontal ligament on the root surface.     

Periodontal healing after intentional auto-alloplastic reimplantation of injured immature upper front teeth

BACKGROUND/AIMS: Conventional endodontic treatment results in high complication quota when performed in immature teeth. Intentional reimplantation with extraoral insertion of an endodontic implant (auto-alloplastic reimplantation) is an alternative. METHOD: In a retrospective study, the healing of 40 teeth reimplanted intentionally according to this method in patients aged 7 to 15 years was evaluated. Clinical tests (palpation, percussion sound, periotest values) and radiographical examinations were used to determine the type of periodontal healing (inflammatory resorption/periodontitis apicalis; replacement resorption/ankylosis; normal healing). RESULTS: Mean lifetime of the replanted teeth was 59.2+/-42.5 months, estimated survival time on the basis of the Kaplan-Meier analysis was 99.5 months. 17 teeth (42.5%) were classified as failures, mostly due to inflammatory resorption or periodontitis apicalis. Further investigations demonstrated that success rate and retention period of intentionally replanted teeth depend on the preoperative condition of the pulp. Teeth with preoperative infection suffered frequently from inflammatory resorption or periodontitis apicalis after being replanted (14 of 28 teeth). Estimated survival time according to Kaplan-Meier was 75.5 months. In contrast, inflammations or progressive resorptions were not observed in teeth without preoperative infection of the pulp. All these 12 teeth showed normal periodontal healing and regular tooth mobility. In the absence of any pathology in clinical or radiological findings after an average functional period of 72.3 months, the prognosis can be presumed excellent. Estimated survival time of 148.3 months according to Kaplan-Meier differs significantly from survival time of teeth infected preoperatively. CONCLUSIONS: From the results of this investigation, it may be concluded that an infection of the pulp - due to delay of treatment or attempts at endodontic therapy - should be avoided before intentional replantation of immature front teeth with pulp necrosis. Periodontal healing of the autologous root is not impaired by the insertion of posts made of Al2O3-ceramics or titanium. The inserted posts do not ankylose. Orthodontic movement of auto-alloplastically replanted teeth is possible.     

Effect of immediate calcium hydroxide treatment and permanent root-filling on periodontal healing in contaminated replanted teeth

Abstract – The effect of immediate permanent root-filling and immediate intracanal calcium hydroxide treatment on experimentally contaminated and necrotized periodontal membranes (PDM) in avulsed and subsequently replanted monkey teeth was studied. Almost the entire root surface in the non-endodontically treated control teeth were covered with inflammatory resorp-tion, A significant shift towards ankylosis not associated with root resorption (> 80% of the total root surface area) was noted following calcium hydroxide treatment. About two thirds of the root surfaces from the teeth with permanent root fillings showed surface resorptions or ankylosis preceded by root resorption. The root surface area which would have been covered by inffammatory resorption, unless endodontic treatment had been implemented, were instead predominantly covered by either surface resorption (permanent root filling) or ankylosis (calcium hydroxide treatment), Ankylosis compared with surface resorption may in the long term lead to progressive loss of root substance due to replacement resorption. It was concluded that calcium hydroxide may be an excellent initial intracanal treatment in teeth with healthy PDM, but care should be taken not to risk unnecessary development of ankylosis by prolonged treatment of teeth with compromised PDM.     

Periodontal conditions of teeth adjacent to extraction sites

The purpose of the present clinical study was to evaluate the effect of tooth extractions on the periodontal conditions of adjacent teeth. 40 patients were selected for the study. Prior to the extractions, baseline data of the adjacent teeth were obtained. Plaque (PII) and gingival indices (GI), pocket probing depths and probing attachment levels were scored. In addition, the alveolar bone height was determined radiographically in relation to the CEJ adjacent to the extraction sites. The contralateral side of the jaw, where no tooth had to be removed, was examined as a control. A limited hygienic phase (scaling and root planing of all surfaces examined) was performed immediately prior to the extractions. Using the same parameters, all sites were reexamined 2-4 months and 6-9 months following the extractions. After the hygienic phase, the teeth adjacent to the extraction sites indicated a decrease in the pocket probing depths by 0.5 to 1.5 mm. In shallow pockets (1-3 mm), this decrease was less pronounced than in moderate to deep pockets (4-9 mm), where it was composed of shrinkage of the gingival tissues and gain of probing attachment. The radiographic level of the bony alveolar crest in relation to the CEJ of the adjacent teeth was not altered by the extraction procedure. The oral hygiene performances of the patients were not influenced during the 9-month observation period. Therefore, neither PII nor GI scores showed relevant improvements.(ABSTRACT TRUNCATED AT 250 WORDS)     

Number of teeth, prevalence of caries and periapical lesions in insulin-dependent diabetics

Abstract – Ninety-four long and 86 short duration diabetics and 86 non-diabetics, aged 20–70 yr, participated in the study. The clinical and radiographic examination comprised recordings of the number of teeth, carious lesions, restorations, endodontically treated teeth and periapical lesions. There were no significant differences between long and short duration diabetics and non-diabetics in the number of teeth and the total number of decayed and filled tooth surfaces (DFS %). However, long duration diabetics exhibited more decayed proximal tooth surfaces (D %) than non-diabetics. There were no significant differences between long and short duration diabetics and non-diabetics in the mean number of endodontically treated teeth and periapical lesions. Women with long diabetes duration, however, exhibited more endodontically treated teeth with periapical lesions than women with short diabetes duration and women without diabetes. Long duration diabetics exhibited teeth with periapical lesions to a greater extent than the other groups. On the whole, diabetics and non-diabetics exhibited a similar caries frequency but among the diabetics there was a group of individuals who had more periapical lesions than the non-diabetics.     

Microbial flora of root canal–treated teeth associated with asymptomatic periapical radiolucent lesions

This study aimed to investigate the composition of microflora in endodontically treated teeth associated with asymptomatic periapical lesions in southern Chinese patients. Twenty-four teeth which had received nonsurgical root canal treatment more than 4 years previously, and which presents an acceptable coronal restoration with a periapical radiolucent area, were re-treated nonsurgically. Bacteriological samples were obtained after removal of the old root canal filling. The samples were inoculated on enriched trypticase soy agar and four selective media for incubation at 37 degrees C in both a carbon dioxide-enriched atmosphere and anaerobically. Eighteen teeth that had received gutta-percha root canal fillings were grouped for analysis, 12 (66.7%) of which contained cultivable microorganisms. The total colony forming units per ml of transport medium ranged from 0 to 2.3 x 10(5). The number of bacterial genera recovered ranged between 0 and 6, with facultative gram-positive cocci being the most prevalent group of bacteria isolated. Facultative anaerobic bacteria were present in all, whereas strict anaerobic bacteria were found in 3 out of the 12 teeth with positive growth. The size of the periapical rarefaction did not show any relationship with the quantity of microorganisms recovered. Coagulase-negative staphylococci, streptococci and Pseudomonas aeruginosa were most frequently isolated in this group of patients. The possible origin of these organisms is discussed.     

Periodontal healing and bone regeneration in response to azithromycin

Azithromycin, first synthesized in 1980, is a macrolide antibiotic related to erythromycin. It is widely used by the medical profession as a broad‐spectrum antibiotic in the treatment of pneumonia, urinary tract infections and tonsillitis. In addition to its antibiotic properties, azithromycin has immune‐modulating effects and is used for this reason in the management of cystic fibrosis and chronic obstructive pulmonary diseases. The drug is taken up by neutrophils, macrophages and fibroblasts, and is slowly released by these cells. Three diverse case reports are presented in which a single course of azithromycin (consisting of one 500 mg tablet being taken a day for three days) was prescribed before any periodontal intervention occurred. Azithromycin was the principal mode of treatment of severe chronic and aggressive periodontitis in Cases 1 and 2. Azithromycin, together with monthly subgingival debridement, was the treatment in Case 3 (severe chronic periodontitis in a poorly controlled diabetic complicated by gingival overgrowth related to medication with a calcium channel blocker). Favourable resolution of inflammation, reduction in pocket depths and evidence of bone regeneration were evident, even when no periodontal treatment had occurred. In Case 3, resolution of gingival overgrowth occurred over eight months. The potential implications for periodontal management, understanding of the pathogenesis of periodontal diseases and periodontal research are briefly discussed.     

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.     

Microbial flora of root canal–treated teeth associated with asymptomatic periapical radiolucent lesions

This study aimed to investigate the composition of microflora in endodontically treated teeth associated with asymptomatic periapical lesions in southern Chinese patients. Twenty‐four teeth which had received nonsurgical root canal treatment more than 4 years previously, and which presents an acceptable coronal restoration with a periapical radiolucent area, were re‐treated nonsurgically. Bacteriological samples were obtained after removal of the old root canal filling. The samples were inoculated on enriched trypticase soy agar and four selective media for incubation at 37°C in both a carbon dioxide‐enriched atmosphere and anaerobically. Eighteen teeth that had received gutta‐percha root canal fillings were grouped for analysis, 12 (66.7%) of which contained cultivable microorganisms. The total colony forming units per ml of transport medium ranged from 0 to 2.3×10⁵. The number of bacterial genera recovered ranged between 0 and 6, with facultative gram‐positive cocci being the most prevalent group of bacteria isolated. Facultative anaerobic bacteria were present in all, whereas strict anaerobic bacteria were found in 3 out of the 12 teeth with positive growth. The size of the periapical rarefaction did not show any relationship with the quantity of microorganisms recovered. Coagulase‐negative staphylococci, streptococci and Pseudomonas aeruginosa were most frequently isolated in this group of patients. The possible origin of these organisms is discussed.