Guided endodontic access of severe calcified tooth without incisal edge ­ case report / Acesso endodôntico guiado de dente calcificado severamente sem borda incisal ­ relato de caso

Pulp tissue may suffer calcification because of trauma, operative procedures or carious lesions. This paper aimed to report and discuss the guided endodontic access as an alternative treatment. A 52 years old female patient had severe root canal calcification of tooth #11 associated with a radiolucent periapical lesion. Firstly, the crown and metal post and core were removed. A digital impression and cone-beam computed tomography "CBCT" scans were performed and imported to implant planning software (SimPlant Version 11; Materialise Dental, Leuven, Belgium).The guided endodontic access template was designed to allow the drill to reach a distance of 2 mm short of the apical foramen, once printed, it was tested in the mouth to evaluate its insertion and stability in the dental arch. The calcified root canal was penetrated using the access drill rotating by a low-speed hand-piece (10,000 rpm) under saline solution irrigation through advancing movements. Then, the apical foramen was negotiated with C-Pilot files #10 and #15. The working length was measured using the iPex-II apex locator. The instrumentation was carried out with Reciproc R50 and 2.5% sodium hypochlorite. One week later, a full-ceramic crown preparation was performed, and polyvinyl siloxane impression was carried out. A total of three follow-up sessions were performed after one week, one and twelve months. Bone neoformation was observed in the site of the periapical lesion and the patient had no signs or symptoms of any discomfort. Therefore, guided endodontics is indicated for severe calcified root canals.(AU)

O tecido pulpar pode sofrer calcificação por trauma, procedimentos cirúrgicos ou como resposta a lesões cariosas. Este trabalho teve como objetivo relatar e discutir o acesso endodôntico guiado como opção de tratamento. Paciente do sexo feminino, 52 anos, com calcificação severa do canal radicular do dente 11 associada a lesão periapical radiolucida. Na primeira intervenção clínica, a coroa e o pino de metal foram removidos. Uma impressão digital e imagens de CBCT foram realizadas e importadas para o software de planejamento de implante (SimPlant Versão 11; Materialize Dental, Leuven, Bélgica) tentando projetar um modelo de acesso endodôntico guiado para permitir que a broca alcance uma distância de 2 mm antes do forame apical, uma vez impresso, foi testado na boca para avaliar sua inserção e estabilidade na arcada dentária. O canal radicular calcificado foi penetrado com broca de acesso girando por peça de mão de baixa velocidade (10.000 rpm) sob irrigação com solução salina por meio de movimentos de avanço. Em seguida, o forame apical foi negociado com as limas C-Pilot nº 10 e nº 15. O comprimento de trabalho foi determinado usando o localizador de ápice iPex-II. A instrumentação foi realizada com Reciproc R50 e hipoclorito de sódio 2,5%. Uma semana depois, foi realizado o preparo da coroa total em cerâmica e a moldagem com polivinilsiloxano. Um total de três sessões de acompanhamento foram realizadas após uma semana, um e doze meses. A neoformação óssea foi observada no local da lesão periapical e a paciente não apresentava sinais ou sintomas de qualquer desconforto. Portanto, o acesso endodôntico guiado é indicado para canais radiculares calcificados severamente.(AU)

Primary versus post-treatment apical periodontitis: microbial composition, lipopolysaccharides and lipoteichoic acid levels, signs and symptoms.

OBJECTIVES: To compare the microbial load and composition and to determine the lipopolysaccharides (LPS) and lipoteichoic acid (LTA) concentrations found in primary apical periodontitis (PAP) and post-treatment apical periodontitis (PTAP), correlating these findings with clinical/tomographic features. MATERIAL AND METHODS: Sixty patients with PAP (31) and PTAP (29) were submitted to clinical and tomographic assessment. Samples were collected from each root canal using paper points for microbiological assessment (culture technique and Checkerboard DNA-DNA hybridization) and determination of LPS and LTA levels (limulus amebocyte lysate and enzyme-linked immunosorbent assays, respectively). Data were correlated with clinical/tomographic findings and statistically analyzed using the Mann-Whitney and Pearson correlation tests (α = 5%). RESULTS: A higher number of cultivable bacteria and LPS were found in PAP (p < 0.05). The median number of species per root canal found in PAP and PTAP was 9 and 22, respectively (p < 0.05). LPS was positively correlated with a larger periapical lesion volume (p < .05). LTA levels were similar in both infections and had no correlation with signs and symptoms. In PAP, gram-positive bacteria were correlated with spontaneous pain (p < .05) and exudate (p < .05). Tenderness to percussion and pain on palpation were correlated to the presence of both gram-positive and negative bacteria. In PTAP, a positive correlation was observed between both gram-positive and gram-negative bacteria with exudate and periapical lesion volume (p < .05). CONCLUSIONS: PAP had higher contents of microbial load and LPS compared with PTAP. However, PTAP presented a more diverse microbiota compared with PAP. Higher content of LPS was positively correlated with larger periapical bone destruction, whereas signs and symptoms with specific microorganisms. CLINICAL RELEVANCE: It was verified that PAP and PTAP are polymicrobial infections with predominance of gram-negative bacteria and a more diverse bacterial population found in PTAP. A wide interaction of specific microbial species resulted in different clinical features in both infections.

Case Report: Interdisciplinary management of a complex odontoma with a periapical involvement of superior anterior teeth.

This case report aims to describe the management of a complex odontoma with endodontic involvement of surrounding teeth utilizing a new bioceramic cement consisting of five mineral oxides (5MO) as a retro-filling material. The patient presented for routine consultation with slight dental mobility in the antero-superior region. Upon clinical and computed tomography examination, bone rarefaction was observed in the apical region of teeth 11 and 12, external root resorption in the involved teeth and necrotic pulp of tooth 12. Root canal treatment was performed in teeth 11 and 12. Later, local surgical excision of the lesion was carried out, finding a mass with clinical features of complex odontoma, with histopathological examination of the mass confirming this diagnosis. Retro-filling of tooth 12 with 5MO was carried out. No signs and symptoms were observed over twelve-months of follow-up, with bone neoformation observed in the region. Therefore, 5MO appears to be an effective bioceramic cement that has reparative features.

Redução de bactérias cultiváveis, lipopolissacarídeos e colagenase/mmp-8 no tratamento endodôntico associado à ativação ultrassônica na infecção endodôntica primária: estudo clínico randomizado / Cultivable bacteria, lipopolysaccharides and neutrophil collagenase/mmp-8 reduction on the endodontic treatment associated to ultrasonic activation in primary endodontic infection: a randomized clinical trial

O objetivo desse estudo clínico randomizado foi avaliar em dentes com infecção endodôntica primária (IEP) os microrganismos anaeróbios cultiváveis (UFC/mL), níveis de endotoxinas (LPS) (EU/mL) e colagenase/MMP-8 da região periapical antes e durante o tratamento endodôntico utilizando diferentes protocolos de irrigação final: irrigação convencional (CNI), ativação ultrassônica passiva (PUA) e ativação ultrassônica continua (CUA). Quarenta e cinco dentes com IEP foram submetidos ao tratamento endodôntico utilizando NaOCl 2.5% como solução irrigadora seguido do uso de EDTA 17%. Os protocolos de limpeza final foram realizados com irrigação com agulha convencional (controle), PUA e CUA; na sequência os canais foram preenchidos com pasta de Ca(OH)2 + SS por 14 dias. Foram feitas coletas do conteúdo do canal radicular após abertura coronária (S1), após diferentes protocolos de irrigação final (S2) e após uso de medicação intracanal com pasta de hidróxido de cálcio [Ca(OH)2] (S3). O conteúdo coletado do canal foi submetido as análises por cultura microbiológica (UFC/mL) e níveis de endotoxinas (EU/mL) pelo Lisado de Amebócitos de Limulus (LAL). Após preparo dos canais e após medicação com Ca(OH)2 foram realizadas coletas do fluido periapical para análise da expressão de MMP-8 por ELISA. A análise estatística dos dados foi realizada pelo testes Kruskal-Wallis e Dunn para analise intergrupos de UFC/mL, LPS e MMP-8, todos eles com nível de significância de 5% (P<0.05). Microrganismos anaeróbios cultiváveis foram detectados em 100 % das amostras iniciais (S1) com valor médio de 1.18 x 105 CFU/mL (20 ­ 1.84 x 106 CFU/mL). CUA apresentou maior efetividade na redução de microrganismos anaeróbios cultiváveis em S3 (97.27%) seguido pela PUA (96.56%) e CNI (96.2%). Endotoxinas foram identificadas em 100% das amostras em S1 com valor médio de 538.10 EU/mL (0.017 x 6190 EU/mL), CUA mostrou uma maior redução nos níveis de LPS em S3 (97.75 %), seguido pela PUA (97.11%) e CNI (90.42%). O protocolo de irrigação final com ativação ultrassônica PUA e CUA favoreceu a redução de MMP-8 em comparação ao grupo CNI. Houve correlação estatística positiva entre os níveis de LPS e MMP-8. Conclui-se que o preparo biomecânico produz a maior redução no número de microrganismos anaeróbios e endotoxinas; O protocolo de irrigação final com PUA e CUA em associação ao preparo biomecânico produz maior redução nos níveis de Endotoxinas e MMP-8 em comparação com CNI. Existe correlação estatística positiva entre os níveis de LPS e MMP-8 presentes nas infecções endodônticas primárias, mostrando a associação do LPS com o processo de destruição tecidual(AU)

The aim of this randomized clinical trial was to evaluate in cultivated anaerobic microorganisms (CFU / mL), endotoxin levels (LPS) (EU / mL) and periapical collagenase / MMP-8 in teeth with primary endodontic infection (EPI) before and during Endodontic treatment using different final irrigation protocols: conventional irrigation (CNI), passive ultrasonic activation (PUA) and continuous ultrasonic activation (CUA). Forty-five teeth with IEP were submitted to endodontic treatment using 2.5% NaOCl as an irrigating solution followed by 17% EDTA. Final cleaning protocols were performed with conventional needle irrigation (control), PUA and CUA; The root canals were then filled with Ca (OH)2 paste for 14 days. Root canal contents were collected after coronary opening (S1), after root canal preparation (S2) and after intracanal calcium hydroxide paste [Ca (OH)2] (S3). Samples of the root canal content was performed to analysis by microbiological culture (CFU / mL) and endotoxin levels (EU / mL) by Limulus Amebocyte Lysate (LAL). After canal preparation and after Ca (OH)2 medication, periapical fluid samples were collected for analysis of MMP-8 expression by ELISA. Statistical analysis of the data was performed by Kruskal-Wallis and Dunn tests for intergroup analysis of CFU / mL, LPS and MMP-8, all with a significance level of 5% (P <0.05). Cultivable anaerobic microorganisms were detected in 100% of the initial samples (S1) with a mean value of 1.18 x 105 CFU / mL (20 - 1.84 x 106 CFU / mL). CUA showed greater effectiveness in reducing anaerobic microorganisms cultivable in S3 (97.27%) followed by PUA (96.56%) and CNI (96.2%). Endotoxins were identified in 100% of samples in S1 with a mean value of 538.10 EU / mL (0.017 x 6190 EU / mL), CUA showed a greater reduction in LPS levels in S3 (97.75%), followed by PUA (97.11%). and CNI (90.42%). The final irrigation protocol with ultrasonic activation PUA and CUA favored the reduction of MMP-8 compared to the CNI group. There was a positive statistical correlation between LPS and MMP-8 levels. It is concluded that the biomechanical preparation produces the greater reduction in the number of anaerobic microorganisms and endotoxins; The final irrigation protocol with PUA and CUA in combination with biomechanical preparation produces greater reduction in Endotoxin and MMP-8 levels compared to CNI. There is a positive statistical correlation between the levels of LPS and MMP-8 present in primary endodontic infections, showing the association of LPS with the tissue destruction process(AU)

Effectiveness in the Removal of Endotoxins and Microbiological Profile in Primary Endodontic Infections Using 3 Different Instrumentation Systems: A Randomized Clinical Study.

INTRODUCTION: This clinical study was conducted to correlate the microbiological profile and levels of endotoxins found in primary endodontic infection with the presence of clinical features and to evaluate the removal of microorganisms and endotoxins using rotary, reciprocating, and hybrid systems for biomechanical preparation. METHODS: Thirty single root canals with primary endodontic infection were evaluated with signs and symptoms and were randomly divided into 3 groups according to the instrumentation system used (n = 10) as follows: rotary Mtwo instruments (VDW, Munich, Germany) with 8 files, the reciprocating Reciproc system (VDW) with a single file, and Genius hybrid instruments with 3 files (1 rotary and 2 reciprocating files) with irrigation using 24 mL 2.5% sodium hypochlorite. Samples were collected before (S1) and after instrumentation (S2) before being submitted to microbiological culture (colony-forming units/mL) and the checkerboard DNA-DNA hybridization test. Endotoxins were quantified using the limulus amebocyte lysate assay. RESULTS: Microbiological culture showed statistical differences in the reduction of colony-forming units/mL with all systems tested (P < .05), but no statistical difference was found among the groups. The most frequently detected species were Capnocytophaga ochracea (53%) and Fusobacterium nucleatum (53%) at S1 and F. nucleatum (50%) and Leptotrichia buccalis (50%) at S2. As for the reduction of endotoxins at S2, Mtwo presented the best results (95.05%) followed by the Genius (91.85%) and Reciproc (64.68%) groups, but no statistical difference was found among the groups. Previous pain, tenderness to percussion, and presence of a sinus tract were associated with specific microorganisms (P < .05). CONCLUSIONS: Signs and symptoms were correlated with microorganisms. Endodontic treatment was effective in reducing bacteria and endotoxins but was not capable of completely removing them from the root canal.