Efectos antirresortivos y antimicrobianos de los antiinflamatorios no esteroideos en lesiones periapicales / Antiresorptive and antimicrobial effects of nonsteroidal anti-inflammatory drugs in periapical lesion

Los antiinflamatorios no esteroideos (AINE) son un grupo de fármacos que han sido comúnmente prescritos por sus propiedades antiinflamato- rias, antipiréticas y analgésicas, mismas que se deben a la inhibición de la formación de prostaglandinas. Este mecanismo ha sido ampliamente respaldado en la literatura; sin embargo, en la actualidad poco se co- noce sobre las propiedades adicionales de estos medicamentos como el efecto antirresortivo y antimicrobiano. La función antirresortiva se debe principalmente al bloqueo de la producción de prostaglandinas en específico la PGE2, que posee gran potencial osteoclastogénico, esencial para la aparición de lesiones periapicales; asimismo, la acción antimicrobiana de los AINE está relacionada con la afectación directa de la perpetuación de biopelícula, potencian la acción de los antibióticos, entre otros. Dichos efectos combinados podrían contribuir en la cura- ción de lesiones periapicales. El objetivo de este estudio es recopilar información actualizada sobre estas funciones agregadas de los AINE, con el fin de dar a conocer a los profesionales estos beneficios en la terapéutica de las lesiones periapicales (AU)

Non-steroidal anti-inflammatory (NSAIDs) are a group of drugs that have been commonly prescribed for their anti-inflammatory, antipyretic and analgesic properties, which are due to the inhibition of prostaglandin formation. This mechanism has been widely supported in the literature; however, currently little is known about the additional properties of these drugs such as the antiresorptive and antimicrobial effect. The antiresorptive function is mainly due to the blockage of prostaglandin production, specifically PGE2, which has great osteoclastogenic potential, and is essential for the appearance of periapical lesions; likewise, the antimicrobial action of NSAIDs is related to the fact that they directly affect the perpetuation of biofilms, enhance the action of antibiotics, among others. These combined effects could contribute to the healing of periapical lesions. The aim of this study is to gather updated information on these added functions of NSAIDs, in order to inform professionals about these benefits in the therapy of periapical lesion (AU)

Tratamiento no quirúrgico de lesión periapical de gran tamaño: Reporte de caso / Non-surgical Therapeutics of large size periapical injury: Clinical case report

Resumen Se describe un caso clínico sobre una mujer de 21 años de edad la cual sufrió trauma dental a los 6 años que comprometió al incisivo superior izquierdo lo cual con el tiempo generó o se formó una gran lesión periapical en esta región. Radiográficamente se observa la formación incompleta de la raíz, las paredes del conducto radicular delgadas, y una extensa lesión periapical. Se realizó el desbridamiento químico-mecánico con limas K y se ejecutó la desinfección del conducto radicular con clorhexidina al 2%. El conducto se deja medicado con hidróxido de calcio (Vitapex®), el cual se reemplaza periódicamente con dicho material hasta los nueve meses, finalmente se obtura con Biodentine®. Se da seguimiento al caso a través de cuatro años, pasando por blanqueamiento interno, carilla de resina hasta llegar a poste intra radicular con corona completa de porcelana en lo concerniente al aspecto estético. En cuanto a la lesión periapical de gran tamaño, se llega a observar por medio de tomografías, disminución de la lesión al mínimo y genera cicatrización ósea. En relación con la observación clínica hay desaparición de la fístula y ausencia de sintomatología.

Abstract This report describes a clinical case involving a 21-year-old woman, who suffered dental trauma at age 6, compromising left tooth 2.1. On time she developed a large periapical injury in this area. Radiographically, incomplete root formation, thin walls of the root canal, and extensive periapical damage is clearly shown. Chemo- mechanical debridement was performed with K files and disinfection of the root canal using 2% chlorhexidine. The root canal was left medicated with calcium hydroxide (Metapex), which was replaced periodically until 9 months. Finally, the root canal was completely sealed with Biodentine. The case had a follow up for over four years and concerning esthetical aspects, through this period of time an internal whitening, resin veneer, intra radicular post and complete crown were provided. Regarding the considerable periapical injury, tomography shows that it has been drastically reduced and generated bone healing. Clinical observations also show that the fistula and symptomatology disappeared.

Effect of Calcium Hydroxide Alone or in Combination with Ibuprofen and Ciprofloxacin on Nuclear Factor Kappa B Ligand and Osteoprotegerin Level in Periapical Lesions: A Randomized Controlled Clinical Study.

INTRODUCTION: The aim of the present study was to evaluate the effects of calcium hydroxide (Ca[OH]2), Ca(OH)2 + ibuprofen, and Ca(OH)2 + ciprofloxacin in terms of receptor activator of nuclear factor kappa B ligand (RANKL) and osteoprotegerin (OPG) levels in asymptomatic periapical lesions. METHODS: Sixty-six patients were randomly divided into 3 groups using a Web program according to the medication selected: Ca(OH)2, Ca(OH)2 + ibuprofen, and Ca(OH)2 + ciprofloxacin. After removing gutta-percha from the root canals, the RANKL and OPG samples were taken from the interstitial fluid of the apical tissues using 3 paper points. At the second appointment, medicaments were removed, and second sampling was performed using the same method. The RANKL and OPG levels were measured by the enzyme-linked immunosorbent assay, and the RANKL/OPG ratio was calculated. RESULTS: According to the intragroup analysis, there were no statistically significant differences between the preoperative and postoperative levels of the RANKL/OPG ratio in any of the groups. Intergroup analyses showed that there were no statistically significant differences among the Ca(OH)2, Ca(OH)2 + ibuprofen, Ca(OH)2 + ciprofloxacin groups in terms of the percentage change in RANKL/OPG levels before and after treatment. CONCLUSIONS: Within the limitations of the present study, it can be concluded that addition of ibuprofen or ciprofloxacin to Ca(OH)2 paste does not provide any extra benefit in terms of lowering RANKL and OPG levels.

Role of Periapical Diseases in Medication-Related Osteonecrosis of the Jaws.

OBJECTIVE: The present study aimed to investigate the role of periapical diseases in inducing medication-related osteonecrosis of the jaws (MRONJ) using an ovariectomized (OVX) mice model. MATERIALS AND METHODS: Twenty C57BL/6N female mice were randomly assigned to two groups. All mice were subjected to bilateral ovariectomy and then treated with oncologic dose of zoledronic acid (ZA) or vehicle for twelve weeks. Eight weeks after commence of drug administration, a pulpal exposure (PE) operation was performed on the first right lower molar to induce periapical periodontitis; the contralateral non-PE tooth was used as control. All animals were sacrificed four weeks after pulpal exposure, and the mandibles were harvested for radiological and histomorphometrical analysis. RESULTS: Micro computed tomography (µ-CT) examination demonstrated that periapical diseases significantly increased alveolar bone resorption, and the resorption was greatly attenuated by ZA treatment. Concurrent ZA therapy significantly increased bone density and histological osteocyte necrosis in the presence of periapical lesions. CONCLUSION: ZA treatment reduced bone absorption resulting from periapical disease but increased the risk of developing MRONJ in the ovariectomized mouse model.

Antibiotic Use in 2016 by Members of the American Association of Endodontists: Report of a National Survey.

INTRODUCTION: This study surveyed the antibiotic prescribing practices of endodontists, and data were compared with previous surveys conducted in 1994 and 1999. METHODS: A 17-question survey was sent via www.surveymonkey.com to 3000 active members of the American Association of Endodontists for responses about antibiotic prescribing practices and demographics. The data were analyzed using descriptive statistics, chi-square tests, and linear regression analyses. RESULTS: Six hundred eighty-six participants (22.86%) completed the survey. The most frequently prescribed antibiotics were amoxicillin (60.71%) followed by penicillin V (30.43%) and clindamycin for patients with allergies (95.4%). Respondents reported prescribing antibiotics for irreversible pulpitis with mild symptoms (1.75%), irreversible pulpitis with moderate symptoms (6.41%), necrotic pulp with symptomatic apical periodontitis (43.59%), chronic apical abscess without (10.50%) or with symptoms (29.74%), acute apical abscess (95.92%), avulsion (70.26%), endodontic surgery (41.69%), retreatment (silver point [23.76%] or gutta-percha [15.60%]), postoperative pain after instrumentation or obturation (12.39%), and perforation repair (5.98%). The type of practice (solo/group) and geographic region (Southeast) were significant predictors of increased antibiotic prescribing; 36.89% of respondents reported prescribing antibiotics that are not necessary, most commonly because of patient expectations. CONCLUSIONS: Since 1999, there has been a significant shift from prescribing penicillin V to amoxicillin as endodontists' first choice of antibiotic and a significant increase in the use of clindamycin for penicillin-allergic patients. Antibiotics continue to be prescribed in clinical situations for which they are typically not indicated, most commonly because of patient expectations. Regional differences in antibiotic prescribing practices by endodontists exist in the United States.

Interleukin-1 and estrogen protect against disseminating dentoalveolar infections.

Dentoalveolar bacterial infections cause localized tissue and bone destruction, but usually remain well-localized within teeth in immunocompetent hosts. However, in certain cases these infections may invade head and neck tissues, resulting in orofacial abscesses, cellulitis and sepsis, with resultant high morbidity and even mortality. In the present studies, we developed a novel model of spreading dentoalveolar infections in mice by treatment with neutralizing antibodies against both interleukin-1α (IL-1α) and IL-1ß. Surprisingly male but not female mice given anti-IL-1 antibodies developed orofacial abscesses, weight loss, splenomegaly and sepsis. Female mice developed abscesses and sepsis comparable to males following ovariectomy (OVX), which was reversed by estrogen supplementation. Anti-IL-1 blockade inhibited IL-12, interferon γ (IFNγ) and IL-6 but not IL-10 expression in infrabony lesions, suggestive of a local anti-inflammatory response. There was greater infiltration of neutrophils and other inflammatory cells into lesions in anti-IL-1-treated animals; however, blood leukocytes had reduced bacterial phagocytic and killing activity ex vivo. Estrogen directly stimulated IL-1 production by macrophages, suggesting that the resistance of females to disseminating dentoalveolar infections may be due to their heightened pro-inflammatory responses following bacterial challenge, leading to enhanced localization of these infections.

Hemostatic Agents in Periapical Surgery: A Randomized Study of Gauze Impregnated in Epinephrine versus Aluminum Chloride.

INTRODUCTION: Adequate bleeding control is essential for the success of periapical surgery. The aim of this study was to evaluate the effects of 2 hemostatic agents on the outcome of periapical surgery and their relationship with patient and teeth parameters. METHODS: A prospective study was designed with 2 randomized parallel groups, depending on the hemostatic agent used: gauze impregnated in epinephrine (epinephrine group) and aluminum chloride (aluminum chloride group). The analysis of the hemorrhage control was judged before and after the application of the hemostatic agents by the surgeon, and 2 examiners independently recorded it as adequate (complete hemorrhage control) or inadequate (incomplete hemorrhage control). RESULTS: Ninety-nine patients with a periradicular lesion were enrolled in this study and divided into 2 groups: gauze impregnated in epinephrine in 48 patients (epinephrine group) or aluminum chloride in 51 (aluminum chloride group). In epinephrine group adequate hemostasis was achieved in 25 cases, and in aluminum chloride group it was achieved in 37 cases (P < .05). CONCLUSIONS: The outcome was better in the aluminum chloride group than in the gauze impregnated in epinephrine group.

Periapical actinomycosis.

Actinomycosis is a rare chronic infection caused by species of Actinomyces and characterised by abscess formation, tissue fibrosis, suppurative lesions and fistulas with purulent discharge containing sulphur granules. Owing to its multiform manners of presentation and non-specificity from its clinical features, it has been considered as a challenging diagnosis. Periapical actinomycosis is one of the rarest forms of actinomycosis occurring in the maxillofacial region. In its occurrence it presents in the form of persistent and recurrent draining fistula in the periapical region. We report a case of periapical actinomycosis occurred in endodontically treated teeth and accidentally found to be actinomycosis during histopatological examination. An insight towards the portal of entry of the organisms into the periapical region is also discussed. The practice of sending even a tiny bit of tissues to histopathology obtained from periapical surgery will very well demonstrate this disease and help in rapid resolution through appropriate antibiotic therapy.

Residual antibacterial activity of chlorhexidine digluconate and camphorated p-monochlorophenol in calcium hydroxide-based root canal dressings

The purpose of this study was to evaluate the residual antibacterial activity of several calcium hydroxide [Ca(OH)2]-based pastes, placed in root canals of dogs' teeth with induced chronic periapical lesions. Root canals were instrumented with the ProFile rotary system and filled with 4 pastes: G1 (n=16): Ca(OH)2 paste + anesthetic solution; G2 (n=20): Calen® paste + camphorated p-monochlorophenol (CMCP); G3 (n=18): Calen®; and G4 (n=18): Ca(OH)2 paste + 2 percent chlorhexidine digluconate. After 21 days, the pastes were removed with size 60 K-files and placed on Petri plates with agar inoculated with Micrococcus luteus ATCC 9341. Pastes that were not placed into root canals served as control. After pre-diffusion, incubation and optimization, the inhibition zones of bacterial growth were measured and analyzed by Mann-Whitney U test at 5 percent significance level. All pastes showed residual antibacterial activity. The control samples had larger halos (p<0.05). The mean residual antibacterial activity halos in G1, G2, G3 and G4 were 7.6; 10.4; 17.7 and 21.4 mm, respectively. The zones of bacterial growth of G4 were significantly larger than those of G1 and G2 (p<0.05). In conclusion, regardless of the vehicle and antiseptic, all Ca(OH)2-based pastes showed different degrees of measurable residual antibacterial activity. Furthermore, unlike CMCP, chlorhexidine increased significantly the antibacterial activity of Ca(OH)2.

Este estudo objetivou mensurar a atividade anti-bacteriana residual de várias pastas à base de hidróxido de cálcio [Ca(OH)2], após permanecerem em canais radiculares de cães com lesões periapicais crônicas induzidas. Os canais radiculares foram instrumentados com o sistema Profile e preenchidos com quatro diferentes pastas: G1-Ca(OH)2 p.a./solução anestésica (n=16), G2-Calen®/PMCC (n=20), G3-Calen® (n=18) e G4-Ca(OH)2 p.a./solução de digluconato de clorexidina a 2 por cento (n=18). Transcorridos 21 dias, amostras foram recuperadas dos canais radiculares com limas Kerr #60 e colocadas em placas de Petri com ágar semeado com Micrococcus luteus ATCC 9341. Pastas não aplicadas nos canais radiculares serviram como controle. Após pré-difusão, incubação e otimização, as zonas de inibição do crescimento bacteriano foram mensuradas e analisadas pelo teste de Mann-Whitney (a<0.05). Verificou-se que todas as pastas apresentaram ação antibacteriana residual, com maiores halos para as amostras-controles. As médias dos halos de inibição para G1, G2, G3 e G4 foram 7,6; 10,4; 17,7 e 21,4 mm, respectivamente. Os halos de inibição de G4 foram significativamente superiores as de G1 e G2 (p<0.05). Portanto, independentemente do veículo, todas as pastas à base de Ca(OH)2 determinaram, em diferentes magnitudes, atividade anti-bacteriana residual mensurável. Ademais, diferentemente do PMCC, a solução de digluconato de clorexidina a 2 por cento ampliou significativamente, a atividade anti-bacteriana residual do hidróxido de cálcio.

Nonsurgical retreatment of teeth with periapical lesions previously managed by either endodontic or surgical intervention.

OBJECTIVE: The purpose of this study was to evaluate the outcome of nonsurgical retreatment of teeth with periapical lesions, which had been previously managed by either endodontic or surgical intervention, and to identify factors that might influence the prognosis. STUDY DESIGN: Seventy-five endodontically and 11 surgically treated teeth with persisting periapical lesions ranging in size from 2 to 11 mm in diameter were included in this study. The teeth were nonsurgically retreated, using calcium hydroxide as intracanal medicament, and were followed for a period of 2 to 8 years. RESULTS: Clinical and radiographic assessment of retreatment showed that complete healing for all cases was 61.6% with an additional category of incomplete healing of 14%; 24.4% failed. The size of the periapical lesions and previous surgical treatment had marginally negative influences on the prognosis, but the differences were not statistically significant. CONCLUSION: The favourable results of this study demonstrated that nonsurgical root canal retreatment is an alternative to surgical intervention of postendodontic or postsurgical failure.

Course of infection and case outcome in individuals diagnosed with microbial colonies morphologically consistent with Actinomyces species.

Actinomycosis is considered to be a rare disease in the oral region. A retrospective study of files of the University of Nebraska Medical Center College of Dentistry, Department of Pathology, revealed 30 cases in which Actinomyces species were detected from the years 1982 to 2001 (28,490 specimens). Biopsy submission forms and patient records were reviewed in each of these cases with particular attention to clinical impression, subsequent treatment, and case outcome. Classic treatment for actinomycosis involves the excision of the affected area as well as long-term antibiotics. Our study indicates that antibiotics may not be necessary in treatment of the localized dental presentation of actinomycosis.

Antibiotic strategy in orofacial/head and neck infections in severe neutropenia.

A strategy for empiric antibiotic therapy for orofacial/head and neck bacterial infections that appear as clinical swellings in patients with severe neutropenia is assessed. Daily examinations were made in the hospital. Only those with peripheral blood neutrophil counts < 100/mm3 that persisted for at least 5 days after the commencement of resolution of the swelling were included in this article. The strategy consisted of sequential additions of a beta-lactam/aminoglycoside combination, metronidazole to intensify anaerobe cover and a beta-lactamase stable agent (such as vancomycin and floxacillin) as dictated by clinical signs. Progressive and complete resolution of infection occurred in 26 of 27 patients treated.

A comparison of erythromycin and cefadroxil in the prevention of flare-ups from asymptomatic teeth with pulpal necrosis and associated periapical pathosis.

In a previous study by our group with patients having asymptomatic teeth with pulpal necrosis and an associated periapical radiolucent lesion (PN/PL), it was shown that prophylactic administration of penicillin V or erythromycin (high-dose, 1-day regimen) resulted in a low incidence of flare-up (mean = 2.2%) and a low incidence of swelling and pain not associated with flare-up. No hypersensitivity responses occurred, and gastrointestinal side effects were found primarily with the erythromycins. To ascertain whether a single-dose administration of a long-acting 1-gm tablet of the cephalosporin antibiotic cefadroxil would result in a similar outcome, the present study was undertaken with 200 patients having quiescent PN/PL. The patients were randomly given either cefadroxil or erythromycin (base or stearate). Evaluations of flare-up were done 1 day, 1 week, and 2 months after endodontic treatment. A 2.0% flare-up incidence was found, with no statistically significant differences for cefadroxil (1.0%), stearate (2.0%), or base (4.0%). No hypersensitivity responses occurred. Gastrointestinal side effects were found primarily with the erythromycins (19.0%). The results showed that a 1-gm, single-dose regimen of cefadroxil was as effective as erythromycin and penicillin in preventing flare-ups and serious sequelae. A comparative analysis of the data from our first study (no peritreatment antibiotics) and the pooled data from our last three investigations (including the current trial) showed that peritreatment antibiotic coverage significantly reduced flare-ups and serious sequelae after endodontic treatment of asymptomatic PN/PL (p less than 0.001).

[Chlorhexidine in the treatment of root canal infection and its sequels]. / Chlorhexidin in der therapeutischen Trias des infizierten Wurzelkanals und seiner Folgeerkrankungen.

The plaque inhibitor chlorhexidine digluconate was used for intra- and transcanal irrigation in the endodontic treatment triad for periapical lesions (circumscribed, diffuse, fistulating, cystic, suspected cystic lesions). 50 patients were followed up by clinical and standardized radiologic studies. In another 18 patients microbiologic criteria were also used. 16 root canals showed pretreatment infection with mixed aerobic and anaerobic organisms. Mechanical preparation of the root canals with or without extension of the foramen and triple irrigation with 0.5% chlorhexidine digluconate produced clinical relief of symptoms (49 pts.), sterility (14 of 18 pts.) and reduction of the size of periapical lesions (12 pts.). At a mean follow-up of 24 months 30 patients have so far shown complete restitution of periapical bone.

The effect of indomethacin on experimental dental periapical lesions in rats.

The role of prostaglandins in the pathogenesis of dental granulomas and associated bone loss was studied by testing the ability of indomethacin, a potent inhibitor of prostaglandin synthesis, to influence bone resorption in experimentally induced dental granulomas. The cusps of maxillary first molar teeth of Sprague-Dawley rats were ground away, exposing the dental pulps to the oral environment. Daily i.p. injections of 0.1 to 0.2 ml of indomethacin (10 mg per kg) dissolved in 95% ethyl alcohol were administered to one group of the rats while the other group received i.p. injections of 0.1 to 0.2 ml of 95% ethyl alcohol. The rats were killed after 6 wk and specimens of the molar teeth and surrounding jaw bone were taken for routine histopathological processing. The specimens from indomethacin-treated rats demonstrated milder inflammatory changes and a significantly lower degree of periapical alveolar bone resorption. These results support the suggestion that prostaglandins are involved in the events leading to bone resorption in dental periapical lesions.

Conservative treatment of periapical actinomycosis.

A patient with periapical actinomycosis of approximately 3 years' duration was treated conservatively with tissue management and antibiotic therapy. Twelve months after therapy, bone regeneration is almost complete and there is no sign of recurrence.