Salivary Metabolomics Fingerprint of Chronic Apical Abscess with Sinus Tract: A Pilot Study.

Chronic apical abscess (CAA) is a lesion of apical periodontitis mostly characterized by areas of liquefactive necrosis with disintegrating polymorphonuclear neutrophils surrounded by macrophages. Its presence leads to local bacterial infection, systemic inflammatory response, pain, and swelling. The use of a novel approach for the study of CAA, such as metabolomics, seems to be important since it has proved to be a powerful tool for biomarkers discovery which could give novel molecular insight on CAA. So, the aim of this study was to verify the possibility to identify the metabolic fingerprint of CAA through the analysis of saliva samples. Nineteen patients were selected for this study: eleven patients affected by CAA with a sinus tract constituted the study group whereas eight patients without clinical and radiographic signs of CAA formed the healthy control group. Saliva samples were collected from each subject and immediately frozen at -80°C. Metabolomic profiles were obtained using a gas chromatography/mass spectrometry instrument. Subsequently, in order to compare the two groups, a multivariate statistical model was built that resulted to be statistically significant. The class of metabolites characterizing the CAA patients was closely related to the bacterial catabolism, tissue necrosis, and presence of a sinus tract. These preliminary results, for the first time, indicate that saliva samples analyzed by means of GC/MS metabolomics may be useful for identifying the presence of CAA, leading to new insights into this disease.

Radiographic and histological evaluation of persistent periapical lesions associated with endodontic failures after apical microsurgery.

AIM: To determine the histology of persistent periapical lesions associated with nonsurgical endodontic treatment failures and to compare radiographically the sizes of periapical lesions and the presence or absence of the radiopaque lamina with the histological findings. METHODOLOGY: Ninety-three anterior teeth designated for apical microsurgery were included in the study. After taking standard radiographs of all cases using the parallel technique, the films were scanned and evaluated for the size of periapical radiolucent lesions and the presence or absence of radiopaque lamina by two calibrated observers. Biopsy specimens were obtained during apical microsurgery and examined under light microscopy by oral pathologists. Histological analysis established diagnoses of granuloma, cyst, abscess and scar tissue. Interobserver agreement was evaluated by the kappa test, and the relationship between histological diagnosis and lesion size was analysed by the Pearson's chi-square test. RESULTS: The 93 specimens consisted of 72% periradicular granulomas; 21.5% radicular cysts, including two keratocysts; 4.3% abscesses; and 2.2% scar tissue. Cystic prevalence increased as the size of the periapical lesion increased; however, there was no correlation between the presence of a radiopaque lamina and histological diagnosis of cyst. CONCLUSIONS: Neither radiographic size nor presence of an associated radiopaque line alone was sufficient to determine the type of lesion. Histological examination is required in order to reach to a definitive diagnosis.

Oral and dental manifestations in Rubinstein-Taybi syndrome: report of a rare case.

Rubinstein-Taybi syndrome, or broad thumb-hallux syndrome, is a well-defined rare congenital disorder characterised by postnatal growth deficiency, craniofacial dysmorphism, broad thumbs and great toes, and mental retardation (intellectual disability). Occurrence may be either sporadic or through autosomal dominant inheritance. Reports of Rubinstein-Taybi syndrome are scarce in the literature. This case report describes the oral and dentofacial findings of Rubinstein-Taybi syndrome affecting a 13-year-old Indian female, including the uncommon presence of talon cusps and an unerupted supernumerary tooth.

Comparative Metabolomics Reveals the Microenvironment of Common T-Helper Cells and Differential Immune Cells Linked to Unique Periapical Lesions.

Periapical abscesses, radicular cysts, and periapical granulomas are the most frequently identified pathological lesions in the alveolar bone. While little is known about the initiation and progression of these conditions, the metabolic environment and the related immunological behaviors were examined for the first time to model the development of each pathological condition. Metabolites were extracted from each lesion and profiled using gas chromatography-mass spectrometry in comparison with healthy pulp tissue. The metabolites were clustered and linked to their related immune cell fractions. Clusters I and J in the periapical abscess upregulated the expression of MMP-9, IL-8, CYP4F3, and VEGF, while clusters L and M were related to lipophagy and apoptosis in radicular cyst, and cluster P in periapical granuloma, which contains L-(+)-lactic acid and ethylene glycol, was related to granuloma formation. Oleic acid, 17-octadecynoic acid, 1-nonadecene, and L-(+)-lactic acid were significantly the highest unique metabolites in healthy pulp tissue, periapical abscess, radicular cyst, and periapical granuloma, respectively. The correlated enriched metabolic pathways were identified, and the related active genes were predicted. Glutamatergic synapse (16-20),-hydroxyeicosatetraenoic acids, lipophagy, and retinoid X receptor coupled with vitamin D receptor were the most significantly enriched pathways in healthy control, abscess, cyst, and granuloma, respectively. Compared with the healthy control, significant upregulation in the gene expression of CYP4F3, VEGF, IL-8, TLR2 (P < 0.0001), and MMP-9 (P < 0.001) was found in the abscesses. While IL-12A was significantly upregulated in cysts (P < 0.01), IL-17A represents the highest significantly upregulated gene in granulomas (P < 0.0001). From the predicted active genes, CIBERSORT suggested the presence of natural killer cells, dendritic cells, pro-inflammatory M1 macrophages, and anti-inflammatory M2 macrophages in different proportions. In addition, the single nucleotide polymorphisms related to IL-10, IL-12A, and IL-17D genes were shown to be associated with periapical lesions and other oral lesions. Collectively, the unique metabolism and related immune response shape up an environment that initiates and maintains the existence and progression of these oral lesions, suggesting an important role in diagnosis and effective targeted therapy.

Spread of odontogenic infections in Port Harcourt, Nigeria.

PURPOSE: Odontogenic infections constitute a substantial portion of diseases encountered by oral and maxillofacial surgeons. Infections start from dental tissues and sometimes rapidly spread to contiguous spaces. The consequence is a fulminant disease with significant morbidity and mortality. The study was aimed at studying the pattern of spread, approach to management, and outcome of these infections at a Nigerian teaching hospital. PATIENTS AND METHODS: A retrospective study of all patients with orofacial infections who presented to our center over an 18-month period was carried out. The medical records were reviewed to retrieve the following: age, gender, source of infection, anatomic fascial spaces involved, associated medical conditions, various treatment modalities, types of antibiotics administered, causative micro-organisms, length of stay in the hospital, and any complications encountered. Infections were classified into 2 categories: those that are confined to the dentoalveolar tissues belong to category I, and those that have spread into the local/regional soft tissue spaces and beyond belong to category II. RESULTS: Odontogenic infections constituted 11.3% of the total oral and maxillofacial surgery cases. A total of 261 patients were treated for odontogenic infections. There were 146 female patients (59.8%) and 98 male patients (40.2%) in the first category, whereas the second category comprised 10 male patients (58.8%) and 7 female patients (41.2%). The fascial spaces involved, in descending order, were submasseteric in 10 (22.7%), submandibular in 9 (20.5%), and sublingual in 6 (13.6%). The causative micro-organisms commonly found were Klebsiella and Streptococcus spp. Incision and drainage were performed in the 17 cases with spreading infection. Amoxicillin, amoxicillin/clavulanate, and metronidazole were the most routinely administered antibiotics. CONCLUSIONS: Our experience shows that delay in presentation, self-medication, aging, male gender, and unusual causative agents are some of the factors associated with spread. Therefore efforts must be made to further improve public dental awareness.

Histopathological profile of surgically removed persistent periapical radiolucent lesions of endodontic origin.

AIM: To determine the types of periapical lesions associated with root filled teeth with persistent periapical pathosis that required surgical treatment based on specific inclusion and exclusion criteria. METHODOLOGY: Periapical lesions from a consecutive clinical sample of 100 patients were examined histopathologically to determine a definitive diagnosis. RESULTS: Females were more represented (n = 56), the average age was 46.5 years and there were no age differences between gender or lesion type. A diagnosis of periapical granuloma was the most common finding with a similar number present in females (n = 40) and males (n = 37). A cyst was present in 18% of the cases with a majority of females (n = 12) represented in the sample. Evidence of foreign material, with an appearance consistent with endodontic sealer materials, was seen in 25 periapical granulomas, two cysts and one scar. Two periapical scars were seen, one had a history of apicectomy and amalgam root-end filling while the other was associated with extruded root filling material. CONCLUSIONS: By using defined clinical inclusion and exclusion criteria a predictable clinical diagnosis of a persistent periapical lesion due to endodontic origin can be reliably made. Periapical granulomas and cysts were the most common periapical lesions of endodontic origin associated with persistent periapical pathosis with the overall incidence of periapical cysts similar to previous studies. The presence of endodontic material in a high proportion of periapical lesions suggests a cause-effect association with the inference that clinicians should employ canal preparation techniques that limit apical extrusion of material.

[Influence of dentoalveolar pathology on the efficiency of conservative treatment of chronic suppurative otitis].

The study was designed to analyse immunoreactivity in patients with chronic suppurative otitis and results of its treatment. A separate group was comprised of patients with dentoalveolar pathology. It is concluded that the efficacy of therapy of chronic suppurative otitis depends on the presence of concomitant dentoalveolar abscess and carious lesions.

Development and evaluation of calcium hydroxide-coated, pericardium-based biomembranes for direct pulp capping.

AIM: The aim of the present study was to develop a bovine pericardium biomembrane (BPB) and to evaluate pulp response in vivo. METHODS: A double-layer bovine BPB/chitosan was manufactured, and the porous chitosan side was coated with calcium hydroxide. The microstructure of the matrices was evaluated with electron microscopy. To test pulp response, cavities were prepared on the occlusal surface of Wistar rats' mandibular left first molars and capped with matrices, followed by appropriate adhesives/composite restorations. The animals were divided into three groups: group 1, calcium hydroxide alone; group 2, BPB without calcium hydroxide; and group 3, BPB coated with calcium hydroxide. Specimens were processed and histologically evaluated at 7, 14, and 30 days, postoperatively. RESULTS: Electron microscopy showed porous chitosan surface and a cohesive calcium hydroxide layer. Histological analysis showed that groups 1 and 3 had mild odontoblast layer disorganization, but normal pulp tissue appearance at 7, 14, and 30 days. At the same time points, group 2 showed a loss of general pulp tissue, pulp necrosis, and periapical abscess in some teeth. CONCLUSION: Coated bovine pericardium-based biomembranes resulted in favorable outcomes in cases of pulp exposure after a 30-day observation period, and might protect against injuries caused by adhesive systems and composites.

Bone tissue formation in extraction sockets from sites with advanced periodontal disease: a histomorphometric study in humans.

PURPOSE: To investigate postextraction bone formation over time in both diseased and healthy sockets. MATERIALS AND METHODS: Core specimens of healing tissues following tooth extraction were obtained at the time of implant placement in patients treated between October 2005 and December 2007. A disease group and a control group were classified according to socket examination at the time of extraction. The biopsy specimens were analyzed histomorphometrically to measure the dimensional changes among 3 tissue types: epithelial layer, connective tissue area, and new bone tissue area. RESULTS: Fifty-five specimens from sites of previously advanced periodontal disease from 45 patients were included in the disease group. Another 12 specimens of previously healthy extraction sockets were collected from 12 different patients as a control. The postextraction period of the disease group varied from 2 to 42 weeks. In the disease group, connective tissue occupied most of the socket during the first 4 weeks. New bone area progressively replaced the connective tissue area after the first 4 weeks. The area proportion of new bone tissue exceeded that of connective tissue by 14 weeks. After 20 weeks, most extraction sockets in the disease group demonstrated continuous new bone formation. The control group exhibited almost complete socket healing after 10 weeks, with no more new bone formation after 20 weeks. CONCLUSIONS: Osseous regeneration in the diseased sockets developed more slowly than in the disease-free sockets. After 16 weeks, new bone area exceeded 50% of the total newly regenerated tissue in the sockets with severe periodontal destruction. In the control group, after 8 weeks, new bone area exceeded 50% of the total tissue.

Residual bacteria in root apices removed by a diagonal root-end resection: a histopathological evaluation.

AIM: To assess bacteria in the apical portion of the root end after 45 degrees root-end resection in teeth with persistent periapical lesions. METHODOLOGY: The study included 27 apical root segments from patients with persistent periapical lesions. Histological sections of the coronal part of the amputated root segment were stained with Brown and Brenn to detect the presence of bacteria in the main root canal and/or in irregular root spaces and dentinal tubules. The quality of each root canal filling was evaluated using preoperative radiographs of filling, length of root filling as assessed from the distance between its apical end and the radiographic apex, diameter of apical preparation, and presence of apical perforations or deviations from the root canal. Two endodontists, blinded to the bacteriological results, independently evaluated the radiographs. RESULTS: Bacteria were present in 23 (85.2%) specimens: five in only the main canal (21.7%), 10 in only the dentinal tubules and irregular spaces (43.5%), and eight in both irregular spaces and dentinal tubules and in the main root canal (34.8%). No correlation was found between the technical quality of the root filling assessed radiographically and bacterial presence in the central canal or irregular areas. CONCLUSIONS: Infected irregular areas were found in the root tips of teeth with persistent periapical lesions. This was found regardless of the radiographic quality of the root filling. Diagonal, 45 degrees root-end resection may expose such contaminated irregularities to the periapical tissue.

Histobacteriologic Conditions of the Apical Root Canal System and Periapical Tissues in Teeth Associated with Sinus Tracts.

INTRODUCTION: This histobacteriologic study described the pattern of intraradicular and extraradicular infections in teeth with sinus tracts and chronic apical abscesses. METHODS: The material comprised biopsy specimens from 24 (8 untreated and 16 treated) roots of teeth associated with apical periodontitis and a sinus tract. Specimens were obtained by periradicular surgery or extraction and were processed for histobacteriologic and histopathologic methods. RESULTS: Bacteria were found in the apical root canal system of all specimens, in the main root canal (22 teeth) and within ramifications (17 teeth). Four cases showed no extraradicular infection. Extraradicular bacteria occurred as a biofilm attached to the outer root surface in 17 teeth (5 untreated and 12 treated teeth), as actinomycotic colonies in 2 lesions, and as planktonic cells in 2 lesions. Extraradicular calculus formation (mineralized biofilm) was evident in 10 teeth. CONCLUSIONS: Teeth with chronic apical abscesses and sinus tracts showed a very complex infectious pattern in the apical root canal system and periapical lesion, with a predominance of biofilms.

Cone-beam computed tomographic and histological investigation of regenerative endodontic procedure in an immature mandibular second premolar with chronic apical abscess.

AIM: The aim of the present study was to investigate the tissue generated after regenerative endodontic procedure (REP) in the root canal space of an immature mandibular second premolar with pulp necrosis and chronic apical abscess using cone-beam computed tomographic (CBCT) and histological methods. METHODS: REP was performed in an immature mandibular second premolar. At the 3-year follow up, CBCT scans were taken to evaluate the outcome of treatment. As the tooth was not restorable to function, it was extracted and processed for histological examination. RESULTS: CBCT showed a reduction in size of the periradicular radiolucency, with a marginal increase in root length. Apical closure and thickening of the root canal walls were apparent. Histologically, the root canal space was filled with minimally-inflamed fibrous connective tissue. Some cementum-like mineralized connective tissue was evident on the internal canal walls. The apical third showed cementum-like deposits at the apex and the outer canal walls, without dentin formation. CONCLUSIONS: The present study of a structurally-failed tooth with prior REP demonstrates that the tissue formed within the root canal space was fibrous connective tissue with cementum-like deposition in the canal space. No evidence of dentin- or pulp-like tissue was found.

Update on the adaptive immune responses of the dental pulp.

Recent advances in immunology have disclosed the enormous complexity of the immune regulatory system. The dental pulp is equipped to mount adaptive immune responses to caries, which include at least antigen-presenting cells, lymphocytes, mast cells and their cytokines, and chemokines. The purpose of this review is to summarize our current understanding of the roles of these cellular and molecular components in the irreversibly inflamed pulp. The immunopathology of abscess formation and the mechanisms for painless pulpitis are also discussed.

Chondroblastic osteosarcoma mimicking periapical abscess.

CASE REPORT: The present report describes a case of chondroblastic osteosarcoma in the periapical region of teeth #29, #30, and #31 of an 18-year-old male. Clinical history showed self-reported discomfort in the right posterior gingiva for over a month. Physical examination showed a small expansion and redness of the right mandibular buccal and lingual cortical plates, but no signs of pain or inflammation were observed. All the teeth responded positively to pulp sensibility. Periapical and panoramic radiographs showed slight periapical radiolucency in the roots of teeth #29 and #30, clear periodontal ligament space widening, and evident loss of lamina dura. Incisional biopsy was performed, and based on microscopic findings the diagnosis of chondroblastic osteosarcoma was confirmed. CONCLUSIONS: Non-endodontic diseases associated with tooth root apex, such as chondroblastic osteosarcoma, should be included in differential diagnosis of jaw lesions that resemble periapical abscess.

Intentional replantation: a case report.

Nonsurgical retreatment and surgical endodontics are not always viable solutions to endodontic disease. Access for retreatment may be limited by posts. Surgical endodontics may be limited by anatomical features including bone thickness and nerve and sinus proximity. Anatomical limitations and complex restorations may prevent implant placement. Intentional replantation is considered by many as a procedure of last resort when nonsurgical or surgical endodontics is contra-indicated. The treatment described demonstrates intentional replantation as a procedure to be considered when endodontic procedures or a dental implant are not possible.

Analysis of Interleukin 17A in periapical abscess and granuloma lesions.

Interleukin 17A (IL-17A) is a proinflammatory cytokine responsible for the initiation and propagation of inflammation. One of its actions is the recruitment of neutrophils to the site of infection. The aim of this study was to investigate whether there is association between IL-17A expression and neutrophil infiltration in periapical abscesses and periapical granulomas, as well as to find which type of T lymphocyte effector (CD4+ or CD8+) expresses IL-17A in these lesions. Elastase, CD4, CD8, and IL-17A were analyzed by immunohistochemistry and immunofluorescence, in the biopsies of periapical lesions. Abscess lesions exhibited the highest labeling area for IL-17A (p = 0.011). During double immunofluorescence staining, there were significantly more CD4+/IL-17A+ cells compared to CD8+/IL-17A+ cells, both in the abscesses (p = 0.025) and granulomas (p = 0.011). In conclusion, IL-17A was intensively expressed in periapical abscesses rich in neutrophils. The high percentage of IL-17A in these cases suggests the participation of this cytokine particularly in the acute stages of the inflammatory process of the periapical lesions.

The root of the problem: Occurrence of typical and atypical periapical pathoses.

BACKGROUND: A preponderance of periapical radiolucencies are of inflammatory etiology (radicular cysts or periapical granulomas) secondary to pulpal disease. In some instances, however, a suspected periapical inflammatory lesion is not a consequence of pulpal disease but instead represents a lesion of noninflammatory origin. The differential diagnosis for such lesions is broad, ranging from odontogenic cysts and tumors to metastatic disease. As the biological behavior of such lesions is varied, the distinction between inflammatory odontogenic periapical lesions and lesions of noninflammatory origin in a periapical location is critical. METHODS: A retrospective study of 5,993 archival periapical biopsies over a span of 15 years from the database of the Oral Pathology Biopsy Service in the Henry M. Goldman School of Dental Medicine at Boston University recorded the incidence of various lesions in a periapical location. RESULTS: Of the cases studied, 97.2% represented lesions of inflammatory origin with histopathologic diagnoses as follows: periapical granuloma (60.0%), radicular cyst (36.7%), periapical fibrous scar (0.27 %), and periapical abscess (0.23 %). The remaining 2.8% cases were lesions of noninflammatory origin with histopathologic diagnoses of odontogenic keratocyst (also known as keratocystic odontogenic tumor), benign fibro-osseous lesions, and ameloblastoma. One patient had Langerhans cell disease, and 1 had central giant cell granuloma. CONCLUSIONS: Although most periapical specimens biopsied represented expected inflammatory periapical lesions, the biological behavior of underdiagnosed lesions may have considerable consequences for both the patient and the clinician. PRACTICAL IMPLICATIONS: This article serves to inform clinicians regarding the diversity of lesions arising in the periapical region of the jaws, to assist in the formulation of differential diagnoses, and to highlight the importance of submission of lesional tissue for histopathologic evaluation and definitive diagnosis when biopsy is clinically indicated.

Complex Apical Intraradicular Infection and Extraradicular Mineralized Biofilms as the Cause of Wet Canals and Treatment Failure: Report of 2 Cases.

This article describes 2 cases that showed persistent intracanal exudation (wet canal) even after several visits of antimicrobial endodontic treatment. Histologic and histobacteriologic investigation was conducted for determination of the cause. The 2 cases involved teeth with apical periodontitis lesions, which presented persistent exudation refractory to treatment after several visits. In case 1, it was not possible to achieve a dry canal, and surgery had to be performed. In case 2, attempts to dry the canal succeeded and the canal was filled, but follow-up examination showed an enlarged apical periodontitis lesion and extraction was performed. Biopsy specimens consisting of the root apex and apical periodontitis lesion for case 1 and the whole root for case 2 were subjected to histologic and histobacteriologic analyses. Both cases showed complex bacterial infection in the apical root, affecting both the intraradicular space and the outer root surface. Case 1 showed bacterial biofilms in ramifications, on untouched walls, and extending to the external root surface to form a thick and partially mineralized structure with high bacterial density. Different bacterial morphotypes were evidenced. Case 2 had a ledge on the apical canal wall created during instrumentation, which was filled with necrotic debris, filling material, and bacteria. The walls of the apical portion of the canal were covered by a bacterial biofilm, which was continuous with a thick extraradicular biofilm covering the cementum and dentin in resorptive defects. The extraradicular biofilm showed areas of mineralization and was dominated by filamentous bacteria. The 2 cases with wet canals and treatment failure were associated with complex persistent infection in the apical part of the root canal system extending to form thick and partially mineralized biofilm structures (calculus) on the outer apical root surface.

A previously unreported association between Nance-Horan syndrome and spontaneous dental abscesses.

Atypical dentofacial structures may be the first indicator of other anomalies linked to a syndrome. This case describes the management of a 9-year-old girl referred for the routine management of supernumerary teeth. The anomalous form of her teeth, together with multiple supernumerary units and a history of congenital cataracts, were suggestive of a diagnosis of Nance-Horan syndrome. This is an X-linked disorder, in which females usually demonstrate mild expression; this case was unusual in respect to the marked phenotype expressed. Unusually, the girl developed 2 spontaneous abscesses of her noncarious upper incisor teeth; a feature never previously described in this syndrome. This report details the patient's dental management and discusses the possible pathogenesis of the dental abscesses, together with the genetic implications of this syndrome.