Diagnóstico clínico, radiográfico e histológico de un caso de fibrosis periapical posendodóntica / Clinical, radiographic, and histologic diagnosis of a postendodontic periapical fibrosis case

Objetivo: La fibrosis periapical posendodóntica es un proceso reparativo asintomático, radiolúcido y no progresivo que se interpreta con frecuencia como una lesión patológica persistente. El diagnóstico de esta entidad suele ser dudoso y sólo puede definirse mediante la correlación de las obser- vaciones clínicas, radiográficas e histológicas. El objetivo de este informe es describir el caso de un paciente que presenta un área radiolúcida periapical persistente y asintomática en un incisivo lateral superior. Caso clínico: Luego de cuatro años y dos meses de ha- ber recibido un tratamiento endodóntico el paciente concurre a la consulta para un examen de rutina. El examen radiográfico del diente revela un área radiolúcida persistente y bien defini- da. A causa de una fractura radicular irreparable, se indicó la extracción de la pieza dentaria. Esto permitió realizar el estu- dio histológico del tejido blando que permanecía adherido en el ápice de la raíz, lo que confirmó y completó el diagnóstico de fibrosis periapical posendodóntica.(AU)

Aim: The postendodontic periapical fibrosis is an asymp- tomatic radiolucent and non-progressive healing process that is often interpreted as a persistent pathological lesion. The diagnosis of this entity is usually uncertain, and it is only de- fined by the correlation of clinical, radiographic and histo- logical observations.The aim of this report is to describe the case of a patient with a long-term persisting asymptomatic and radiolucent area in a upper lateral incisor. Clinical case: Four years and two months after receiv- ing an endodontic treatment the patient comes to our office for a routine control. Radiographic examination revealed the presence of a persistent well defined radiolucent area. Sur- gical tooth extraction was required due to the presence of a complicated root fracture.This allowed to perform a histolog- ical study of the soft tissue attached to the apex of the ex- tracted root, which confirmed and completed the diagnosis of postendodontic periapical fibrosis (AU)

Tratamiento de la osteítis condensante en molar: informe de caso / Molar condensing osteitis treatment: Case report

En la actualidad, la principal causa por la que acuden los pacientes al odontólogo es el dolor dental, endonde la mayoría presenta un padecimiento pulpar o periapical irreversibles, que pueden estar asociados a factores traumáticos e irritativos. Sin embargo, pocosde ellos son asintomáticos, como la osteítis condensante que es escasamente mencionada en elámbito de la Endodoncia; por lo tanto, el objetivo de este caso clínico es el de proporcionar información acerca de la osteítis condensante siguiendo los lineamientos internacionales de Case Report (CARE). La osteítis condensante tiene una incidencia muy baja en pacientes y se debe diagnosticar correctamente al momento de tratar este tipo de lesiones con las diferentes herramientas de diagnóstico que se conocen. En este caso, se presenta un paciente del sexo femenino de 58 años de edad con un estado prediabético, que refiere un fractura del segundo molar inferior derecho, al cual radiográficamente se le encontróuna lesión periapical radiopaca en la raíz distal. Se muestra la secuencia del tratamiento, el manejo clínico y la rehabilitación.

At present, the main reason for patients to visit adentist is dental pain, where most of them presenta pulp or periapical irreversible condition, whichmay be associated with traumatic and irritative factors. However, few of them are asymptomatic as osteitiscondensing that is barely mentioned in thefield of endodontics. The aim of this case report isto provide information about the condensing osteitisfollowing international Case Report (CARE)guidelines. Condensing osteitis has a very low incidence in patients and should be correctly diagnosed with the different available diagnostic tools. In thiscase a 58-years-old female patient, with prediabeticstate, referred of a right lower second molar fracturewhich radiographically showed a radiopaque periapicallesion in the distal root of the molar. The sequence of treatment, clinical management and rehabilitation is presented.

Dentes com vitalidade pulpar e lesão periapical: displasia cemento-óssea periapical / Teeth with pulp vitality and apical periodontitis: periapical cemento-osseous dysplasia

Apesar da afirmação dogmática de que "se o dente tem lesão periapical, não existe mais vitalidade pulpar", isso não corresponde à realidade, pois existem periapicopatias em que os dentes portadores permanecem com vitalidade pulpar. Para fundamentar esse raciocínio, será discutido no presente artigo: 1) O conceito de periapicopatia verdadeira, 2) As diferenças entre ápice e periápice, 3) A distinção entre pericemento apical e periodonto apical, e 4) Considerações sobre a classificação das periapicopatias verdadeiras. Entre as quatro situações clínicas em que o dente com lesão periapical mantém a vitalidade pulpar, escolheu-se, para este primeiro trabalho de uma série, a Displasia Cemento-Óssea Periapical, que não requer qualquer tratamento, apenas controle ao longo do tempo.

[An 18 month evaluation of MM-MTA pulpotomy on primary decayed molars]. / Evaluation sur 18 mois de la pulpotomie au MM-MTA sur des molaires temporaires cariées.

Pulpotomy is the most performed and controversial therapeutic in pediatric dentistry. Formocresol is known to have a toxic effect on living tissues, a mutagenic and carcinogenic potential with a systemic uptake of formocresol via pulpotomized teeth, other alternative products have been investigated. 40 molars were pulpotomized using Micro Mega Mineral Trioxide Aggregate (MM-MTA), which eliminates the need for the use of formocresol. The effects of this material were evaluated both clinically and radiographically. Post-operative control examinations were performed at 1, 6, 12, and 18 months trying to detect spontaneous or stimulated pain, pathological tooth mobility, abscesses or fistulas, internal or external pathological tooth resorption, periapical bone destruction, or canal obliteration. Pain was absent at 18 months post operatively. Thirty six molar treated with the MM-MTA didn't show any mobility or pain, one molar presented a pathological resorption and one molar presented an abscess without a fistula at 12 month. The observations were compared to others related to formocresol, ferric sulfate, MTA, and laser pulpotomies, using the Chi-square test x2. The abundance of positive result strongly demonstrate that the MM-MTA pulpotomy on carious temporary molars is a promising technique.

The dynamics of periapical lesions in endodontically treated teeth that are left without intervention: a longitudinal study.

INTRODUCTION: The long-term dynamics of periapical lesions in endodontically treated teeth is not fully elucidated, thus presenting a clinical dilemma regarding the need for an intervention. The aim of the study was to retrospectively evaluate the long-term dynamics of periapical lesions that were left without intervention in endodontically treated teeth. METHODS: Periapical status surveys of patients treated in a public dental clinic were retrospectively evaluated for the presence of periapical lesions in endodontically treated coronally restored teeth. The dynamics of the included periapical lesions was evaluated based on the periapical index (PAI) score changes between 2 consecutive periapical surveys of at least a 4-year interval. The influence of various factors on lesion dynamics was statistically evaluated. RESULTS: The study cohort consisted of 74 patients with a total of 200 endodontically treated teeth having periapical lesions that fulfilled the inclusion criteria. Fifty-seven (28.5%) lesions remained unchanged, 103 (51.5%) lesions worsened (PAI score increased), and 40 (20%) lesions improved (PAI score decreased). Poor root canal filling and poor restoration were found to adversely affect the long-term dynamics of the periapical lesions (P < .05). Age, sex, and the presence of a post had no statistically significant influence on lesion dynamics (P > .05). CONCLUSIONS: Poor root canal filling and poor restoration may adversely affect the long-term dynamics of periapical lesions that are left without intervention in endodontically treated teeth. Therefore, in cases of poor root canal filling or poor restoration, further intervention may be indicated.

A retrospective analysis of immediately placed implants in 418 sites exhibiting periapical pathology: results and clinical considerations.

PURPOSE: While immediate implant placement has demonstrated a high degree of clinical success, questions remain about whether immediate placement of implants into sites demonstrating periapical pathology will result in treatment outcomes equivalent to those attained when implants are placed into sites that do not demonstrate periapical pathology. MATERIALS AND METHODS: A retrospective study was carried out of patients who presented with periapical pathology and were treated with tooth extraction, defect debridement, and immediate implant placement between 1994 and 2008. All immediately placed implants were followed for a minimum of 24 months after restoration. Implant survival was assessed with the Albrektsson et al criteria and using measurements from the osseous crest to the most coronal extent of the rough surface of the implant on the midbuccal aspect of the implant. A classification system for periapical lesion morphology is also proposed. RESULTS: Four hundred eighteen implants were placed. They were followed for a mean of 67.3 months. Five implants were either lost or demonstrated progressive bone loss beyond acceptable levels, resulting in a cumulative survival rate of 97.8%. CONCLUSIONS: Implant placement at the time of extraction of teeth demonstrating periapical pathology will result in implant survival rates comparable to those of implants placed immediately into sites without periapical pathology.

Cemento-osseous dysplasia in an elderly Asian male: a case report.

Cemento-osseous dysplasia is a disorder typically found in middle-aged black women. However, the present report describes a case in a 61-year-old Vietnamese male. Without proper pulp testing and diagnosis, the radiographic presentation can easily be misdiagnosed as periapical periodontitis. On the basis of pulp vitality, lack of clinical symptoms and radiographic features, the diagnosis in this case was periapical cemento-osseous dysplasia at the mixed stage, which generally requires no treatment. At the 18-month follow-up, the patient was still asymptomatic and none of the clinical signs had changed. This case highlights the importance of careful clinical examination, including a pulp vitality test, and of having an unbiased view of age, gender, and ethnicity when diagnosing this condition.

Pain prevalence and severity before, during, and after root canal treatment: a systematic review.

INTRODUCTION: Anticipation and experience of root canal associated pain is a major source of fear for patients and a very important concern of dentists. Pretreatment, treatment, and posttreatment pain is anticipated, experienced, remembered, and shared by patients. The purpose was to determine the influence of root canal treatment on pain prevalence and severity and estimate the prevalence and severity of pretreatment, treatment, and posttreatment pain in patients receiving root canal treatment. METHODS: Defined searching of MEDLINE, Embase, Cochrane, and PsycINFO databases identified 5,517 articles. Systematic review, including title scanning, abstract scanning, full-text review, and quality rating, provided 72 studies for meta-analysis. L'Abbe plots were used to evaluate the influence of root canal treatment on pain prevalence and severity. Pretreatment, treatment, and posttreatment pain prevalence and severity data were analyzed. RESULTS: L'Abbe plots revealed that pain prevalence and severity decreased substantially after treatment. Mean pretreatment, 24-hour posttreatment, and 1-week posttreatment pain prevalences with associated standard deviations were 81 (28%), 40 (24%), and 11 (14%), respectively. Pretreatment, 24-hour posttreatment, and 1-week posttreatment pain severities, on a 100-point scale, were 54 (24%), 24 (12%), and 5 (5%), respectively. Supplemental injections were frequently required (60 [24%]). CONCLUSIONS: Pretreatment root canal-associated pain prevalence was high but dropped moderately within 1 day and substantially to minimal levels in 7 days. Pretreatment root canal-associated pain severity was moderate, dropped substantially within 1 day of treatment, and continued to drop to minimal levels in 7 days. Supplemental anesthesia was often required.

Periapical bone defects of root filled teeth with persistent lesions evaluated by cone-beam computed tomography.

AIM: To evaluate and categorize the bone defects of root filled teeth with persistent periapical lesions by cone-beam computed tomography (CBCT). METHODOLOGY: Slice images of 532 teeth with persistent periapical lesions were obtained by CBCT in 427 patients and were examined by two endodontists. The periapical lesions were categorized into five types according to the characteristics of the bone defect based on CBCT images. The prevalence of each type was determined and analysed statistically at a 5% significance level using logistic regression. RESULTS: Of the 532 teeth analysed, 67% had buccal or labial bone plate defects (type II), 4% palatal or lingual bone plate defects (type III), 7%'through and through' defects (type IV) and 10% apical root protrusions from the bone plate (type V). Mandibular teeth had a significantly greater prevalence of type I lesions (P=0.0005) and a significantly lower prevalence for types IV (P=0.041), V (P=0.001), V-1 (P=0.015) and V-2 (P<0.001) as compared to maxillary teeth. CONCLUSION: CBCT accurately identified the type of periapical bone defect in persistent lesions. Because 10% of the teeth had apical root protrusions, which could not be identified by periapical radiography, the diagnostic information obtained by CBCT was an essential component of the treatment planning process.

Long-term observation of autotransplanted teeth with complete root formation in orthodontic patients.

INTRODUCTION: The objective of this investigation was to examine the factors influencing the long-term prognosis of autotransplanted teeth with complete root formation. METHODS: Thirty-eight teeth, autotransplanted in 32 patients, were examined more than 6 years after transplantation. Periodontal health, condition of restoration, mobility, occlusal contact, level of gingival margin, and course of orthodontic movement were investigated clinically and with radiographs. RESULTS: More than 6 years after autotransplanation, 33 teeth survived in 27 patients. The survival rate was 86.8% (mean observation time, 9.2 years). Abnormal findings were observed in 9 teeth, so the success rate was 63.1%. An inadequate root filling tended to give rise to abnormal findings. CONCLUSIONS: The success of autotransplantation of a tooth with complete root formation is affected by the quality of root filling. When possible, clinicians should consider autotransplantation before root formation is complete.

The effect of the gap between the post restoration and the remaining root canal filling on the periradicular status in a Turkish subpopulation.

OBJECTIVE: The aim of this study was to evaluate whether the gap between the post restoration and the remaining root canal filling had an impact on the periapical health of endodontically treated teeth in a Turkish subpopulation. STUDY DESIGN: Digital panoramic radiographs, evaluated for this cross-sectional study, were randomly selected from files of patients who attended to Yeditepe University, Faculty of Dentistry, between June 2007 and December 2008. The total number of teeth with endodontic posts and crowns was 407. Two observers assessed the radiographs and evaluated the quality of root canal filling and the gap between the root canal filling and the post restoration. Periapical status of the teeth was assessed by the Periapical Index (PAI) scores. Only the teeth with a minimum of 5 mm apical root canal filling that was classified as "good endodontic treatment" were included in the study. Teeth that had no root canal filling, poor endodontic treatment, or less than 5 mm remaining root canal filling beyond post restoration were not assessed. Chi-square test was used for statistical analysis and significance level was established at 5%. RESULTS: In cases with good endodontic treatment, there were 207 teeth that had no gap between the remaining root canal filling and the post restoration. In this group, 135 (65%) teeth had healthy periapex and 72 (35%) teeth showed signs of apical periodontitis. There were 81 teeth that had a gap between the remaining root canal filling and the post restoration. Of these teeth, 69 (85%) had periapical pathosis; however, only 12 (15%) teeth had healthy periapex. CONCLUSION: Statistical analysis revealed that the success rate of good endodontic treatment was significantly affected by the gap between the post restoration and remaining root canal filling (P < .001).

Strategies for the endodontic management of concurrent endodontic and periodontal diseases.

Endodontic and periodontal diseases can provide many diagnostic and management challenges to clinicians, particularly when they occur concurrently. As with all diseases, a thorough history combined with comprehensive clinical and radiographic examinations are all required so an accurate diagnosis can be made. This is essential since the diagnosis will determine the type and sequence of treatment required. This paper reviews the relevant literature and proposes a new classification for concurrent endodontic and periodontal diseases. This classification is a simple one that will help clinicians to formulate management plans for when these diseases occur concurrently. The key aspects are to determine whether both types of diseases are present, rather than just having manifestations of one disease in the alternate tissue. Once it is established that both diseases are present and that they are as a result of infections of each tissue, then the clinician must determine whether the two diseases communicate via the periodontal pocket so that appropriate management can be provided using the guidelines outlined. In general, if the root canal system is infected, endodontic treatment should be commenced prior to any periodontal therapy in order to remove the intracanal infection before any cementum is removed. This avoids several complications and provides a more favourable environment for periodontal repair. The endodontic treatment can be completed before periodontal treatment is provided when there is no communication between the disease processes. However, when there is communication between the two disease processes, then the root canals should be medicated until the periodontal treatment has been completed and the overall prognosis of the tooth has been reassessed as being favourable. The use of non-toxic intracanal therapeutic medicaments is essential to destroy bacteria and to help encourage tissue repair.

Histology of periapical lesions obtained during apical surgery.

The aim of this was to evaluate the histology of periapical lesions in teeth treated with periapical surgery. After root-end resection, the root tip was removed together with the periapical pathological tissue. Histologic sectioning was performed on calcified specimens embedded in methylmethacrylate (MMA) and on demineralized specimens embedded in LR White (Fluka, Buchs, Switzerland). The samples were evaluated with light and transmission electron microscopy (TEM). The histologic findings were classified into periapical abscesses, granulomas, or cystic lesions (true or pocket cysts). The final material comprised 70% granulomas, 23% cysts and 5% abscesses, 1% scar tissues, and 1% keratocysts. Six of 125 samples could not be used. The cystic lesions could not be subdivided into pocket or true cysts. All cysts had an epithelium-lined cavity, two of them with cilia-lined epithelium. These results show the high incidence of periapical granulomas among periapical lesions obtained during apical surgery. Periapical abscesses were a rare occasion. The histologic findings from samples obtained during apical surgery may differ from findings obtained by teeth extractions. A determination between pocket and true apical cysts is hardly possible when collecting samples by apical surgery.

A report on the clinical and radiographic outcomes of 38 cases of apexification with mineral trioxide aggregate.

The aim of the study was to report on the clinical and radiographic assessment of 38 cases of apexification using MTA over a three year period. Thirty-eight cases of immaturely developed teeth requiring endodontic therapy were treated using MTA to achieve an apical barrier prior to obturation with gutta-percha. The teeth were clinically and radiographically assessed. The findings indicate that apexification using MTA is a predictable procedure. In particular, the number of visits and the total time taken to achieve an apical barrier was markedly less than conventional techniques using calcium hydroxide. The presence of a preoperative periapical radiolucency had no effect on the outcome. MTA shows promise as a viable alternative to calcium hydroxide to achieve root-end closure and using MTA, the number of visits to achieve a successful apical barrier may be markedly reduced. The presence of preoperative periapical radiolucencies did not affect the outcome or the treatment protocol.

Restoration of the endodontically treated tooth: an online study guide.

The Editorial Board of the Journal of Endodontics has developed a literature-based study guide of topical areas related to endodontics. This study guide is intended to give the reader a focused review of the essential endodontic literature and does not cite all possible articles related to each topic. Although citing all articles would be comprehensive, it would defeat the idea of a study guide. This section will focus on restoration of endodontically treated teeth.

Technical quality of root fillings and periapical status in root filled teeth in Jönköping, Sweden.

AIM: To study changes in technical quality of root fillings and periapical status in root filled teeth in random samples of 20 to 70 year-olds between 1973 and 2003. METHODOLOGY: Data from dentate subjects aged 20-70 years from examinations conducted in 1973 (n = 498), 1983 (n = 530), 1993 (n = 547) and 2003 (n = 491) were used for the analysis. Length of root fillings were measured on radiographs to the nearest 0.1 mm. Adequate seal was defined as a root filling without lateral and/or apical voids. Periapical status was assessed according to the periapical index. All observations were made by one calibrated observer registered from full mouth radiographic examinations. Teeth with root fillings ending within the canal without lateral or apical voids were considered adequate. The association between root filling quality and periapical status was analysed by means of the Chi-squared test and a multilevel logistic regression analysis. RESULTS: Adequately root filled teeth had a significantly lower frequency of apical periodontitis than inadequately root filled teeth (11.8% vs. 22.8%). The frequency of technically adequate root fillings increased statistically significant from 1973 (23.7%) to 2003 (36.4%) without a concomitant improvement of the periapical status in root filled teeth over time (24.5% vs. 24.6%). CONCLUSIONS: This study reports on an improving technical quality of root fillings over time, without a concomitant improvement of the periapical status in root filled teeth. A larger proportion of treated molars over time may be of importance for the result.

Procesos endoperiodontales. II. Lesiones endoperiodontales / No disponible

Analiza una clasificación clínica de las lesiones endoperiodontales, la historia clínica para alcanzar un diagnóstico así como las opiniones terapéuticas de las mismas (AU)

Analysis of clinical classification for the endoperiodontal lesions, of the clinical history required to achieve a diagnosis and of their therapeutic options (AU)

Vasoactive intestinal peptide receptor expression in chronic periapical lesions.

AIM: To use radioreceptor analysis for evaluating whether vasoactive intestinal peptide (VIP) receptors are present in chronic periapical lesions and to determine whether differences in its expression are found according to the size of the lesions. METHODOLOGY: Twelve periapical lesions were obtained from teeth diagnosed with chronic apical periodontitis and indicated for endodontic surgery; they were classified according to the size of the lesion in two groups of six samples (lesion size greater or smaller than 5 mm), and then processed and labelled with (125)I-VIP. Binding sites were identified by (125)I-VIP and standard VIP competition assays. Mann-Whitney's test was used to establish statistically significant differences in the VIP receptor expression between groups. RESULTS: Vasoactive intestinal peptide receptor expression was found in all periapical lesion samples. There was a statistically significantly higher expression in periapical lesions <5 mm (P < 0.001). CONCLUSION: Vasoactive intestinal peptide receptors were expressed in chronic periapical lesions with levels inversely proportional to lesion size.

Radiological assessment of periapical status using the periapical index: comparison of periapical radiography and digital panoramic radiography.

AIM: To compare the use of periapical radiographs and digital panoramic images displayed on monitor and glossy paper in the assessment of the periapical status of the teeth using the periapical index (PAI). METHODOLOGY: A total of 86 subjects were examined. All participants underwent a full-mouth radiographic survey (14 periapical radiographs) and a panoramic radiography. The periapical status, using the PAI score, of all appraised teeth was assessed. RESULTS: Periapical radiographs allowed the assessment of the periapical status of 87% of teeth using the PAI. On the contrary, digital radiography had a significantly reduced potential to allow assessment of the periapical status (P<0.01). Only 57.6% and 34.1% of teeth could be appraised using digital panoramic images displayed on monitor and glossy paper respectively (P<0.01). The total percentage of teeth with periapical pathosis was five fold higher when assessed with digital panoramic images displayed on glossy paper compared with periapical radiographs (P<0.01). CONCLUSIONS: Teeth were best viewed on periapical radiographs except maxillary second and third molars, which were better viewed in orthopantomograms. Orthopantomograms on screen were scorable more often than when on printed images. Apical periodontitis was scored more often on paper than on screen, and more often on screen than in periapical radiographs.

Prevalence, duration and aetiology of bacteraemia following dental extractions.

OBJECTIVE: To investigate the prevalence, duration and aetiology of bacteraemia following dental extractions, analysing the factors affecting its development. SUBJECTS AND METHODS: The study group was composed of 53 patients undergoing dental extractions under general anaesthesia. Peripheral venous blood samples were collected at baseline and at 30 s, 15 min and 1 h after the dental extractions. Samples were inoculated into BACTEC PLUS aerobic and anaerobic blood culture bottles and were processed in Bactec 9240. Subculture and further identification of the bacteria isolated was performed by conventional microbiological techniques. RESULTS: The prevalence of bacteraemia following dental extractions was 96.2% at 30 s, 64.2% at 15 min and 20% at 1 h after completing the surgical procedure. The bacteria most frequently identified in the positive blood cultures were Streptococcus spp. (63.8%), particularly Streptococcus viridans. CONCLUSIONS: In our series, the majority of patients undergoing dental extractions developed bacteraemia, usually of a streptococcal nature, independently of the grade of oral health and of the number of extractions performed. Positive blood cultures persisted for at least 1 h after the dental procedure in a considerable number of patients, questioning the supposedly transient nature of bacteraemia following dental extractions.