Baseline MMP expression in periapical granuloma and its relationship with periapical wound healing after surgical endodontic treatment.

BACKGROUND: Matrix metalloproteinases (MMPs) catalyzes the degradation of the extracellular matrix components and have a major role in many physiological processes including wound healing. In the current study, we examined the correlation of baseline MMPs 1, 2, 7, and 9 expressions with periapical wound healing after surgical endodontic treatment. METHODS: 27 patients aged between 15 and 57 years presenting with chronic apical periodontitis or chronic apical abscess of an anterior tooth with previously attempted or failed root canal treatment were included in this study. During surgical endodontic treatment, tissue from the periapical lesion sample was collected and used for gross histopathological analysis as well as mRNA expression analysis of MMPs 1, 2, 7, and 9. Patients were recalled for follow-up after 6  months to evaluate the healing status both clinically and radiographically and healing was correlated with baseline MMP expression. RESULTS: Out of 27 patients, healing was observed in 15 patients at the end of 6 months, and in 21 patients after 12 months.. Six patients showed no healing even after 12 months. Analysis of baseline MMP 1, 2, 7, and 9 expression levels with healing status showed the mean relative expression of MMP2 and MMP9 to be considerably increased in the non-healing group as compared to the healing group. CONCLUSION: Overexpression of MMP2 and MMP9 may be considered as a potential prognostic biomarker for periapical wound healing after surgical endodontic treatment. However, further studies are desirable to establish its precise relationship with periapical wound healing.

Epithelioid cell granuloma with caseating necrosis possibly caused by periapical periodontitis: a case report.

BACKGROUND: Epithelioid cell granuloma with caseating necrosis is a typical pathological finding in tuberculosis. While specific inflammation, including that related to tuberculosis, can induce caseating granuloma formation, there have been very few reports on the induction of caseating granuloma by non-specific inflammation. Chronic periapical periodontitis is usually related to bacterial biofilm formation as well as fungal or viral infection in the periapical lesion. However, it is difficult to eliminate these extraradicular pathogenic microbes by normal endodontic therapy alone, and more invasive surgical removal is almost always required. CASE PRESENTATION: Here we describe the case of a 30-year-old Japanese woman who had suffered from dull pain related to periapical periodontitis for approximately 10 years. Although the causal tooth had been previously extracted at the Department of Oral Surgery of another hospital in 2015, inflammation of the surrounding tissue had not abated. She was referred to our hospital in May 2016 and underwent surgical debridement via an intra/extraoral approach under general anesthesia. A caseating granuloma accompanied by a small amount of fungi was histopathologically confirmed in the excised specimen. Her inflammation has not been exacerbated since the operation. CONCLUSIONS: This is the first report in which non-specific inflammation is shown to induce caseating granuloma arising in the jaw. Our report also highlights the importance of sufficient root canal treatment during the first stage of the procedure.

Pro-inflammatory and anti-inflammatory cytokine expression in post-treatment apical periodontitis.

OBJECTIVE: This study evaluated the expression of pro-inflammatory (IL-1ß, IL-6, IFN-γ and TNF-α) and anti-inflammatory (IL-4 and TGF-ß) cytokines in apical periodontitis lesions. Correlations between these cytokines and clinical and cone-beam computed tomographic (CBCT) data were also assessed. MATERIAL AND METHODS: Apical periodontitis lesions' data were obtained from 27 patients subjected to periradicular surgery. Specimens were processed for histopathologic and immunohistochemical analysis. Sections were evaluated according to the amount of positive staining for each antibody. Expression levels of the target mediators were compared with clinical and CBCT data. RESULTS: Twenty lesions were diagnosed as granuloma and 7 as cyst. In granulomas, IL-4 expression was significantly higher than IL-6 (p=0.001) and TNF-α (p=0.001). There was a significant relationship between high levels of TNF-α and lesions <5 mm (p=0.017). In cysts, IL-6 expression was significant lower than IL-4 (p=0.001) and IFN-γ (p=0.004). There was a significant relationship between high levels of TGF-ß and endodontic treatment performed ≤4 years before (p=0.045). In general, IL-4 was the most expressed mediator in both cysts and granulomas. CONCLUSIONS: There was a balance between the expression of pro-inflammatory and anti-inflammatory cytokines associated with the chronic periradicular inflammatory process. TNF-α and TGF-ß were related to some clinical and CBCT data.

Pro-inflammatory and anti-inflammatory cytokine expression in post-treatment apical periodontitis

Abstract Objective: This study evaluated the expression of pro-inflammatory (IL-1β, IL-6, IFN-γ and TNF-α) and anti-inflammatory (IL-4 and TGF-β) cytokines in apical periodontitis lesions. Correlations between these cytokines and clinical and cone-beam computed tomographic (CBCT) data were also assessed. Material and Methods: Apical periodontitis lesions' data were obtained from 27 patients subjected to periradicular surgery. Specimens were processed for histopathologic and immunohistochemical analysis. Sections were evaluated according to the amount of positive staining for each antibody. Expression levels of the target mediators were compared with clinical and CBCT data. Results: Twenty lesions were diagnosed as granuloma and 7 as cyst. In granulomas, IL-4 expression was significantly higher than IL-6 (p=0.001) and TNF-α (p=0.001). There was a significant relationship between high levels of TNF-α and lesions <5 mm (p=0.017). In cysts, IL-6 expression was significant lower than IL-4 (p=0.001) and IFN-γ (p=0.004). There was a significant relationship between high levels of TGF-β and endodontic treatment performed ≤4 years before (p=0.045). In general, IL-4 was the most expressed mediator in both cysts and granulomas. Conclusions: There was a balance between the expression of pro-inflammatory and anti-inflammatory cytokines associated with the chronic periradicular inflammatory process. TNF-α and TGF-β were related to some clinical and CBCT data.

Dental Implants Placed in Periodontally Infected Sites in Humans.

BACKGROUND: The purpose of the present study was to evaluate fresh socket implant outcome leaving granulomatous tissue into the bone defects. MATERIALS AND METHODS: Subjects requiring tooth extractions in periodontal infected sites were selected for this prospective study. Only patients with 4-wall defects and asymptomatic ones were included. The fresh sockets were randomly scheduled into two groups: In one group (Removal Group, RG) granulomatous tissue was removed and, in the other group (Left Group, LG) granulomatous tissue was left. Implants were positioned immediately after tooth extraction, and were loaded after 3 months in both groups. Intraoral digital radiographs were performed at temporary prosthesis placement; at 12, 24 and 36 months to evaluate marginal bone levels changes. Moreover, clinical parameters were acquired at the same time points. RESULTS: Sixty patients were included in this study. Three-hundred seventy-two implants were placed immediately after tooth extraction and, at 3-year follow-up, a survival rate of 98.66% was reported, 2 implants were lost in RG and 3 implants in LG. At 36-month follow-up, not statistically significant differences were found between RG and LG in marginal bone level changes and clinical parameters (p > 005). Moreover, not statistically significant differences were found in intragroup comparisons over time (p > 0.05). CONCLUSIONS: With the limits of this study it was concluded that granulomatous tissue left in infected fresh sockets doesn't injury dental implant outcome.

Interradicular septum as guide for pilot drill in postextractive implantology: a technical note.

The extraction of teeth results in rapid bone resorption both vertically and horizontally in the first month. The loss of alveolar ridge reduces the chance of implant rehabilitation. The atraumatic extraction, implant placement in extraction socket, and an immediate prosthesis have been proposed as alternative therapies to maintain the volume and contours tissue and reduce time and cost of treatment. Thus, this paper aims to present a clinical case where the extraction was performed using interradicular septum as guide for pilot drill in postextractive implantology with implant placement and immediate provisionalization in a inferior molar. The advantages of this technique are to place the implant exactly in the center of the alveolar ridge, to mantain the edges of the alveolar ridge and reduce postextractive bone resorption, and has great advantages in final prosthetic rehabilitation.

Lesiones periapicales: diagnóstico y tratamiento / Periapical lesions. Diagnosis and treatment

Las lesiones periapicales resultado de la necrosis de la pulpa dental son las patologías que más frecuentemente ocurren encontradas en el hueso alveolar. El tratamiento consiste en la eliminación de los agentes infecciosos mediante el tratamiento del canal radicular, permitiendo la cicatrización de la lesión

Periapical lesions, which are a result of the necrosis of the dental pulp, are the most frequently occurring diseases found in the alveolar bone. The treatment involves the removal of infectious agents by treating the root canal, allowing the wound healing

Expression and immunohistochemical localization of leptin receptor in human periapical granuloma.

AIM: To investigate the expression and immunohistochemical localization of leptin receptor (LEPR) in human periapical granulomas. METHODOLOGY: Periapical inflammatory lesions were obtained from extracted human teeth and teeth which underwent periapical surgery. After their histopathological categorization as periapical granulomas (n = 20), they were examined by immunohistochemistry using human LEPR monoclonal antibodies. LEPR mRNA expression was also determined by quantitative real-time PCR (qRT-PCR), and the amount of LEPR protein was analysed by immunoblot. RESULTS: All granuloma samples expressed LEPR. Amongst inflammatory cells, only macrophages showed expression of LEPR. Western blot analysis revealed the presence in the samples of a protein with apparent molecular weight of ~120 kDa, corresponding to the estimated molecular weight of LEPR. The qRT-PCR analysis demonstrated the expression of LEPR mRNA, corresponding the size of the amplified fragment (338 bp), assessed by agarose gel electrophoresis, to that of LEPR mRNA. CONCLUSIONS: Human periapical granulomas express LEPR. In periapical granulomas, only macrophages showed expression of LEPR. This finding suggests that leptin can play a role in inflammatory and immune periapical responses.

Traumatic ulcerative granuloma with stromal eosinophilia around mini dental implants without the protection of a denture base.

This is a report of a case of an unusual oral lesion after the placement of mini implants for the retention of a mandibular overdenture. A patient received four 2-mm-wide dental implants in the anterior mandible and had her mandibular denture relined with a soft material. After 3 months, she was not wearing her mandibular denture, and two nodular ulcerated lesions were observed near the mini implants. The lesions ceased following excision and regular denture wearing. Clinical and microscopic examination led to the diagnosis of traumatic ulcerative granuloma with stromal eosinophilia (TUGSE). TUGSE is rare lesion with a benign course that may occur following injury of the oral mucosa by mini implants under certain circumstances.

[Oral pulse granuloma of the mandible- a case report]. / Orales Hülsenfruchtgranulom des Unterkiefers.

The oral pulse granuloma represents a rare form of oral foreign body granulomas and results from encapsulation of particles of vegetable nutrition. Histologically, the oral pulse granuloma consists of multinucleated foreign body type giant cells, hyaline rings and chronic inflammation tissue. Intraosseous granulomas can be distinguished from extraosseous granulo- mas. Intraosseous granulomas are often asymptomatic, whereas the extraosseous type may be clinically apparent as an indolent swelling of the mucosa. Therapy consists of curettage or surgical excision. We report on the clinical, radiological and histopathological characteristics of an oral pulse granuloma in the mandible associated with an erupting tooth 46 of a seven-year-old boy, and the surgical management and follow-up.

Nasopalatine duct cyst, a delayed complication to successful dental implant placement: diagnosis and surgical management.

The dental literature reports frequently on both the success and survival of dental implants, whereby the focus remains on the biological response of hard and soft tissue to the implants. The predication and anticipation of adverse implant events can then lead to the preemption of implant loss. However, biological situations can arise that are outside the control of the clinician. The author reports a case history of the late manifestation of a nasopalatine duct cyst in close proximity to a dental implant and its subsequent surgical management.

Reparación expectante de lesiones periapicales de origen endodóntico con cemento MTA-Fill-Apex en una sola cita / pectant repair of apical lesion of endodontic origin with MTA Fill-Apex in a single visit

Presentamos el caso de un paciente del sexo femenino de 26 años de edad, aparentemente, sana con diagnóstico de periodontitis apical crónica en incisivo central (4.1) y lateral inferior derecho (4.2). El tratamiento de conductos se realizó en sesión única y la obturación del sistema de conductos radiculares con técnica de obturación termomecánica y cemento sellador MTA Fill-Apex. La paciente refirió encontrarse asintomática a las 72 horas, posteriormente se realizó control clínico-radiográfico a los 4 meses, en el que se observó adecuada reparación del área periapical, así como ausencia de sintomatología. Se discute la influencia del cemento sellador MTA Fill-Apex utilizado, así como el tratamiento en sesión única en la reparación de lesiones periapicales de origen endodóntico (AU)

We report a case of a female of 26 years oldapparently healthy, diagnosed with chronic apical periodontitis in the lower central incisor (4.1) and lower right side (4.2). Root canal therapy was performed in single session and seal the root canal system obturation technique and sealer thermomechanical MTA Fill-Apex. The patient reported feeling no symptoms at 72 hours, then subjected to clinical and radiographic controls at 4 months, which showed adequate repair of periapical area and the absence of symptoms. We discuss both the influence of the use of the sealer MTA Fill Apex and the single-session treatment for the periapical lesions repair (AU)

Protocol for immediate implant replacement of infected teeth.

Extraction and immediate implant placement has become routine procedure due to reduced treatment time and the preservation of anatomical structures. However, in many cases, this technique involves teeth with different degrees of tissue compromise due to underlying infections. Until now, the degree of implant compromise has not been described, nor has a clinical management protocol been established for these cases. The aim of this article is to report the clinical results of a protocol used for immediate implant placement and provisionalization in infected extraction sockets. A classification of the implant surface compromise (in contact with previously infected tissue) is also described to facilitate the comparative analysis. It is possible to maintain the benefits of immediate implant placement and provisionalization in infected sites by applying a clinical protocol that considers antibiotic therapy, a thorough curettage of the infected tissue, antisepsis, and sufficient primary implant stability.

Super-EBA and IRM as root-end fillings in periapical surgery with ultrasonic preparation: a prospective randomized clinical study of 206 consecutive teeth.

OBJECTIVE: This study evaluated the treatment outcome after periapical surgery with the use of 2 different retrograde root-filling materials and the influence of 3 pre- and perioperative variables on the periapical healing. STUDY DESIGN: Two hundred six teeth in 164 patients were randomly allocated to receive either IRM or Super-EBA as a retrograde root-end seal. The teeth were reviewed 12 months after surgery. The influence of lesion size, lesion type, and orthograde root filling quality on healing was analyzed. RESULTS: One hundred ninety-four teeth in 153 patients were reviewed. Radiologic evaluation and clinical examination revealed 91% success rate for the IRM group and 82% for the Super-EBA group. There was no statistical significance in the healing outcome between the 2 groups (Fisher exact test). The analyzed pre- and perioperative variables had no significant influence on the treatment outcome (Z test). CONCLUSIONS: Both retrograde materials tested in this study can serve as a root-end seal in periapical infected teeth, according to the results of the healing outcome after 12 months' follow-up.

Microsurgical endodontic retreatment of a maxillary molar with a separated file: a case report.

BACKGROUND: A separated instrument complicated orthograde endodontic retreatment of a maxillary molar tooth with apical periodontitis. METHODS: The tooth was treated utilizing microsurgical techniques that employed an operating microscope, ultrasonics, micro-instrumentation and mineral trioxide aggregate as a root-end filling material. RESULTS: Healing was evident at a 12-month review appointment. CONCLUSIONS: Microsurgical techniques have significantly improved the outcomes for healing of periapical lesions when compared to traditional approaches to endodontic surgery. Success rates have been shown to be comparable with conventional orthograde treatment.

Symptoms before periapical surgery related to histologic diagnosis and postoperative healing at 12 months for 178 periapical lesions.

PURPOSE: To compare the preoperative signs and symptoms with the histologic diagnosis and postoperative healing at 12 months for 178 periapical lesions. MATERIALS AND METHODS: A total of 152 patients who had undergone periapical surgery from 2005 to 2008 were studied. The study included patients presenting with signs and symptoms before periapical surgery with a sufficient tissue sample (periapical lesion) for histologic analysis and a minimal follow-up of 12 months. The signs and symptoms present in the soft tissues at the initial examination were recorded. The histologic analysis established the diagnosis as granuloma, cyst, or scar tissue. The postoperative healing at 12 months was evaluated according to the criteria of von Arx and Kurt. RESULTS: Of the 152 patients, 147, with 178 periapical lesions, were included in the present study. No significant relationship was found between the preoperative signs and symptoms, lesion type, and evolution. However, scar tissues were asymptomatic in 78.1%, and 36.4% of granulomas were painful. Of the 8 cysts, 50% were asymptomatic and 50% caused pain. Fibrous scars created no soft tissue alterations in 68.7%. Granulomas had fistulized in 31.7%, and 75% of cysts had produced no alterations. The lesions with swelling had worse healing, and those with no soft tissue alterations had better postoperative healing. CONCLUSIONS: Chronic periapical lesions (granuloma, cyst, and scar tissue) are usually asymptomatic and do not create soft tissue alterations. However, they can deteriorate, producing pain and fistulization. Worse postoperative healing was observed for lesions with swelling, although the difference was not significant.

Microsurgical endodontic retreatment of post restored posterior teeth: a case series.

Post-treatment apical periodontitis may persist due to biological factors as outlined by Nair or when treatment procedures have been ineffective in eliminating the intraradicular infection. This case series reports on the management of five posterior teeth restored with posts where microsurgical techniques were employed utilising the operating microscope, ultrasonics, micro-instrumentation and mineral trioxide aggregate as a root-end filling material. Healing was evident at 12-month review appointments. Microsurgical techniques have significantly improved the outcomes for healing of periapical lesions when compared to traditional approaches to endodontic surgery. Success rates have been shown to be comparable with conventional orthograde treatment.

Management of dens invaginatus type I and open apex: report of three cases.

INTRODUCTION: Dens invaginatus is a critical condition for endodontic treatment once it frequently presents a complex internal anatomy and might be associated with incomplete root and apical development. METHODS: Three cases of dens invaginatus with open apex in maxillary lateral incisors are presented. In the first case, apexification with calcium hydroxide pastes was performed. In the second case, initial treatment was carried out, but the patient missed follow-up appointments for 15 months. In the third case, periradicular surgery was done as a result of the persistence of exudates and incomplete root canal development after conservative endodontic treatment. Oehlers' type I dens invaginatus was also present in the opposite maxillary lateral incisor in 2 patients, but no treatment was required. RESULTS: At subsequent follow-up, the periradicular region was completely healed, and postoperative radiographs revealed good bone healing in all patients. Patient #2 had an increase in root length, and after 38 months the apical third was completely calcified. CONCLUSIONS: A careful clinical and radiographic examination should be conducted to identify dens invaginatus associated with incomplete root development and open apexes. Adequate periradicular healing was observed after the infection, and the anatomical features in the root canal system were accessed. Because a long period is required to determine the clinical outcome, patient compliance must be encouraged.

Periapical radiography and cone beam computed tomography for assessment of the periapical bone defect 1 week and 12 months after root-end resection.

OBJECTIVES: Our aim was to compare periapical radiography and cone beam CT (CBCT) for assessment of the periapical bone defect 1 week and 12 months after root-end resection. METHODS: 50 patients (58 teeth) with a persisting apical periodontitis in a root-filled tooth (incisor, canine or premolar) were treated with root-end resection. 1 week and 12 months post-operatively, a CBCT scan (NewTom 3G) and a periapical radiograph (Digora) were obtained. Three observers detected and measured the periapical bone defects on periapical radiographs and CBCT images (coronal and sagittal sections). RESULTS: 1 week post-operatively, a periapical bone defect area was measured in all teeth by all observers. The defect was 10% smaller on periapical radiographs (mean = 12.4 mm2, SD = 8.2) than on the CBCT images measured in the coronal plane (mean = 13.0 mm2, SD = 7.8), a difference which was not statistically significant (P = 0.58). 12 months post-operatively (n = 52), there was considerable variation between the observers' detection of a remaining defect on the periapical radiographs and the CBCT images. The average agreement between the periapical radiograph and the CBCT images in the coronal sections was 67%, and more defects were detected on CBCT than on periapical radiographs. CONCLUSIONS: On average, the periapical bone defect measured on periapical radiographs was approximately 10% smaller than on coronally sectioned CBCT images 1 week post-operatively. More remaining defects were detected 1 year after periapical surgery on CBCT images than on periapical radiographs, but it is uncertain how this information is related to success or failure after root-end resection.