Chronic Periapical Lesions Research Articles

Fresh‐Socket Implants in Periapical Infected Sites in Humans

The aim of the present study is to compare the outcome of the immediate placement of implants when used in the replacement of teeth with and without chronic periapical lesions. Thirty patients requiring a single-tooth extraction of a monoradicular or premolar tooth were selected. The control group (CG) included 15 patients without periapical lesions but with root caries and root fractures. The test group (TG) included 15 patients with periapical lesions, periapical radiolucencies, and no signs of pain, fistulas, or suppuration. Thirty teeth were extracted, and implants were immediately positioned in fresh sockets and loaded after 3 months in both groups. Clinical parameters (probing depth [PD], modified plaque index, modified bleeding index [mBI], marginal gingiva level [MGL], and keratinized mucosa [KM]) and marginal bone levels were evaluated at baseline and 12 and 24 months after implant placement. Comparisons between CG and TG values over time were performed by the Student two-tailed t test. At the 24-month follow-up, a survival rate of 100% was reported for all implants. The mean bone loss was 0.82 +/- 0.52 mm for the CG and 0.86 +/- 0.54 for the TG. Plaque accumulation was 0.74 +/- 0.29 for the CG and 0.69 +/- 0.29 for the TG. The mBI was 0.77 +/- 0.33 for the CG and 0.72 +/- 0.36 for the TG. The soft tissue profile MGL and KM remained stable for up to 24 months for the CG and TG. The mean PD was 2.05 +/- 0.66 mm for the CG and 1.99 +/- 0.57 mm for the TG. Differences that were not statistically significant were reported between the CG and TG over time and between time points. At the 24-month follow-up, endosseous implants placed immediately in extraction sites affected by periapical infection rendered an equally favorable soft and hard tissue integration of the implants, revealing a predictable outcome.

Distinct Th1, Th2 and Treg cytokines balance in chronic periapical granulomas and radicular cysts

Periapical lesions are a host response that involves immune reaction to prevent dissemination of bacteria from an infected root canal. The purpose of this study was to evaluate the levels of nitric oxide (NO), IL-4, TGF-beta, tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma) in chronic periapical lesions and to determine their possible association with clinical and radiographic parameters. Seventeen human radicular cysts and 30 periapical granulomas were used in this study. Cytokines and NO were assessed by enzyme-linked immunosorbent assay and by the Griess reaction respectively confirmed by immunohistochemical. TNF-alpha and IFN-gamma were detected in 10% of granulomas and in 41.2% and 70% of radicular cysts. IL-4 was reactive in 24% of cysts, and TGF-beta was positive in all samples. Patients with tenderness showed significantly higher levels of IFN-gamma and IL-4 (P < 0.05). Swelling was associated with high levels of TNF-alpha, IFN-gamma, and IL-4 (P < 0.05). Lesions presenting bone resorption were associated with high levels of NO (P < 0.05). Periapical granulomas display a regulatory environment characterized by high TGF-beta and low inflammatory cytokine levels, while radicular cysts has mist Th1 and Th2 inflammatory reaction with the presence of IFN-gamma, TNF-alpha, and IL-4.

Application of a Chairside Anaerobic Culture Test for Endodontic Treatment

Periapical lesions are caused by bacterial infections. The fundamental objective of endodontic treatment is to eliminate bacteria present in the root canal system because they play an important role in the development and maintenance of periapical lesions. Therefore, confirming the absence of bacteria before filling root canals is important. Anaerobic culture tests have been used in many endodontic cases, and they have brought about good treatment outcomes. These tests, however, require specific apparatuses and bacteriological techniques. Here, we report a chairside anaerobic culture test that does not require any specialized apparatuses or techniques. We also report two endodontic cases in which this simple test was used. Both patients were diagnosed with chronic purulent periapical lesions. After confirming the absence of bacteria in the root canals, they were filled with gutta-percha points. At followup, the radiolucencies showed recovery, although longterm observation is under way. From these results, the authors conclude that this simple chairside anaerobic culture test is effective for evaluating periapical lesion treatment procedures.

SEM evaluation of the apical external root surface of teeth with chronic periapical lesion

The aim is to verify, under scanning electron microscopy, the occurrence of apical root resorption in anterior and posterior teeth with chronic and radiographically visible periapical lesions. Thirty-two teeth were extracted, the apical thirds (n = 39) were removed, and prepared to analyse the external apical root surface. All specimens presented irregular areas of root resorption with different depths, located mainly around the apical foramen. Teeth with chronic periapical lesions present areas of external apical root resorption with irregular surface and different depths located mainly around the apical foramen. Root resorptions may show different configurations and destroy the apical root structure more or less extensively.

Immediate Implant Placement Into Fresh Extraction Sites With Chronic Periapical Pathologic Features Combined With Plasma Rich in Growth Factors: Preliminary Results of Single-Cohort Study

The purpose of this prospective study was to evaluate the clinical outcome of implants immediately placed into fresh extraction sockets of teeth affected by chronic periapical pathologic findings, using plasma rich in growth factors (PRGFs) as an adjunct during the surgical procedure. A total of 30 partially edentulous patients with teeth requiring extraction and chronic periapical lesions were included in the present study. A total of 61 transmucosal implants were installed immediately after extraction and careful debridement combined with PRGF placement into the socket. Before insertion, the implant surface was bioactivated by humidification with liquid PRGFs. The prosthetic phase occurred 3 to 4 months after surgery. The implant success and survival and radiographic bone loss were evaluated after 1 year of function. Patient satisfaction for mastication function, phonetics, and esthetics was assessed using a questionnaire. Of the 61 implants, 1 had failed 2 months after insertion because of infection. No additional complications were recorded. The overall implant success and survival rate was 98.4% at 1 year of function. The mean follow-up was 18.5 months (range 10 to 21). All prostheses were successful. The peri-implant bone loss after 1 year averaged 0.41 +/- 0.22 mm. All patients reported full satisfaction for mastication function, phonetics, and esthetics. The use of PRGFs combined with an immediate implant placement procedure can be considered a safe, effective, and predictable treatment option for the rehabilitation of fresh postextraction infected sockets.

Evaluation of periapical changes following endodontic therapy: digital subtraction technique compared with computerized morphometric analysis

The aim of this study was to compare two methods for the evaluation of periapical lesion changes following endodontic therapy (digital subtraction technique and morphometric analysis) by outlining the radiolucent area. 13 human anterior teeth with pulp necrosis and chronic periapical lesions were used. Periapical radiographs were taken immediately after endodontic therapy (0) and then 2 months, 4 months and 6 months post treatment, using an intraoral radiographic film holder stabilized with impression material. The films were processed in a standard manner and the digitized images were submitted to digital subtraction using Adobe Photoshop 6.0. New bone formation or bone resorption areas were then measured. In the morphometric analysis, the periapical lesions were outlined using VixWin 2000 and the area (in square millimetres) was recorded. The obtained data were submitted to agreement analysis for comparison of the two techniques. There was no correlation between the areas of radiographic changes detected by digital subtraction and periapical lesion outline (r = 0.02-0.45). The new bone formation areas observed by digital subtraction presented higher values, with bone changes being especially evident in the 2 month follow-up radiographs, which suggests a higher sensitivity for this method. Both methods are suitable for the evaluation of periapical lesion changes, but the digital subtraction technique is more sensitive for detecting radiographic periapical changes.

Radiographic Morphometric Study of 37 Periapical Lesions in 30 Patients: Validation of Success Criteria

The purpose of this study was to establish the midterm prognosis of periapical surgery by use of the ultrasound technique, comparing a scale obtained by image analysis with the success rates according to other prognostic scales. A clinical follow-up study was performed between September 2004 and September 2005. Thirty-six patients with chronic periapical lesions were treated with periapical surgery via the ultrasound technique and root-end filling with silver amalgam. Evolution was analyzed by use of the different currently accepted assessment scales at 6 and 12 months after intervention with a scale obtained by radiographic image analysis. Thirty patients with a mean age of 40.5 years were studied. The mean follow-up period was 14.2 months. Thirty-seven lesions were analyzed. A positive correlation at 6 months was observed between the radiographic scale proposed in this study and the scales of Rud and Andreasen and von Arx et al. At 12 months, the proposed radiographic scale only correlated with the functional tooth concept established by Friedman. There was no statistically significant relation between the radiographic scale from the image analyzer and the criteria of Rud and Andreasen and von Arx et al.

Immediate implants placed into infected sockets: a case report with 3-year follow-up

The esthetics and functional integrity of the periodontal tissue may be compromised by dental loss. Immediate implants became a viable option to maintain the periodontal architecture because of their anatomic compatibility with the dental socket and the possibility of eliminating local contamination. This article describes the procedure of immediate implant placement in the anterior maxilla replacing teeth with chronic periapical lesions, which were condemned due to endodontic lesions persisting after failed endodontic treatment and endodontic surgery, and discusses the relationship between the procedure and periapical lesions. Surgical removal of hopeless teeth 11, 12 and 21 was performed conservatively in such a way to preserve the anatomy and gingival esthetics. A second surgical access was gained at the apical level, allowing the debridement of the surgical chamber for elimination of the periapical lesion, visual orientation for setting of the implants and filling of the surgical chamber with xenogenous bovine bone graft. After this procedure, the bone chamber was covered with an absorbent membrane and the healing screws were positioned on the implants. Later, a provisional partial removable denture was installed and the implants were inserted after 6 months. After 3 years of rehabilitation, the implants present satisfactory functional and esthetic conditions, suggesting that immediate implant placement combined with guided bone regeneration may be indicated for replacing teeth lost due to chronic periapical lesions with endodontic failure history in the anterior maxilla.

P.179 Endodontic microsurgery: a systematic review

The purpose of this study was to establish the midterm prognosis of periapical surgery by use of the ultrasound technique, comparing a scale obtained by image analysis with the success rates according to other prognostic scales.A clinical follow-up study was performed between September 2004 and September 2005. Thirty-six patients with chronic periapical lesions were treated with periapical surgery via the ultrasound technique and root-end filling with silver amalgam. Evolution was analyzed by use of the different currently accepted assessment scales at 6 and 12 months after intervention with a scale obtained by radiographic image analysis.Thirty patients with a mean age of 40.5 years were studied. The mean follow-up period was 14.2 months. Thirty-seven lesions were analyzed. A positive correlation at 6 months was observed between the radiographic scale proposed in this study and the scales of Rud and Andreasen and von Arx et al. At 12 months, the proposed radiographic scale only correlated with the functional tooth concept established by Friedman.There was no statistically significant relation between the radiographic scale from the image analyzer and the criteria of Rud and Andreasen and von Arx et al.

Correlation of Radiographic Size and the Presence of Radiopaque Lamina With Histological Findings in 70 Periapical Lesions

This study was conducted to relate the histological diagnosis of chronic inflammatory periapical lesions with the radiographic images of these lesions. A total of 70 biopsy specimens obtained during periapical surgery were stained with hematoxylin and eosin and examined under a microscope. Histological analysis established the diagnosis as granuloma, cyst, or scar tissue. The location of the lesion was recorded, as were the radiographic size (maximum and minimum diameter in mm and area in mm(2)) and the presence of radiopaque lamina around the lesion, using an image analyzing system. The distribution of the biopsy specimens was 65.7% granulomas, 25.7% scar tissue, and 8.6% cysts, 1 of which was a keratocyst. The largest lesions were cysts and epithelialized granulomas, with statistically significant differences. Radiopaque lamina was observed around 9 lesions; of these, only 2 were histologically diagnosed as cysts, with the rest as granulomas. Most of the apical lesions were granulomas. Cysts had the largest radiotransparent images; however, in the 70 cases studied, neither the radiographic size nor the presence of associated radiopaque lamina alone was sufficient to determine the type of lesion. Histological analysis is required.

Intraosseous Injection of Clindamycin Phosphate Into the Chronic Apical Lesion of Lower Molar - a Case Report

Periapical disease is the result of bacteria, their product, and the host response to them. Early histological studies of diseased periapical tissue have not been able to demonstrate viable bacteria in the lesions studied. Recent reports indicate that many of periapical lesions are indeed infected before and after endodontic treatment. The validity and applicability of the microbial delivery overcome many disadvantages that we see with systemic drugs. In this case report we presented a novel approach of managing chronic diffuse periapical lesion of lower molar based on specific selection of intracanal medicament in combination with direct periapical injection. We used bacterial culturing and antibiotic sensitivity test to select specific intracanal medicament, in addition we presented an intraosseous injection technique to locally deliver the selected medicament directly into the periapical lesion. Our findings are encouraging and promising. The validity and applicability of the technique needs to be tested in a well controlled clinical trial.

Matrix metalloproteinases (MMP-1, -8, -13) in chronic periapical lesions

Matrix metalloproteinases (MMPs) are proteolytic enzymes capable of degrading almost all extracellular matrix and basement membrane components in many destructive pathological processes, such as chronic inflammation and bone-destructive lesions. The aim of this study was to determinate the correlation between concentration of collagenases (MMP-1, -8, -13) in chronic periapical lesions and their dimension calculated with software predilection through X-ray. Chronic periapical tissues were collected by periapical surgery from 60 teeth with clinically and radiographically verified different chronic periapical lesions (20 granulomas, 20 diffuse periapical lesions, 10 cysts). Ten normal pulps used as controls were obtained by extirpation of the pulp of impacted third molars after their surgery. For rapid analysis of MMP-1, -8, -13 collagenase activities in the examined material Chemicon Collagenase Activity Assay Kit were used. From the X-ray trough software predilection (Image Tool3 Program) of the volume of chronic periapical tissue, correlation between concentration of MMPs in the periapical lesions and their dimension was confirmed. Different concentrations of collagenases (MMP-1, -8 and -13) in chronic periapical process from different inflammation types showed different activity of MMPs. The obtained results showed the highest values of collagenases concentration (MMP-1, -8, -13) in chronic diffuse lesions (5.39 ng/ml). Low values of concentration of MMPs accompanied less serious lesions, whereas chronical periapical lesions of large dimension had high concentration of MMPs, which was proportional to progression of the lesion and destruction of bone tissue. This study confirmed the destructive role of collagenases (MMP-1, -8 and -13) in inflammation process, which directly depends on the concentration of MMPs in pathologically changed tissue.

Serum Interleukin-6 as a Serologic Marker of Chronic Periapical Lesions: A Case-control Study.

Background and aims Chronic periapical disease with pulpal origin is an inflammatory condition caused by bacterial infection. Chronic infection could affect general health by increasing the production of cytokines such as interleukin-6 (IL-6) that probably play a role in pathogenesis of pulpal and periapical diseases. The aim of the present study was a comparative evaluation of the level of serum IL 6 in patients with periapical lesions and healthy controls. Materials and methods This analytical case-control study included 40 patients with chronic peri-apical lesions and 40 individuals without any oral diseases. All of the participants were in good general health. After obtaining an informed consent, clinical and radiographic examinations were carried out and blood samples were collected. Serum IL-6 was measured using ELISA. Data were analyzed using t-test by SPSS 14.0 computer software. Results Serum IL-6 concentration was significantly higher in test group compared to the controls (P < 0.05). Conclusion The results of the present study indicate that IL-6 produced in periapical lesions may serve as a marker of pathologic inflammatory activities in chronic periapical lesions.

Comparative immunohistochemical and quantitative analysis of inflammatory cells in symptomatic and asymptomatic chronic periapical lesions

It has been demonstrated that lymphocytes, plasma cells, macrophages and neutrophil granulocytes represent the predominant cells of the inflammatory lesion of the dental granulomas. Other cells, such as mast cells, eosinophils, dendritic cells comprise minor, but functionally important cell populations. Most of the data considering cells that take part in these processes have been derived from immunohistological studies. This study was undertaken with the aim to determine the phenotype profile of inflammatory cells of dental granulomas using immunohistochemical method in order to study the differences of their quantitative properties and distribution between symptomatic and asymptomatic lesions. The material for the analysis originated from 42 individuals with clinic and radiographic diagnosis of chronic periapical lesions. The tissue was take either during the periradicular surgery, or tooth extraction. Cryostat tissue sections were stained using the alkaline phosphatase-antialkaline phosphatase assay (APAAP). This method is highly valid and sensitive using a panel of specific monoclonal antibodies: CD3, CD4, CD8, CD19, CD38, CD14, CD1a, CD83, CD80, CD86, CD45 and CD123. The composition of the cell population revealed that there was no homogenous and site-specific pattern of the distribution of inflammatory cells. The results of our investigation revealed that the majority of inflammatory cells comprised lymphocytes and plasma cells, followed by subpopulations CD4+, CD8+ and CD14+ cells. Much lower in number were CD80+, CD86+ and CD83+ and CD1a+ cells. There were no statistically significant differences in mean values of inflammatory cells number between symtomatic and asymptomatic lesions, with the exception of CD86+ cells, the number of which was statistically higher in symptomatic lesions. Inflamatory infiltrate cells in dental granulomas are dominated by T- and B-lymphocytes. It points out the complexity of immunopathogenic events in imitiating and progressing of dental granulomas that involve mechanisms of both cellular and humoral immunity. Regarding the quantitative presence of immunocompetent cells in symptomatic and asymptomatic lesions no statistically significant difference was determined unless in mature dendritic cells present in symptomatic lesions.

A Twenty-year Survey of Pathologic Reports of Two Common Types of Chronic Periapical Lesions in Shiraz Dental School.

Background and aims Accurate differential diagnosis between radicular cysts and periapical granulomas cannot be made from radiographs alone. Histological prevalence studies, therefore, assume special importance and may aid the clinician in making judgments regarding therapy. The incidence of radicular cysts has ranged with wide discrepancies in data. The purpose of this study was to evaluate recorded pathologic reports of two common types of chronic periapical lesion in Shiraz Dental School. Materials and methods In this study, biopsy reports of 227 specimens of chronic periapical lesions were reviewed. The following information was extracted from each report: patient’s gender, age, tooth associated with the lesion and the pathological diagnosis. Probable significant differences in the occurrence of lesions between different ages and genders were analyzed using chi-square test. Results 15.9% of the lesions were granulomas, and 84.1% were cysts. A slight difference in the occurrence of the lesions was found between males and females with no statistical significance (P > 0.005). The highest incidence of both lesions was in the third decade of life. No significant differences were found in age distribution of the lesions. The most common location for two lesions was the maxillary anterior teeth. Conclusion Histological differentiation between cysts and granulomas is not always accurate and serial sectioning of excisional biopsies is more valuable than randomized sectioning of curetted biopsies.

Interleukin‐17 plays a role in exacerbation of inflammation within chronic periapical lesions

Interleukin (IL)-17 plays an important role in inflammation and certain autoimmune diseases. However, its role in the pathogenesis of chronic dental periapical lesions has not been studied. Periapical lesion mononuclear cells (PL-MNC) were isolated from inflammatory cells and phenotypically analyzed by immunocytochemistry. The cells were cultured in vitro and IL-17 and IL-8 were measured in the culture supernatants. Controls were peripheral blood (PB) MNC. The level of IL-17 and the proportion of neutrophils were significantly higher in symptomatic lesions. In addition, the production of IL-17 was higher in culture supernatants of PL-MNC isolated from lesions with a predominance of T cells, and the IL-17 concentration correlated with the proportion of CD3+ and CD4+ cells. There was a positive correlation between the levels of IL-17 and IL-8 in the group of symptomatic lesions. The relationship between these cytokines was additionally confirmed on the basis of augmented production of IL-8 by both PL-MNC and PB-MNC treated with IL-17. Our results suggest that IL-17, by stimulating the production of IL-8, may play a role in exacerbating inflammation within chronic periapical lesions.

Vasoactive intestinal peptide receptor expression in chronic periapical lesions

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. 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. 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). Vasoactive intestinal peptide receptors were expressed in chronic periapical lesions with levels inversely proportional to lesion size.

Immunohistochemical detection of Langerhans cells in dental granulomas and radicular cysts

Dental granulomas (DGs) and radicular cysts (RCs) are chronic periapical lesions frequently involving the jaws. Langerhans cells (LCs) are dendritic cells responsible for the presentation of antigens to T lymphocytes. This study examined the expression of LCs in DG and RCs by immunohistochemical staining. Eighteen cases of DGs and 26 cases of RCs were analyzed using anti-CD1a marker. CD1a-labeled LCs were observed in 11.1% of DGs and in 69.2% of RCs, showing a significant correlation (P < 0.0001; Fisher's test). In DGs, LCs were only observed in granulation tissue, showing discrete immunostaining density. In RCs, LCs exhibited both a round and a dendritic shape in all epithelial layers. Although a correlation was observed between immunostaining density and epithelial thickness, as well as between immunostaining and inflammatory intensity, the differences were not significant in radicular cysts. Langerhans cells provide important insight into the immunopathogenesis of chronic periapical lesions.

Pathogenesis of apical periodontal cysts: guidelines for diagnosis in palaeopathology

AbstractApical periodontal cysts are benign lesions developing in relation to the apices of non‐vital teeth due to inflammatory response from the infective pulp. These are epithelium‐lined bony cavities containing fluid. Despite being widely reported in medical/dental literature, this common condition is poorly diagnosed and documented in the archaeological literature. We aim to clarify the correct terminology, demonstrate bony manifestations at different stages of pathogenesis of chronic periapical dental lesions into granuloma and apical periodontal cysts, and to describe diagnostic criteria which would provide practical guidelines for the diagnosis of these conditions.Three identified skulls from the International Exchange Collection, housed in the Anthropological Museum at the University of Coimbra, are used to identify the progression of this condition from a small periapical granuloma to a large apical periodontal cyst with expansion of alveolar and facial bones. The pathogenesis of this condition is described, together with its surgical management in the early 20th century in Portugal, which is the period in which these individuals lived. Confusion resulting from the different terminologies can be avoided if the term periapical granuloma is used to define apical bony lesions smaller than 3 mm at their maximum intra‐bony diameter, and the term apical periodontal cysts for the larger lesions. We recommend that these terminologies and parameters be used as a standard in future studies. This will make inter‐observer and inter‐population comparisons more accurate. Copyright © 2007 John Wiley &amp; Sons, Ltd.

Pattern of Antibiotic Prescription among Dentists in Iran.

This study examines the antibiotic prescription in dentists participated in 9(th) Congress of Iranian Association of Endodontists in Esfahan/2006. A questionnaire for this cross sectional study was designed for evaluating the patterns of antibiotic prescription. It included some demographic information, clinical signs, and conditions in need for antibiotic and prophylactic prescription and their choices. Data was analyzed using Pearson's Chi-square test. High percentage of responders prescribe antibiotic for fever (78.2%) and diffuse swelling (85.1%). However, some situations such as acute pulpitis, chronic periapical lesions and marginal gingivitis were irrationally prescribed. This study showed a fairly good pattern of antibiotic prescription but it was far from ideal.