Chronic Periapical Periodontitis Research Articles

Endodontic treatment of large periapical lesions: An alternative to surgery

Introduction: Non-surgical treatment with calcium hydroxide offers a high success rate in the healing of large periapical lesions. Case Series: We present the healing of large periapical lesions with conservative, non-surgical treatment in three young patients presenting large periapical lesions and diagnosed with chronic periapical periodontitis. Non-surgical endodontic treatment was carried out involving canal preparation, irrigation with 2.5% sodium hypochlorite, filling of the canal with 75% calcium hydroxide and 25% Kri-1 iodoform paste mixed with sterile saline solution, and sealing of the cavity with composite. The filling was replaced several times, after which endodontic treatment was finally carried out. Complete apical healing was observed in all cases. Conclusion: Non-surgical treatment as a first option allows us to avoid the trauma of surgery in young individuals.

Imaging of extraradicular biofilm using combined scanning electron microscopy and stereomicroscopy

Microorganisms are able to survive and induce persistent infection in extraradicular areas. The objective of this study was to evaluate the relationship between extraradicular biofilm and persistent periapical periodontitis. Thirty-five apical samples with different stages of pulp and periapical pathology (vital pulp, pulp necrosis without radiographically visible periapical lesions, chronic periapical periodontitis that had not received root canal therapy and persistent periapical periodontitis) were initially evaluated using scanning electron microscopy. The same samples were then processed using Brown and Brenn-modified Gram staining. We detected extraradicular biofilm in all samples with persistent periapical periodontitis and in three samples with chronic periapical periodontitis. The extraradicular bacteria predominantly had rod and filament morphology and were surrounded by varying amounts of amorphous extracellular material. The surfaces outside the root of the apical samples with vital pulp and pulp necrosis were covered by fibers, and no extraradicular microorganisms were present, which suggests that extraradicular biofilm is closely associated with failed endodontic treatments, thus resulting in persistent infection.

A case of primary diffuse large B‐cell non‐Hodgkin's lymphoma misdiagnosed as chronic periapical periodontitis

Lymphoma is a malignant neoplasm of component cells of the lymphoid system which is very rare in the jaws. Here we report a case of primary diffuse large B-cell lymphoma located in the periapical region of a mandibular molar which was misdiagnosed as chronic periapical periodontitis. The present case was diagnosed at an early stage and effectively managed by chemotherapy. Although lymphoma of the mandible is rare, it must be considered in the differential diagnosis of radiolucent lesions in this region. Lack of knowledge of this rare presentation may lead to delays in diagnosis and poor prognosis.

Regenerative Treatment of a Cemental Tear Using Enamel Matrix Derivatives: a Ten-Year Follow-up

A patient presented with chronic periapical periodontitis on tooth 45. The root canal was re-treated and a wide apical perforation was closed with MTA® as an apical plug. At reevaluation six month later, the tooth presented with increased mobility, bleeding on probing and probing pocket depths of 9 mm. Despite good periapical healing radio graphically, the tooth showed signs of localized marginal bone loss that was diagnosed as being due to a cemental fracture. The tooth was splinted, a muco-periostal flap was raised and the fragment of cementum was removed. The defect was treated in a regenerative approach, using enamel matrix derivatives (EMD). Six month after therapy, the probing pocket depths decreased to values of ≤ 3 mm and a defect fill was radiographically visible. The 10-year follow up showed a stable situation. It can be concluded that the occurrence of a local delamination of the root surface may contribute to the development of plaque-induced periodontal destruction. Its removal and the regenerative conditioning of the root surface with EDTA and EMD may result in a, at least partial, resolution of the problem and regeneration of bone at the affected the site.

Antibiofilm Effects of Azithromycin and Erythromycin on Porphyromonas gingivalis

Antibiotic resistance of biofilm-grown bacteria contributes to chronic infections, such as marginal and periapical periodontitis, which are strongly associated with Porphyromonas gingivalis. Concurrent azithromycin (AZM) administration and mechanical debridement improve the clinical parameters of periodontal tissue in situ. We examined the in vitro efficacy of AZM against P. gingivalis biofilms. The susceptibilities of adherent P. gingivalis strains 381, HW24D1, 6/26, and W83 to AZM, erythromycin (ERY), ampicillin (AMP), ofloxacin (OFX), and gentamicin (GEN) were investigated using a static model. The optical densities of adherent P. gingivalis cells were significantly decreased by using AZM and ERY at sub-MIC levels compared with those of the controls in all the strains tested, except for the effect of ERY on strain W83. AMP and OFX inhibited P. gingivalis adherent cells at levels over their MICs, and GEN showed no inhibition in the static model. The effects of AZM and ERY against biofilm cells were investigated using a flow cell model. The ATP levels of P. gingivalis biofilms were significantly decreased by AZM at concentrations below the sub-MICs; however, ERY was not effective for inhibition of P. gingivalis biofilm cells at their sub-MICs. Furthermore, decreased density of P. gingivalis biofilms was observed three-dimensionally with sub-MIC AZM, using confocal laser scanning microscopy. These findings suggest that AZM is effective against P. gingivalis biofilms at sub-MIC levels and could have future clinical application for oral biofilm infections, such as chronic marginal and periapical periodontitis.

Receptor for advanced glycation end products (RAGE)-expressing endothelial cells co-express AGE and S100 in human periapical granulomas

Objective The engagement of the receptor for advanced glycation end products (RAGE) by AGE or S100 perturbs homeostatic mechanisms and provides a basis for cellular dysfunction in pathological situations. To assess the mechanism of vascular immune reactions in chronic periapical periodontitis, we analysed co-expression of RAGE and AGE or S100 in periapical granulomas. Methods Surgically removed periapical lesions, which had been diagnosed as chronic periodontitis, were inspected histologically using paraffin-embedded sections stained with haematoxylin and eosin. Cryostat sections of the tissues, which were identified histologically as periapical granulomas, were then examined by double immunohistochemistry using polyclonal antibodies raised against human CD34 and monoclonal antibodies specific for human RAGE, AGE or S100. Dual-colour immunofluorescence image analysis was also performed to assess the co-expression of RAGE and AGE or RAGE and S100 by endothelial cells. Results Marked expression of RAGE, AGE, and S100 by CD34 + endothelial cells was noted. Dual-colour immunofluorescence image analysis revealed that the RAGE-expressing endothelial cells co-expressed AGE and S100; however, the number of RAGE–AGE-expressing endothelial cells was significantly higher than that of RAGE–S100-expressing endothelial cells. Conclusions Co-expression of RAGE and AGE by endothelial cells in periapical granulomas is more relevant than that of RAGE and S100. The possible engagement of RAGE and AGE may trigger cellular activation and mediate tissue injury.

Chronic periapical periodontitis containing mature human hair shaft: a case report

A case is reported of a 44-year-old male who was referred with persistent pus discharge associated with his UL2 which had been root treated on two occasions. Radiographic examination revealed a radiolucency of approximately 8 mm diameter. An apicectomy was performed and histopathological examination revealed the presence of mature birefringent hair-shaft structures within a chronic periapical periodontitis. This article presents a rare occurrence, the presence of human hair in the periapical tissues.

Causes of persistent sinus tract after treatment of chronic periapical periodontitis

慢性根尖周炎通过根管治疗后大多能彻底治愈,但也有少数病例久治不愈,窦道或瘘管持续存在.导致这一状况的原因很多,常见的包括有遗漏根管、根管清理不彻底、根尖封闭不密合、根裂以及根尖周存在特殊感染等,下面结合3例典型病例做一浅显分析。

Detection of Bacteroides forsythus and Porphyromonas gingivalis in infected root canals during periapical periodontitis by 16S rDNA

Periapical periodontitis is termed when inflammation of the periodontium is caused by irritants of endodontic origin. Bacterial strains in the root canals were not easy to be identified by the traditional agar culture. In this study a 16S rDNA-based polymerase chain reaction detection method was used to determine the occurrence of Bacteroides forsythus and Porphyromonas gingivalis in chronic periapical periodontitis among Chinese patients. 217 patients with chronic periapcial periodontitis were recruited and a total of 266 teeth were collected. The subjects had no systemic diseases, no antibiotics taken, no root canal treatment (RCT) performed on the infected teeth in the last 3 months. The DNA of bacteria in the root canal was extracted and amplified using universal 16S rDNA primers. The amplification was performed to detect B. forsythus and P. gingivalis using oligonucleotide primers designed from species-specific 16S rDNA signature sequences. B. forsythus and P. gingivalis were detected in 26 and 40% of the participants, respectively. 24 out of 217 infected root canals demonstrated the existence of both types of bacteria, the utility of a 16S rDNA-based PCR detection method showed high sensitivity and high specificity to directly detect B. forsythus, P. gingivalis or other pulpal microorganisms from samples of root canal infections. The results indicated that B. forsythus or P. gingivalis might be a member of the microbiota associated with chronic periapical periodontitis and there was a strong association between the studied species and periodontitis.

Inadvertent Injection of Sodium Hypochlorite into the Periradicular Tissues during Root Canal Treatment

This paper describes a sodium hypochlorite (NaOCl) incident occurring during routine endodontic treatment of a patient who presented with chronic periapical periodontitis of a maxillary canine tooth and discusses the immediate and late treatment of this case.

Detection of Bacteroides forsythus and Porphyromonas gingivalis in infected root canals during periapical periodontitis by 16S rDNA

Periapical periodontitis is termed when inflammation of the periodontium is caused by irritants of endodontic origin. Bacterial strains in the root canals were not easy to be identified by the traditional agar culture. In this study a 16S rDNA-based polymerase chain reaction detection method was used to determine the occurrence of Bacteroides forsythus and Porphyromonas gingivalis in chronic periapical periodontitis among Chinese patients. 217 patients with chronic periapcial periodontitis were recruited and a total of 266 teeth were collected. The subjects had no systemic diseases, no antibiotics taken, no root canal treatment (RCT) performed on the infected teeth in the last 3 months. The DNA of bacteria in the root canal was extracted and amplified using universal 16S rDNA primers. The amplification was performed to detect B. forsythus and P. gingivalis using oligonucleotide primers designed from species-specific 16S rDNA signature sequences. B. forsythus and P. gingivalis were detected in 26 and 40% of the participants, respectively. 24 out of 217 infected root canals demonstrated the existence of both types of bacteria, the utility of a 16S rDNA-based PCR detection method showed high sensitivity and high specificity to directly detect B. forsythus, P. gingivalis or other pulpal microorganisms from samples of root canal infections. The results indicated that B. forsythus or P. gingivalis might be a member of the microbiota associated with chronic periapical periodontitis and there was a strong association between the studied species and periodontitis.

The transition from pulpitis to periapical periodontitis in dogs’ teeth

The purpose of the study was to histologically analyse transition from pulpitis to periapical periodontitis on dog's teeth. Pulps of mandibular premolars (37 roots) were exposed using a low-speed handpiece. Teeth were left open to the oral environment for 20, 35, 50 and 65 days. After the experimental period animals were sacrificed. Undemineralised teeth with surrounding bone, embedded in methylmetacrylate, were prepared for standard histological analysis. All teeth with pulpitis (five roots), regardless of the experimental period, had acute serose periapical periodontitis. All teeth (15 roots) with partial pulp necrosis had subacute periapical periodontitis. Teeth with complete pulp necrosis (19 roots) had chronic periapical periodontitis and in one case suppurative apical periodontitis. The condition of the pulp correlates with the histopathological findings of periapical tissue in the open types of pulp infection. Acute periapical periodontitis begins during pulpitis and can occur before 20 days of pulp exposure in the dog.

Confocal immunolocalization of VE‐cadherin‐ and CXC chemokine‐expressing endothelial cells in periapical granulomas

To determine whether endothelial cells (ECs) in periapical granulomas can express vascular endothelial (VE)-cadherin, CXCL8 and CXCL10 by examining with two-colour confocal laser scanning microscope. Periapical lesions were surgically removed from patients with chronic periapical periodontitis (n = 20), and the paraffin-embedded sections were prepared after being fixed with cold acetone. The 7-mum-thick sections were stained with haematoxylin-eosin and then examined pathologically using a light microscope. The lesions diagnosed as periapical granulomas (17 specimens) were analysed further using immunofluorescence and antibodies specific for human VE-cadherin, CXCL8, and CXCL10. The slides were carefully examined using a confocal laser scanning microscope. The numbers of positive ECs were counted, and the comparison between VE-cadherin-positive ECs and CXCL8 or CXCL10 was assessed statistically using one-way ANOVA followed by a Student-Newman-Keuls test. The expression of CXCL8 and CXCL10 by ECs was detected in 60.4 +/- 13.4 and 67.2 +/- 13.9%, respectively. However, the percentage of VE-cadherin-expressing ECs was 40.4 +/- 10.5%, which was significantly lower (P < 0.01) than CXCL8 and CXCL10-expressing ECs. Two-colour immunofluorescence staining revealed that ECs co-expressed VE-cadherin and CXCL8 (37.4 +/- 14.1%) or CXCL10 (39.1 +/- 13.8%). VE-cadherin expression in ECs was lower than CXCL8 and CXCL10, suggesting that inflamed ECs in periapical granulomas could increase vascular permeability and that leukocyte chemotaxis mediated by ECs might occur. These findings may suggest the possibility that ECs could play a pivotal role in cell recruitment in periapical granulomas.

Involvement of Inducible Nitric Oxide Synthase and Receptor for Advanced Glycation End Products in Periapical Granulomas

We examined the presence of the receptor for advanced glycation end products (RAGE) in periapical granulomas and analyzed the interaction between RAGE and inducible nitric oxide synthase (iNOS) to elucidate inflammatory reaction mechanisms. Periapical lesions were surgically removed from 37 patients with chronic periapical periodontitis and halved. Paraffin sections were prepared from half of each lesion and stained with hematoxylin and eosin, whereas cryostat sections were prepared from the other half. Based on the histological evaluation, 33 of the lesions were diagnosed as periapical granulomas. These were examined by immunohistochemistry using serial cryostat sections probed with anti-human iNOS or RAGE antibodies. Macrophages, lymphocytes, and endothelial cells expressed RAGE and these cell types, in addition to plasma cells, exhibited anti-iNOS immunoreactivity. Serial cryostat sections demonstrated the infiltration of RAGE-expressing cells around iNOS-producing cells, suggesting that these molecules may be important in the tissue injury associated with periapical periodontitis.

A Case of Cutaneous Odontogenic Sinus

Despite the fact that cutaneous sinus tracts of odontogenic origin are well documented, the condition is still commonly misdiagnosed, because chronic periapical periodontitis may be asymptomatic and is rarely open to the skin. A 75-year-old Japanese woman presented to our clinic with the chief complaint of a left cheek skin lesion with mild pain. Physical examination revealed a subcutaneous nodule covered with erythematous skin on her left buccal region. Cultures from the subcutaneous nodule grew Bacteroides species and Peptostreptococcus micros but did not yield acid-fast bacilli, fungi, or Actinomyces. Stains of smeared pus showed a considerable number of Gram-negative rods. The histopathological examination revealed a focal abscess formation in the lower dermis and subcutaneous tissue. Dental evaluation, including an orthopantogram, showed a radiolucent alveolar area at the left lower first molar apex, suggesting a periapical abscess. Antibiotic therapy for three weeks associated with surgical root canal therapy eliminated the subcutaneous nodule. A high degree of suspicion is required to correctly diagnose a lower facial lesion as being of odontogenic origin, and prompt dental evaluation should be considered.

Participation of Bacterial Biofilms in Refractory and Chronic Periapical Periodontitis

The aim of this study was to examine morphologically the participation of extraradicular biofilm in refractory periapical periodontitis. Six teeth and five extruded root filling gutta-percha points associated with refractory periapical periodontitis were investigated by scanning electron microscope. In nine of 11 samples examined, bacterial biofilms were seen at the extraradicular area. The gutta-percha surface was covered with glycocalyx-like structures, and filaments, long rods, and spirochete-shaped bacteria were predominant in the extraradicular sites. Planktonic cells, which were filaments and spirochete-shaped bacteria, emigrated from the glycocalyx structures in some spots. In the extracted teeth, biofilm consisting of both bacteria and glycocalyx-like structures were observed on the periapical root surfaces. Next to the residual periodontal ligament, a few filaments, rods, and fusiforms were attached on the healthy cementum surface. The present findings suggested that bacterial biofilms formed in the extraradicular areas were related to refractory periapical periodontitis.

Expression of inflammatory cytokine genesin vivo by human alveolar bone-derived polymorphonuclear leukocytes isolated from chronically inflamed sites of bone resorption

Alveolar bone-derived polymorphonuclear leukocytes (PMNs) were characterized for their ability to produce inflammatory cytokines such as interleukin-1 alpha (IL-1 alpha), IL-1 beta, tumor necrosis factor alpha (TNF alpha), and IL-6 in vivo. Periapical exudates (PE) were collected from periapical lesions with chronic periapical periodontitis through root canals. Cells and noncellular supernatants were then isolated by centrifugation. The concentration of cytokines present in the noncellular supernatants were determined by ELISA. High concentrations of IL-1 alpha, IL-1 beta, and IL-6 were detected in PE, however, TNF alpha was not. PE contains predominantly PMNs ( > 95% of residing cells) with a few percent of lymphocytes and/or macrophages. These alveolar bone-derived PMNs were purified by the Ficoll-Hypaque gradient method and were analyzed for cytokine mRNA expression using the cytokine-specific reverse-transcription polymerase chain reaction. Highly purified PMNs ( > 99.5%) isolated from PE expressed significant levels of mRNA for IL-alpha, IL-1 beta, and TNF alpha. IL-6 mRNA was not detected, although a high concentration of IL-6 was detected in supernatants of PE by ELISA. The IL-6 secretion in PE could be derived from macrophages, T lymphocytes, osteoblasts, or fibroblasts around periapical lesions. These data strongly suggest that human PMNs derived from alveolar bone can spontaneously produce IL-1 alpha, IL-1 beta, and TNF alpha at sites of inflammation, and probably initiate inflammation and regulate augmentation of bone resorption in vivo.

Histopathological observations of periapical repair in teeth with radiolucent areas submitted to two different methods of root canal treatment

Dogs' teeth with induced chronic periapical periodontitis were treated endodontically by two different methods, and the results were compared. A total of 40 root canals from the upper and lower premolars of two dogs were prepared chemomechanically. In method 1, a high-concentration (5.25%) hypochlorite solution was used during the instrumentation of the root canal, and an antibacterial dressing was applied between sessions, followed by filling of the root canal. In method 2, a low-concentration (0.5%) sodium hypochlorite solution was used as an adjunct to mechanical debridement, and the root canal was filled during the same session. The histopathological results showed that method 1 led to better periapical repair than method 2.

Replantation of infected deciduous teeth: A contribution to the problem of their preservation until normal shedding: Preliminary report

A preliminary report has been presented of five cases in which deciduous teeth were replanted. The replantations involved three teeth with chronic periapical periodontitis, one with pulpitis, and one in which complete avulsion occurred as the result of an accident. The satisfactory results (which include fast healing, normal clinical appearance, firm retention in the alveolus, normal resorption of the deciduous roots, and normal eruption of the underlying permanent teeth) indicate that replantation of deciduous teeth that cannot be otherwise saved should be done routinely in pedodontics instead of space maintenance after extraction.