Periapical Inflammatory Lesions Research Articles

Nonsurgical Minimally Invasive Endodontic Treatment of Large Periapical Lesions: A Report of Three Cases

Introduction Periapical lesions develop as a result of microorganisms from necrotic pulp tissue or retained foreign bodies in the periapical tissue, leading to acute or chronic inflammation. It has been proven that the majority of inflammatory periapical lesions can be effectively treated using nonsurgical endodontic management. However, the selection between surgical and nonsurgical endodontic treatment for managing large periapical lesions remains a controversial issue. This report aims to reveal the effectiveness of nonsurgical, minimally invasive endodontic treatment for large periapical lesions in conjunction with lesion decompression and aspiration. Case Presentation This article presents three cases with large periapical lesions related to severe bone destruction with different causes that were managed with nonsurgical endodontic treatment, involving multiple visits for intracanal medication with calcium hydroxide. In all three cases, the long-term clinical assessments and CBCT scans consistently showed complete healing. The follow-up period ranged from 24 to 48 months. Conclusion The successful results demonstrated the efficacy of nonsurgical endodontic management, which is a minimally invasive approach when addressing large inflammatory periapical lesions with diverse causes.

Rev-erbα attenuates refractory periapical periodontitis via M1 polarization: An in vitro and in vivo study.

Rev-erbα has been reported to regulate the healing of inflammatory lesions through its effect on the immune system in a variety of inflammatory disease. Moreover, the balance of macrophages polarization plays a crucial role in immune response and inflammatory progression. However, in refractory periapical periodontitis (RAP), the role of Rev-erbα in inflammatory response and bone resorption by regulating macrophage polarization remains unclarified. The aims of the present study were to investigate the expression of Rev-erbα in experimental RAP and to explore the relationship between Rev-erbα and macrophage polarization through the application of its pharmacological agonist SR9009 into the in vivo and in vitro experiments. Enterococcus faecalis-induced RAP models were established in SD rats. Histological staining and micro-computed tomography scanning were used to evaluate osteoclastogenesis and alveolar bone resorption. The expression of Rev-erbα and macrophage polarization were detected in the periapical tissues from rats by immunofluorescence, flow cytometry, and western blots. Furthermore, immunohistochemical staining and enzyme-linked immunosorbent assay were performed to explore the relationship between Rev-erbα and inflammatory cytokines related to macrophage polarization. Compared to healthy periapical tissue, the expression of Rev-erbα was significantly down-regulated in macrophages from inflammatory periapical area, especially in Enterococcus faecalis-induced periapical lesions, with obvious type-1 macrophage (M1)-like dominance and the production of pro-inflammatory cytokines. In addition, Rev-erbα activation by SR9009 could induce type-2 macrophage (M2)-like polarization in periapical tissue and THP1 cell line, followed by increased secretion of anti-inflammatory cytokines IL-10 and TGF-β. Furthermore, intracanal application of SR9009 reduced the lesion size and promoted the repair of RAP by decreasing the number of osteoclasts and enhancing the formation of mineralized tissue in periapical inflammatory lesions. Rev-erbα played an essential role in the pathogenesis of RAP through its effect on macrophage polarization. Targeting Rev-erbα might be a promising and prospective therapy method for the prevention and management of RAP.

Genetic polymorphism of interleukins 6 and 17 correlated with apical periodontitis: A Cross-sectional study.

Interleukins 6 and 17 act in bone resorption in the presence of infections of endodontic origin for host defense. Genetic polymorphisms may be associated with increased bone loss, represented by areas of large periapical lesions. This study aimed to verify the frequency of interleukin 6 and 17 gene polymorphism in patients with asymptomatic apical periodontitis or chronic apical abscess and to verify the existence of correlations between periapical lesion area with age, gender, and presence of the polymorphism, in the studied population, in the state of Pernambuco. A population consisting of thirty diagnosed individuals was included. The area of the lesions was measured in mm². Genomic DNA was extracted and genotyping was performed by Polymerase Chain Reaction Restriction Fragment Length Polymorphism for interleukin 6 (rs 1800795) and interleukin 17 (rs 2275913). Fisher's exact, chi-square, and odds ratio tests were used. A logistic regression analysis was also performed using sex, age, and the presence of polymorphism as covariates, in addition to linear regression to test the relationship between age and lesion area. All tests used a significance level of 0.05% (p ≤0.05%). There was no statistical significance in the occurrence of large areas of periapical lesions correlated with age, sex, and diagnosis, nor in the distribution of alleles in the polymorphism of interleukins 6 and 17 in the studied groups. The frequency of homozygous and heterozygous polymorphism was high. The polymorphism of these interleukins is not correlated with the increase in the areas of asymptomatic periapical inflammatory lesions.

Influence of the quality of canal obturation and prosthetic restoration on the peri-apical region

The periapical inflammatory lesion of endodontic origin (LIPOE) is a very common condition and constitutes both a diagnostic and a therapeutic challenge in dentistry. The present study aims to describe the frequency of LIPOE after endodontic treatment consecutive to the quality of root canal fillings and prosthetic restorations of abutment teeth and to identify the qualities of root canal fillings and prosthetic restorations associated with the occurrence of LIPOE. This is a prospective, descriptive and cross-sectional study carried out from March 2019 to August 2022. One hundred and eighty patients wearing Joint Prostheses for at least 2 years with endodontically treated abutment teeth have been recruited; the evaluation of the quality of prosthetic restoration was established according to the criteria of Hickel R while the quality of the root canal filling was judged according to the criteria of Schaeffer MA. The frequency of LIPOE on the abutment teeth was 59.4%. The results highlighted that inadequate quality of prosthetic restoration and root canal filling is associated with the occurrence of LIPOE with a highly significant difference (p˂0.000) In order, to reduce the prevalence of LIPOE and mitigate its effects, it is essential to follow the rules of the art when considering mechanical and biological imperatives during endodontic treatment, as well as good training in prosthetic restoration.

Prevalence of barodontalgia in Brazilian aviation pilots and flight attendants

Introduction: Barodontalgia is an unusual toothache associated with a change in atmospheric pressure. Many cases of barodontalgia occur in teeth that already have some clinical alteration: deep caries lesions, previous restorative treatment, pulp necrosis, pulpitis, inflammatory periapical lesions, and failed dental restoration. The occurrence of barodontalgia is more common in climbers, divers, and aviation professionals. The objective of this research was to investigate the prevalence and characteristics of barodontalgia in Brazilian pilots, copilots, and flight attendants. Material and Methods: An electronic questionnaire with ten questions about barodontalgia was applied to a group of aviation professionals. Results: One hundred and forty captains, 23 copilots, and 95 flight attendants (174 men and 84 women) answered the questionnaire. The prevalence of barodontalgia in this sample was 21.7%. There was a low correlation between barodontalgia and age (CI = −0.233) and length of service in the profession (CI = −0.272). Barodontalgia was more frequent during the cruise (57.1%) and landing phases (25%). Mandibular molars were the teeth most affected by barodontalgia (48.2%). Most aviation professionals who manifested barodontalgia used to visit the dentist more than once a year. Conclusion: The prevalence of barodontalgia in Brazilian crew members was high and mainly affects male flight attendants.

Incidental Pathologic Findings from Orthodontic Pretreatment Panoramic Radiographs

Panoramic radiography is frequently performed for new patients, follow-ups and treatment in progress. This enables dental clinicians to detect pathology, view important structures, and assess developing teeth. The objective of the study was to determine prevalence of incidental pathologic findings (IPFs) from orthodontic pretreatment panoramic radiographs at a university dental hospital. A retrospective cross-sectional review was conducted of pretreatment panoramic radiographs, using data collection sheets with predefined criteria. Demographic data and abnormalities (impacted teeth, widening of periodontal ligament, pulp stones, rotated teeth, missing teeth, unerupted teeth, crowding, spacing, supernumerary teeth, and retained deciduous teeth) were reviewed. SPSS 28.0 was used to analyze data with statistical tests set at a 5% significance level. Results: One hundred panoramic radiographs were analyzed with an age range of 7 to 57 years. The prevalence of IPFs was 38%. A total of 47 IPFs were detected with altered tooth morphology predominantly (n = 17). Most IPFs occurred in males (55.3%), with 44.7% in females. A total of 49.2% were in the maxilla and 50.8% in the mandible. This difference was statistically significant (p < 0.0475). Other abnormalities were detected in 76% of panoramic radiographs; 33 with IPFs and 43 without. A total of 134 other abnormalities detected showed predominantly impacted teeth (n = 49). Most of these abnormalities were in females (n = 77). Conclusions: The prevalence of IPFs was 38%, predominated by altered tooth morphology, idiopathic osteosclerosis, and periapical inflammatory lesions. Detection of IPFs from panoramic radiographs underscored the importance for clinicians to examine them for comprehensive diagnosis and treatment planning, especially in orthodontics.

Radiographic patterns of periosteal bone reactions associated with endodontic lesions.

The formation of new bone by periosteum due to an insult is called periosteal bone reaction (PBR). This study assessed the cone beam computed tomography (CBCT) patterns of periosteal bone reactions associated with periapical inflammatory lesion (apical periodontitis/periapical rarefying osteitis). Twenty-two small field of view CBCT images of patients with PBR were selected from a database of a private practice limited to endodontics. The volume of the periapical inflammatory lesion, the presence of cortical fenestration, the distance of the root apices to the affected cortex, and the location, pattern, and longest diameter of the periosteal reaction were recorded. Statistical analysis was performed using Wilcoxon Ranksum, Fischer's exact, Spearman Correlation Coefficient, and paired t-test. In all cases, periosteal bone reaction manifested as either parallel (90.9%) or irregular (9.1%). No correlation was found between periapical inflammatory lesion volume and the periosteal reaction's longest diameter (p > 0.05). Cortical fenestration was noted in 72.7% of the cases. In addition, the findings showed that periosteal reactions were located mostly on the buccal and were present 53.8% and 100% of the time in the mandible and maxilla, respectively. The periosteal reactions of endodontic origin had a nonaggressive form (i.e., parallel or irregular), and none of the lesions resulted in a periosteal reaction with an ominous Codman's triangle or spicule pattern.

The Enigma of a Massive Lesion Invading the Maxillary Sinus: A Case Report

Radicular cyst is a periapical inflammatory lesion mandatorily associated with a non-vital tooth which usually manifests as an asymptomatic slow growing painless swelling. The present case reported to the Department of Oral and Maxillofacial Surgery Chhattisgarh Dental College and Research Institute with an unusual presentation of an infected radicular cyst of maxilla invading the maxillary sinus. This case report highlights the advancing capability of an infected radicular cyst involving maxillary sinus its systematic treatment planning and execution. The cystic lesion covered the entire right maxilla and anteriors on the left side while involving maxillary sinus. It was surgically treated with enucleation and removal of inflamed sinus lining along with extraction of involved teeth and impacted mesiodens. The surgical site healed completely along with resolution of symptoms. A six month post-op radiograph revealed good bone healing.nbsp

Diagnostic imaging of chronic inflammatory periapical lesions

Diagnostic imaging of chronic inflammatory periapical lesions

PRF: An autologous biomaterial for surgical management of periapical lesion – A case report

Periapical surgery is done to eliminate periapical pathology, it aids in the repair of the wound. Platelet-rich fibrin (PRF) enables the production of fibrin network that are loaded with platelets and growth factors, which are then employed to speed up bone regeneration, hence, used to enhance bone formation. A patient of 18 years reported pain in the maxillary anterior region and clinically slight swelling was appreciated with the same region, diagnosed with periapical inflammatory lesion, and managed by performing periapical surgery using PRF. Optimal healing and regeneration of bone were achieved in this case. PRF is the material of choice for many clinicians nowadays since it shows its regenerative property even when used alone or in addition to any other biomaterial. Other than having a high concentration of platelet, it has numerous growth factors that readily repair and regenerate hard tissue.

L-PRF ASSOCIATED WITH BIO-OSS® AS AN OPTIONAL TREATMENT FOR RADICULAR CYST: CASE REPORT

To regenerate bone and soft tissue, multiple types of treatment have been developed, including the use of bone grafting, membranes, and growth factor/cytokines/host modulating agents. Leukocyte-platelet-rich fibrin (L-PRF) is a second-generation platelet concentrate that forms a natural fibrin matrix with immune regulation node and inflammation retrocontrol properties that can be useful in healing of apical defects. In the present case, a bovine bone substitute graft was associated with L-PRF clot to achieve bone and soft tissue regeneration in a periapical inflammatory lesion. The case developed with satisfactory bone healing, which suggests that the association of L-PRF and bone grafts may positively affect the regeneration of bone in wide circumferential apical defects.

Evaluation of endodontically treated teeth and related apical periodontitis using periapical and endodontic status scale: Retrospective cone-beam computed tomography study.

The purpose of this study was to evaluate the technical treatment quality and the status of apical pathology of endodontically treated teeth, as well as apical periodontitis (AP) prevalence, in a Turkish population using cone-beam computed tomography (CBCT). The CBCT images obtained between January 2018 and April 2020 were retrospectively examined. The quality of the endodontic treatments and the related periapical inflammatory lesions were classified according to the periapical and endodontic status scale (PESS). The data were statistically analysed using logistic regression, crosstabs and chi-square tests. AP was detected in 41% of 429 endodontically treated teeth. The prevalence of AP was significantly higher in teeth with inadequate root canal treatment compared with those with adequate treatment, 70.8% and 29.3%, respectively. Inadequate canal length and homogeneity, and complications were significantly associated with the prognostic periapical status scores of higher risk.

An uncovered extensive fusion of two separated periapical lesions in CBCT imaging: the importance of multiplanar radiographic appraisal

Objectives: This report is aimed to present a case of an uncovered fusion of two seemingly separated periapical rarefying osteitis lesions on two adjacent teeth through Cone Beam Computed Tomography (CBCT) imaging and to describe the significance of a comprehensive multiplanar appraisal in interpreting CBCT radiographs.&#x0D; Case Report: An 18-year-old female patient came to Universitas Airlangga Dental Hospital for a CBCT examination of her right central maxillary incisor (tooth 11) as referred by her dentist. Based on the clinical report provided, the patient had a slight palpable swelling of the labial gingival anterior maxilla with sign of crepitus. Caries lesions were found on teeth 11 and 12 in which the vitality tests showed negative responses. Thus, it was provisionally suspected as a periapical inflammatory lesion. CBCT was done and the 3D-reconstructed images of the bone showed there were two neighboring radiolucent ovoid lesions attached on one-third apical of teeth 11 and 12, separated by a firm-apparent cortex. It was later discovered that the two lesions were actually fused as one elongated and extensive lesion through the multiplanar appraisal of three orthogonal views provided in CBCT application.&#x0D; Conclusion: CBCT 3D-reconstructed and panoramic reformatted images should be used with caution, either for linear measurement or diagnostic purposes, as they should only be used to illustrate the diagnosis and/or provide a better understanding of the problem to the patients and their treatment plans. A comprehensive multiplanar appraisal is required to provide a diagnostically complete interpretation.

Study of the Focal Aggregations of Cholesterol Crystals and Foamy Macrophages in the Chronic Periapical Lesions of Young and Elderly Patients

Background: Cholesterol crystals and foamy macrophages can delay the healing of inflammatory periapical lesions. The purpose of this study was to evaluate the relationship between age and the presence of focal aggregations of cholesterol crystals and foamy macrophages in these lesions. Methods: In this descriptive-analytic study, 770 samples of inflammatory periapical lesions including 335 periapical granulomas, 329 radicular cysts, and 106 residual periapical cysts were evaluated histopathologically in order to find at least two focal aggregations of cholesterol crystals and foamy macrophages in two age groups of young (20-35 years old) and elderly (over 50 years old) adults. Finally, the data were entered into SPSS version 23.0 and analyzed using chi-square and Fisher’s exact tests. Results: In the present study, 74.3% of the samples lacked at least two focal aggregations of foamy macrophages, and 84% of the samples lacked at least two focal aggregations of cholesterol crystals. The frequency of focal aggregations of cholesterol crystals was not significantly different between the two age groups (P=0.14). However, the frequency of foamy macrophages was significantly higher in the age group of young adults than in elderly adults (P=0.002). Conclusions: According to the obtained results, it does not appear that the healing rate of periapical lesions in young and elderly adults has necessarily significant difference; and whereas, it is lower in the elderly adults than in young adults, probabely relates to factors other than the accumulation of cholesterol crystals or foamy macrophages.

Expression of epithelial growth factors and of apoptosis-regulating proteins, and presence of CD57+ cells in the development of inflammatory periapical lesions.

The mechanisms that stimulate the proliferation of epithelial cells in inflammatory periapical lesions are not completely understood and the literature suggests that changes in the balance between apoptosis and immunity regulation appear to influence this process.Objective:To evaluate the expression of the epidermal growth factor (EGF), its receptor (EGFR) and of the keratinocyte growth factor (KGF), the presence of CD57+ cells, the epithelial cell proliferation index, and the expression of the Bcl-2 protein in inflammatory periapical lesions (IPL) at different stages of development.Methodology:Our sample was composed of 52 IPLs (22 periapical granulomas - PG - and 30 periapical cysts - PC), divided into three groups: PGs, small PCs, and large PCs. Specimens were processed for histopathologic and immunohistochemical analyses. Sections were evaluated according to the amount of positive staining for each antibody.Results:We found no significant differences among the groups regarding Bcl-2 (p=0.328) and Ki-67 (p>0.05) expression or the presence of CD57+ cells (p=0.748). EGF (p=0.0001) and KGF (p=0.0001) expression was more frequent in PCs than in PGs, and CD57+ cells were more frequent in IPLs with intense inflammatory infiltrates (p=0.0001). We found no significant differences in KGF (p=0.423), Bcl-2 (p=0.943), and EGF (p=0.53) expression in relation to inflammatory infiltrates or to the type of PC epithelial lining, but observed greater KGF expression (p=0.0001) in initial PCs. EGFR expression was similar among the groups (p>0.05).Conclusion:More frequent EGF and KGF expression in PCs and the greater presence of CD57+ cells in lesions with intense inflammatory infiltrates suggest that these factors influence IPL development. The greater KGF expression in initial PCs suggests its importance for the initial stages of PC formation.

ALDH1 expression and potential clinical implications in chronic inflammatory periapical lesions.

Aldehyde dehydrogenase 1 (ALDH-1) is a marker of stem cells in a variety of diseases, but its role in individuals with chronic inflammatory periapical lesions remains unknown. The aim of this study was to investigate the presence of cells with a stem cell profile based on the immunoexpression of ALDH-1 in periapical granulomas (PGs) and radicular cysts (RCs). A total of 51 cases of periapical lesions (25 PGs and 26 RCs) were subjected to immunohistochemical study. The anti-ALDH-1 antibody was applied using the immunoperoxidase technique. An immunoexpression score (intensity vs. percentage of cells) was used, with the cases being classified as low expression (score: 0 to 4) and high expression (score: 6 to 9). The Chi-square test was used with a 5% level of significance. Immunoexpression of ALDH-1 was detected in all cases of PGs and RCs. In PG cases, the expression was diffuse in connective tissue cells, with most cases exhibiting high expression (n = 18; 69.2%), while in RC cases the expression revealed focal distribution in cells of the capsule and epithelial cells of the cystic lining, with most cases classified as low expression (n = 18; 72%). Significant differences in the expression scores of ALDH-1 were observed in PGs (p = 0.003). The variable expression of ALDH-1 suggests the presence of cells with stem cell profiles in PGs and RCs. These findings suggest that periapical tissues infiltrated by chronic inflammation can recruit important cells for the repair or evolution of periapical lesions.

Associação entre a periodontite apical e as doenças cardiovasculares: uma revisão da literatura

Aim: The present study aims to review the data available in the literature to verify whether apical periodontitis (AP) is a risk factor for cardiovascular diseases (CVDs). Materials and Methods: a search was carried out in the databases of Pubmed and Google Scholar about a possible association of AP with the development of cardiovascular problems. After the selection criteria, 8 scientific articles were included to be analyzed in detail. Literature Review: although BP is a local inflammatory process, its pathogenesis can result in the development of systemic complications. Assuming that a localized inflammatory response is capable of causing the release and activation of systemic pro-inflammatory mediators, such as interleukin cytokines and tumor necrosis factors, some automatic effects are a possible association between a chronic AP and CVDs, due to the potential for the emergence of endothelial damage and atheroma. Discussion: although the correlation between periapical inflammatory lesions and systemic diseases is still questionable, mainly due to the discredit in which the subject was treated in the past and the limited amount of conclusive information currently available, the data reviewed in this paper propose that there is a positive association between AP and CVDs, with a higher prevalence of AP in patients with cardiovascular problems. Conclusion: a limited amount of findings are scientifically available. Therefore, it is suggested to carry out more research on the subject, aiming the search for relevant and well-grounded evidence on this association.

Association of Inflammatory Periapical Lesions with Maxillary Sinus Abnormalities: a Retrospective Cone-Beam Computed Tomography Study.

Statement of the Problem: Odontogenic infections such as periapical lesions (PLs) can cause changes in the adjacent tissues. Infection of the maxillary posterior teeth can be easily transmitted to the maxillary sinus and cause changes in the maxillary sinus mucosa. Cone-beam computed tomography (CBCT) has high accuracy and sensitivity for detection of odontogenic lesions and is efficient for maxillary sinus assessment. Purpose: This study aimed to assess the maxillary sinuses for abnormalities such as mucosal thickening, polyps, and periostitis, and evaluate the periapical status of maxillary posterior teeth considering the presence of PLs, their size and distance from the sinus floor by evaluating CBCT images.Materials and Method: This retrospective, cross-sectional study evaluated the CBCT scans of 143 patients, depicting the posterior maxilla with at least one premolar or molar tooth present in this region. Sinus abnormalities (mucosal thickening, sinus polyps, and periostitis) and presence/ absence of PLs, its size, and its distance from the sinus floor were all assessed on CBCT scans. Data were analyzed using the Chi-square test in SPSS version 21 (a= 0.05).Results: PLs were observed in 31.2% of the cases. In presence of PLs, mucosal thickening was noted in 56.8%, sinus polyps in 29.6% and periostitis in 1.3% of the maxillary sinuses. All teeth with a CBCT periapical index (CBCTPAI) score of 5 were associated with sinus abnormalities; there was neither correlation between the sizes of lesions, nor their distance from the sinus floor with sinus abnormalities (p> 0.05).Conclusion: PLs in the posterior maxilla have a direct correlation with the maxillary sinus abnormalities. However, the size or distance of PLs from the sinus floor had no significant effect on the frequency of sinus abnormalities.

English

BACKGROUND Local response of the bone surrounding the apex of the tooth as a result of pulp necrosis or destruction of the periapical tissues caused by significant periodontal disease is known as a periapical inflammatory lesion. Intraoral radiography is the most commonly used technique but has limitations in representing only 2- dimensional images. CBCT was created primarily to provide 3-dimensional maxillary skeletal images and a smaller and mid field of view (FOV) have a higher spatial resolution and improved diagnostic potential. The intention of this study was to compare and evaluate the results of limited view CBCT and DDI in the diagnosis of periapical pathology. METHODS In this study, a total of 25 patients who visited the oral medicine department with clinical and or radiographic findings were included. Periapical lesions were assessed using a cone-beam CT periapical index (CBCTPAI) scoring system in both direct digital imaging (DDI) radiographs and CBCT images. RESULTS Periapical lesions were found to be more prevalent in 30 - 39 years (40 %) with a male predilection (64 %) and maxillary anterior (36 %) more commonly affected. Wilcoxon signed-rank test performed to assess the mean difference between the two imaging modalities revealed a P &lt; 0.001 and was statistically significant. CONCLUSIONS This study highlights the role of CBCT in diagnosing periapical lesions which can be missed or misdiagnosed on DDI. KEY WORDS Cone Beam Computed Tomography (CBCT); Direct Digital Imaging (DDI); Periapical Lesions

Considerations for Orthodontic Treatment in Patients with Endodontically Treated Teeth with Inflammatory Periapical Lesion

Considerations for Orthodontic Treatment in Patients with Endodontically Treated Teeth with Inflammatory Periapical Lesion