Periapical Bone Lesions Research Articles

Wound healing of apical tissues after root canal therapy: a long-term clinical, radiographic, and histopathologic observation study

The purpose of this study was to evaluate the pulp healing process and the dentin-cementum complex in 51 endodontically treated human teeth after long observation periods and to correlate histologic observations with conventional periapical radiographic findings. Specimens were obtained from the extraction of 77 treated teeth, which were deemed to be unrestorable, with no evidence of periapical bone lesion at the follow-up. After stringent evaluation of the radiographs, 51 cases that 3 independent evaluators assessed as having normal periapical conditions were selected. The specimens were histologically evaluated using serial sections. In the majority of the cases, complete healing was observed, with no signs of acute or chronic inflammatory processes in the remaining apical tissue or periodontal tissue fragments. Some cases showed moderate inflammation in the root canal tissue. Narrowing of the apical root canal by cementum was a common finding in most cases, but total closure was not observed. Debris intermixed with necrotic tissue and sealer particles was a common finding in the pulp stump. Bacteria were present in the coronal portion of the root in almost all cases, but in only 1 case could bacteria be demonstrated in the coronal and apical portions of the root. Apical tissue of properly treated teeth with no signs of periapical changes is only rarely significantly inflamed. When the tissue is inflamed, microbial causes can always be demonstrated. Despite the presence of microorganisms coronally in nearly all cases, apical tissue is seldom affected.

Inflammatoric Mediators in Periapical Bone Lesion

The cytokines affecting periapical bone lesions have been reviewed for current understanding of the mechanisms and mediators involved. Periapical bone lesions can result from dental disease that spreads into the root canal and expands to the surrounding periapical tissue. This will create periradicular tissue inflammation, where cells like monocytes, PMNs and lymphocytes regulate and are regulated by cytokines responsible for inflammation. Periapical bone resorption can be caused by inflammation, by cytokines including IL-1, MMP-8, GM-CSF. Meaning of level MMP-8s from root-canal exudates during endodontic treatment could be use as biochemical indicator of the inflammatory status of the periapical tissue. In addition, various cytokines such as TGF-β 1 , IL-6, IL-10 promote bone proliferation. The variance in cytokine receptor expressions may explain the selective recruitment in the inflitration of inflammatory cells at the local inflammation site. Cytokines, each having their own duty, are key mediators of periapical bone resorption bone resorption that still needs to be investigated in detail.

Bacterial status in root-filled teeth exposed to the oral environment by loss of restoration and fracture or caries--a histobacteriological study of treated cases.

To describe histological and microbiological findings in teeth where root fillings had been exposed to caries and the oral environment for a prolonged period. For inclusion in the study, only teeth with a follow-up period of 3 years or more and those that had been without proper restoration for at least a period of 3 months were considered. Some root fillings had been without restoration for several years. In all, 39 roots representing 32 teeth were examined by histology. The majority of the specimens were without a discernible periapical bone lesion as assessed by radiography. Osteolytic lesions were seen with five roots. Longitudinal tissue sections stained with a modified Brown/Brenn staining technique revealed presence of stainable bacteria in abundance at the canal entrance and in dentinal tubules but were absent mid-root and apically in all but two specimens. Soft tissue attached to the root tip and in apical ramifications displayed distinct inflammatory cell infiltrates, suggesting microbial exposure in 7 of the 39 roots examined. In all other specimens, inflammatory cell infiltrates were either nonexistent or sparse and then associated with extruded sealer material. Well-prepared and filled root canals resist bacterial penetration even upon frank and long-standing oral exposure by caries, fracture or loss of restoration.

Effects of sympathectomy on experimentally induced pulpal inflammation and periapical lesions in rats

The role of sympathetic nerves in bone physiology is largely unknown. Recent studies have shown a correlation between sympathectomy and bone remodeling. The present experiments were aimed to study the effects of unilateral sympathectomy on bilateral experimentally induced pulpitis and periapical lesions in the rat maxilla and mandible. Adult male Sprague–Dawley rats were used. Experimental rats ( n=11) had the right superior cervical ganglion surgically removed (SCGx) and control rats ( n=5) had sham surgery. Pulpal inflammation and periapical bone lesions in the maxilla and mandible were created 14 days later in both experimental and control rats by exposing the dental pulp in the first and second molars and leaving them open to the oral microflora. The rats were perfused 20 days thereafter and the jaws processed for immunohistochemistry with neuropeptide Y (NPY) and ED1 as primary antibodies. Sympathectomy resulted in an almost complete loss of NPY-immunoreactive (IR) fibers in the right SCGx jaws. In the non-sympathectomized (non-SCGx) left side and in the control rats, sprouting of NPY-IR fiber was observed in the inflamed pulp tissue adjacent to reparative dentin formation and in the apical periodontal ligament of the partially necrotic first molars. Significantly more ED1-IR osteoclasts were found in the resorptive lacunae lining the periphery of the periapical lesions on the SCGx side compared with the non-SCGx side ( P<0.04) and the controls ( P<0.03). The size of the periapical lesions were larger on the SCGx side compared with the non-SCGx side ( P<0.03) in the mandible, but not in the maxilla. We conclude that inflammation causes sprouting of NPY-IR nerve fibers and that unilateral removal of the SCG increases both the area of the periapical lesions and the number of osteoclasts in the inflamed region.

A new technique for the study of periapical bone lesions: ultrasound real time imaging.

This study describes the use of a real time-ultrasound imaging technique (echography) for the study of periradicular lesions. Twelve patients with periapical lesions of endodontic origin, diagnosed with conventional clinical and radiographic examination, were examined further using echography at the site of the diagnosed lesions. Each lesion was echographically characterized and described by an expert echographist together with an endodontist. Once the major echographic features were identified, information on the size of the lesion, its content, and its vascular supply was obtained and recorded. A tentative differential diagnosis between a cyst and a granuloma was made based on the data. In all cases it was possible to obtain an echographic image. It was also possible to measure the lesions, to evaluate their content and to view their vascularization in different regions of the mouth. Ultrasound real time imaging is a promising diagnostic technique in endodontology, but further work is required to refine the process.

Evidence-based endodontics: The one-visit treatment idea

Evidence-based endodontics: The one-visit treatment idea

Analysis of sensitivity and specificity of a new digital subtraction system: An in vitro study

The purpose of this study was to compare a new digital subtraction system with conventional radiograph images for the detection of periapical and periodontal bone lesions. Periapical and periodontal bone lesions were simulated with cortical bone chips of varying sizes placed on a human dry mandible. Radiographic film images were acquired from varying projections and were subsequently digitized, registered, and subtracted. Four clinicians evaluated the subtracted images, and sensitivity and specificity were calculated. The mean sensitivity and specificity of the Diagnostic Subtraction Radiography system for detecting bone lesions of all sizes with varying projection geometry were 87.90% and 85.23%, respectively. The corresponding results for conventional radiograph images were 47.54% and 97.38%. The difference in sensitivity was statistically significant, whereas the difference in specificity was not. These results indicate that, even when radiographs are taken from disparate projection geometries, the Diagnostic Subtraction Radiography system is capable of excellent discrimination between healthy and disease states in this in vitro model.

Comparison of diagnostic accuracy of digital imaging by using CCD and CMOS-APS sensors with E-speed film in the detection of periapical bony lesions

Objective. The purpose of this study was to compare E-speed Plus film and digital imaging with a charge-coupled device (CCD) sensor and a complementary metal-oxide semiconductor active pixel sensor (CMOS-APS) in the detection of periapical bone lesions. Study design. Periapical lesions were created in the cortical and trabecular bone of 10 dried human mandibles. Seventy radio-graphic images and 140 digital images were evaluated by 6 endodontists and 2 radiologists. Receiver operating characteristics curves and analysis of variance were used for statistical analysis. Results. No statistically significant differences were found between film, CCD, and CMOS-APS systems. Lesion detection occurred with significantly greater accuracy in cortical bone than in trabecular bone, as well as when the cortical plate was involved. Conclusions. That no differences were found between the two sensors lends support for the use of CMOS-APS sensors, which require less system power and may have longer life spans than CCD sensors. Digital imaging required 50% less radiation than film to obtain the same diagnostic information. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:356-62)

Interpretation of Artificial and In Vivo Periapical Bone Lesions Comparing Conventional Viewing Versus a Video Conferencing System

The purpose of this study was to compare the interpretation of conventional radiographs transmitted by a video teleconferencing system to conventional viewbox interpretation for both artificial and in vivo periapical bone lesions. A total of 30 radiographic images were used in this study: 20 radiographic images of artificial lesions and 10 radiographs from actual patients. Two endodontists evaluated the 30 images by giving a "yes" or "no" response when determining whether a periapical lesion was present on the radiograph. The study was conducted in two sessions, separated by a 6-wk interval to minimize evaluator recall. Results of the study revealed no statistical difference between the ability of the evaluator to identify periapical bone lesions using conventional radiographs on a viewbox and his ability to interpret the same images transmitted on a monitor screen.

OR 13 Comparison of diagnostic accuracy of digital imaging and E-speed film in the detection of periapical bone lesions

OR 13 Comparison of diagnostic accuracy of digital imaging and E-speed film in the detection of periapical bone lesions

Interpretation of periapical lesions comparing conventional, direct digital, and telephonically transmitted radiographic images

The purpose of this study was to evaluate direct digital radiography (DDR) and telephonically transmitted images versus conventional radiography in the interpretation of artificial periapical bone lesions. Five teeth were chosen from four cadaver jaw specimens. Three types of DDR images were evaluated: DDR stored images, DDR transmitted images, and DDR reversed images. A total of 150 DDR computer monitor images and 56 D-speed film images were evaluated by three endodontists and one endodontic graduate student. The Wilcoxon signed-ranks test was used for statistical analyses of the results. DDR reversed images were statistically inferior to DDR stored images, DDR transmitted images, and conventional radiography images (p < 0.0001). There were no statistically significant differences between DDR stored images, DDR transmitted images, and conventional film images in the ability of the evaluator to identify artificial periapical bone lesions (p > 0.05).

Diagnostic accuracy of direct digital dental radiography for the detection of periapical bone lesions: II. Effects on diagnostic accuracy after application of image processing

The diagnostic accuracy of direct digital radiography for the detection of small experimentally made periapical lesions was evaluated. A comparison was made between original digital images and images processed with different enhancement facilities of the digital system. Seven observers assessed the digital images in original mode and after individual image treatment. The diagnostic accuracy was calculated. The processing functions used by the observers were recorded, and the effect of processing was evaluated. The overall diagnostic accuracy was not different for the two image modes. Neither were the individual results of the observers different. The image processing was most effective when alterings of contrast and brightness were used. More complicated processing procedures had less effect on the diagnostic accuracy. Image processing of direct digital images of high quality has a limited effect on the diagnostic accuracy. Basic processing functions, that is, alterings of contrast and brightness, were preferred for the detection of periapical lesions.

Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma of permanent incisors

Little long-term data are available on the frequency by which pulp canal obliteration (PCO) subsequent to trauma leads to pulp necrosis (PN). In this study, 82 concussed, subluxated, extruded, laterally luxated, and intruded permanent incisors presenting with PCO were followed for a period of 7 to 22 yr (mean 16 yr). At final clinical examination, 51% of the observed teeth responded normally to electric pulp testing (EPT). An additional 40% of the teeth although not responding to EPT were clinically and radiographically within normal limits. Yellow discoloration was a frequent finding. During the observation period, periapical bone lesions suggesting PN developed in seven teeth (8.5%). Twenty-yr pulp survival rate was 84%, as determined from life-table calculations. There was no higher frequency of PN in obliterated teeth subjected to caries, new trauma, orthodontic treatment, or complete crown coverage than intact teeth. Although the incidence of PN in teeth displaying PCO seems to increase over the course of time, prophylactic endodontic intervention on a routine basis does not seem justified.

Diagnostic accuracy of direct digital dental radiography for the detection of periapical bone lesions: Overall comparison between conventional and direct digital radiography

Objective The diagnostic accuracy of direct digital radiography for the detection of small, experimentally made, periapical lesions was compared with that of E-speed film. The high- and low-contrast resolutions of the imaging systems were also compared. Study design The high-contrast resolution was evaluated with a line-pair plate. The low-contrast resolution was determined with a contrast-detail plexiglass phantom. To evaluate the diagnostic accuracy, the periapical region of dry human mandibles was examined. Receiver operating characteristic based on the readings of seven observers were generated. Results The high-contrast resolution of the digital system was inferior, but the low-contrast resolution was comparable to that of E-speed film. For diagnostic accuracy no significant difference was seen between the areas under the receiver operating characteristic curves. Conclusions The quality of the direct digital images is comparable to that of E-speed film for the detection of periapical bone lesions.

Room for improvement?: The accuracy of dental practitioners who diagnose bony pathoses with radiographs

The impact of any effort aimed at improving diagnostic accuracy by improving clinical decision making in diagnostic radiology will be limited by the ability of the clinician to correctly recognize the presence of abnormalities on radiographs. We carried out a study designed to examine whether dentists are able to correctly identify various kinds of periapical bone lesions visible on intraoral radiographs and diagnose their pathologic nature. General dental practitioners (n = 98) assessed 32 radiographs that showed either normal bone (10) or one abnormality (22) in the periapical bone. The "gold standard" for pathosis was histopathologic analysis. The dentists were asked to judge for the presence of an abnormality and to decide whether an active pathologic process was present. On average dentists identified 81% of all visible abnormalities correctly. Subsequently, they diagnosed 59% of all the pathologic cases correctly. Dentists, however, incorrectly identified 55% lesions on radiographs when experts had stated that no abnormality was visible. There is room for improvement of diagnostic accuracy of bony pathology.

Some considerations in the evaluation of diagnostic tests in dentistry.

EditorialSome considerations in the evaluation of diagnostic tests in dentistry.A Wenzel and E H VerdonschotA WenzelSearch for more papers by this author and E H VerdonschotSearch for more papers by this authorPublished Online:29 May 2014https://doi.org/10.1259/dmfr.23.4.7835521SectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail About Next article FiguresReferencesRelatedDetailsCited byCan preoperative imaging help to predict postoperative outcome after wisdom tooth removal? 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Application of computer-aided image interpretation to the diagnosis of periapical bone lesions.

An image analysis system was developed for the computer-aided diagnosis of periapical bone lesions in dental radiographs. The system was designed to (1) identify the periapical region, (2) determine the presence of a periapical lesion and (3) estimate the size of the lesion in cases when a lesion had been found. To initiate the procedure, an observer indicates an arbitrary point on the root in a digitized radiograph. From this initial point, the location of the radiographic projection of the apex of the root is automatically computed. Next, the trabecular bone pattern is detected through texture analysis. A local absence of the trabecular bone pattern in the periapical region is marked as a periapical bone lesion. When a lesion has been identified, its size is estimated based on local edge properties. Observer interaction is only allowed to adjust the result of the apex localization procedure if the apex has not correctly been localized. In an experiment with randomly selected radiographs of 111 mandibular roots, the performance of the system was tested against the consensual diagnosis of four expert observers. The sensitivity of the system to identify a lesion was 83.3%, the specificity 75.6% and the diagnostic accuracy 80.2%. The correlation between the size of the lesions as estimated by the system and by the observers was 0.67 (P < 0.01). When the procedure was repeated, the percentage of correctly reproduced lesion sizes by the system was 92.8%. The determination of the presence of a lesion was reproducible in 98.2% of all the cases.

Diagnosing periapical bone lesions on radiographs by means of texture analysis

Trabecular pattern, the radiographic projection of trabecular bone, is a repeated structure that appears in a dental radiograph. Texture analysis, the computer image analysis of repeated patterns, is a technique that can be used to automate the diagnosis of periapical lesions with the detection of the absence of the texture that corresponds to the trabecular bone. The purpose of this study was to determine whether it is feasible to use texture analysis to identify the presence of the trabecular pattern in radiographs and to detect a periapical bone lesion based on a local absence of this pattern. Thirty-two mandibular periapical films, 16 with and 16 without periapical lesions, were used in this study. Texture analysis was carried out on the digital images of these radiographs. In the 16 films with lesions, they were all correctly identified, and no lesions were found in the 16 films without lesions. This result is based on the a priori knowledge of the user about the localization of the disease. Locating periapical regions without user interaction is a goal for future research.

Application of digital image analysis in dental radiography for the description of periapical bone lesions: a preliminary study

This paper describes an application of digital image analysis for the description of periapical bone lesion in dental radiography. These techniques enable the problem of observer variability to be circumvented, and can eventually be used for the quantitative assessment of bone lesions. Since periapical bone lesions appear radiographically as dark areas compared with their surrounding tissues, an edge-detection method was developed to extract the boundaries between anatomy and pathology. The original data were transformed in such a way that only the outlines remained. The lesion was assumed to be demarcated by a continuous outline, so all the contour points not being part of a continuous outline were excluded. With only limited operator interaction, the lesion contour could be projected successfully onto the original image. The result of this operation was a simplified diagnostic examination process promising a higher degree of objectivity in periapical bone lesion detection. It is concluded that the results encourage further development of image processing techniques suitable for the definitive detection and diagnosis of periapical bone lesions.

Radiological visibility of small artificial periapical bone lesions.

Previous studies have indicated that the visibility of periapical lesions on a radiograph is determined by erosion of either the cortex or the junction area between cortex and spongiosa. In the present study, artificial lesions, varying in diameter from 1.6 to 4.5 mm, were produced with a round dental bur at 32 sites in 27 blocks from four dried human mandibles embedded in paraffin and radiographed under standardized conditions. The radiographs were evaluated by three observers with differing degrees of radiological experience, and the results expressed as Mean Visibility Index (MVI) and Mean Difference Index (MDI). Six parameters were measured at each site, thickness of the bone, of the cortex and of the spongiosa, density of the spongiosa, cortex/spongiosa ratio, and erosion of the cortex, and their correlation with the two indices determined by stepwise and multiple regression. It was found that MVI was significantly associated not only with the erosion of the cortex but also the density of the spongiosa and the diameter of the lesion. MDI was found to be associated mainly with cortex erosion.